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A5684 - Transition to Oral from Intravenous Prostacyclins therapy in Pulmonary Arterial Hypertension
Author Block: Z. Safdar1, S. Sahay2; 1Pulmonary-Critical Care Medicine, Houston Methodist Hospital/Weill Cornell Medical College, Houston, TX, United States, 2Division of Pulmonary Medicine, Houston Methodist Hospital/Weill Cornell Medical College, Houston, TX, United States.
Introduction: Intravenous (iv) prostacyclins (PGs) remains the therapy of choice for patients with severe Pulmonary Arterial Hypertension (PAH). With long-term use of iv PGs requiring indwelling catheters, multiple complications such as repeated line infections, vascular access issues may necessitate transition to recently available oral PG. Methods: At the Houston Methodist Pulmonary Hypertension Center, 4 PAH subjects on stable background treatment (ERA, PDE5 inhibitor or both) were rapidly transitioned to oral treprostinil extended release tablets from iv treprostinil due to repeated line infections, vascular access issues or at patient’s request. Transition was completed at home in 1 patient and 3 patients were transitioned in hospital. Time required to transition varied from 3 to 14 days and the longest transition time (14 days) was for in home transition. Oral treprostinil total daily dose was calculated using the formula: 0.0072 x iv treprostinil (ng/kg/min) x weight (kg). For in hospital transition, iv treprostinil dose was decreased by 1/3 every 8 hours till weaned off and 1 hour following each iv treprostinil dose decrease, oral treprostinil dose was administered in 1/3 increments of the calculated total daily dose. This transition was guided by symptoms, physical examination and/or BNP levels. A slower at home transition scheme was followed for patient safety. Demographic, hemodynamic, six-minute walk distance (6MWD) and survival data was collected. Results: Three females and 1 male with mean age of 53±16 years (mean±SD) were successfully transitioned from iv treprostinil to oral treprostinil. Mean duration of PAH prior to transition was 13±11 years (range from 1 to 26 years). Mean pulmonary artery pressure was 43±15 mmHg, right atrial pressure (RAP) was 8±6 mmHg, cardiac output (CO) was 5±2.1 L/min and cardiac index was 3±1.4 ml/min/m2 prior to transition. IV treprostinil dose was 51±25 ng/kg/min (range was 14-70 ng/kg/min) prior to transition and the dose of oral treprostinil was 8.0±4.2 mg three times per day post transition. Post-transition echocardiogram showed a RVSP of 54±13 mm Hg, RAP of 10±7 and CO of 4±1.8 L/min. Post-transition 6MWD was 468±96 meters. All patient were alive at the time of last follow-up and maintianed on oral treprostinil tablets. Conclusions: Although PAH patients require iv prostanoid therapy for severe PAH but carefully selected stable patients on background PAH therapy can be transitioned to oral treprostinil. This transition can be undertaken in hospital or at home without any adverse events and may offer substantial quality of life benefits.