View Abstract

A3695 - Successful Transition from Oral Selexipag to Intravenous Epoprostenol
Author Block: J. L. Morales-Estrella1, A. Chen2, G. A. Heresi1; 1Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, United States, 2Pharmacy, Cleveland Clinic Foundation, Cleveland, OH, United States.
No guidelines exist on how to transition from the oral selective prostacyclin agonist selexipag (UPTRAVI®), to intravenous prostacyclin in patients with pulmonary arterial hypertension (PAH). Hence, we report a successful transition in a 72-year-old female with a clinical diagnosis of pulmonary veno-occlusive disease (PVOD) resulting in severe pre-capillary pulmonary hypertension complicated with severe right ventricular failure. At diagnosis, she had a favorable hemodynamic response to sildenafil 20mg thrice daily and IV epoprostenol at 6 ng/kg/min, with further up-titration limited by development of pulmonary edema, confirming PVOD-like physiology. After a year of stability and due to patient’s preference for non-parenteral options, she was transitioned from the low-dose parenteral prostacyclin to oral selexipag at a maintenance dose of 1400 mg thrice a day. Three months later she was hospitalized to the intensive care unit with decompensated right heart failure. After forced diuresis a right heart catheterization demonstrated: mPAP 42 mmHg, mean RA 10 mmHg, mean PCWP 14 mmHg, PVR 8 WU; thermodilution CI 2.37 l/min/m2 and assumed Fick CI 1.40 l/min/m2. Shared decision was made to transition back to parenteral therapy. Selexipag was discontinued without weaning, followed with a rapid titration of IV epoprostenol by 1ng/kg/min every 30 minutes until the goal rate of 6 ng/kg/min. The last dose of selexipag was given 9.5 hours before initiation of IV epoprostenol. She experienced no medication-related adverse effects. DISCUSSION: Selexipag is the first-in-class oral selective prostacyclin receptor agonist approved for PAH. Limited published experience exists on how to transition from this newer oral therapy to more potent parenteral therapy. Clinicians caring for patients with PAH may encounter several limitations when prompt transition from such therapy is necessary. Specifically, selexipag tablets cannot be split and, because selexipag is commonly a non-formulary drug, the various dosage concentrations may not be immediately available. Oral therapy without a parenteral formulation also poses a problem for those patients with PAH who are hospitalized and unable to swallow tablets. In contrast to the recently reported experience by Gibbs and Poonyagariyagorn (2017), no overlap between oral and intravenous therapy was used in our patient. As demonstrated in this case, it may be safe to discontinue selexipag without weaning in patients with PAH, if followed by rapid titration of an intravenous prostacyclin in closely monitored setting.