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Karampitsakos T, Tzouvelekis A, Chrysikos S, Bouros D, Tsangaris I, Fares WH. Pulmonary hypertension in patients with interstitial lung disease. Pulm Pharmacol Ther 2018; 50:38-46. [PMID: 29605286 DOI: 10.1016/j.pupt.2018.03.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 03/12/2018] [Accepted: 03/28/2018] [Indexed: 01/20/2023]
Abstract
Interstitial lung diseases (ILDs) comprise a broad and heterogeneous group of more than two hundred diseases with common functional characteristics. Their diagnosis and management require a multidisciplinary approach. This multidisciplinary approach involves the assessment of comorbid conditions including pulmonary hypertension (PH) that exerts a dramatic impact on survival. The current World Health Organization (WHO) classification of PH encompasses many of the interstitial lung diseases into WHO Group 3, while sarcoidosis, Pulmonary Langerhans Cell Histiocytosis and lymphangioleiomyomatosis are placed into WHO Group 5 as diseases with unclear or multifactorial mechanisms. Connective tissue diseases could span any of the 5 WHO groups based on the primary phenotype into which they manifest. Interestingly, several challenging phenotypes present with features that overlap between two or more WHO PH groups. Currently, PH-specific treatment is recommended only for patients classified into WHO Group 1 PH. The lack of specific treatment for other groups, including PH in the setting of ILD, reflects the poor outcomes of these patients. Thus, identification of the optimal strategy for ILD patients with PH remains an amenable need. This review article provides a brief overview of biomarkers indicative of vascular remodeling in interstitial lung disease, summarizes the current state of knowledge regarding patients with PH and ILD and highlights future perspectives that remain to be addressed.
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Affiliation(s)
| | - Argyrios Tzouvelekis
- First Academic Department of Pneumonology, Hospital for Thoracic Diseases, "Sotiria", Medical School, National and Kapodistrian University of Athens, Athens, Greece; Division of Immunology, Biomedical Sciences Research Center "Alexander Fleming", Athens, Greece
| | - Serafeim Chrysikos
- 5(th) Department of Pneumonology, Hospital for Thoracic Diseases, "Sotiria", Athens, Greece
| | - Demosthenes Bouros
- First Academic Department of Pneumonology, Hospital for Thoracic Diseases, "Sotiria", Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Iraklis Tsangaris
- Second Critical Care Department, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Wassim H Fares
- Section of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.
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Abstract
Pulmonary hypertension that develops in the setting of underlying lung diseases such as COPD or idiopathic pulmonary fibrosis (IPF) is associated with decreased functional status, worsening hypoxemia and quality of life, and increased mortality. This complication of lung disease is complex in its origin and carries a unique set of diagnostic and therapeutic issues. This review attempts to provide an overview of mechanisms associated with the onset of pulmonary hypertension in COPD and IPF, touches on appropriate evaluation, and reviews the state of knowledge on treating pulmonary hypertension related to underlying lung disease.
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Affiliation(s)
- Michael J Cuttica
- Northwestern Pulmonary Hypertension Program, 676 St Claire Suite 1400, Chicago, IL, 60611, USA.
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53
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Wang L, Jin YZ, Zhao QH, Jiang R, Wu WH, Gong SG, He J, Liu JM, Jing ZC. Hemodynamic and gas exchange effects of inhaled iloprost in patients with COPD and pulmonary hypertension. Int J Chron Obstruct Pulmon Dis 2017; 12:3353-3360. [PMID: 29200842 PMCID: PMC5702173 DOI: 10.2147/copd.s141798] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Studies have shown that vasodilators such as iloprost can be useful for treating pulmonary hypertension (PH). However, in patients with COPD, vasodilators may inhibit hypoxic pulmonary vasoconstriction and impair gas exchange. The efficacy and safety of iloprost inhalation was assessed in 67 patients with PH associated with COPD (COPD-PH), diagnosed by right heart catheterization. Of these, 37 patients had severe PH (mean pulmonary arterial pressure [mPAP] >35 mmHg or mPAP 25-35 mmHg with low cardiac index [<2.0 L⋅min-1⋅m-2]). All patients received a single 20 µg dose of iloprost via a nebulizer (4.4 µg delivered at the mouthpiece). No serious adverse events were reported. Hemodynamic and gas exchange parameters (arterial blood gas and shunt fraction [Qs/Qt]) were measured or calculated at baseline and 10 min after iloprost inhalation. mPAP decreased by 2.1 mmHg (95% CI, -3.3 to -1.0), pulmonary vascular resistance (PVR) decreased by 62.4 dyn⋅s⋅cm-5 (95% CI, -92.9 to -31.8), and cardiac output increased by 0.4 L⋅min-1 (95% CI, 0.2-0.5). There was a more significant decline in PVR in patients with severe COPD-PH than in those with nonsevere COPD-PH. Hypoxemia and intrapulmonary shunt were more extreme in patients with severe COPD-PH. However, there were no significant differences in arterial blood gas and Qs/Qt between patients with nonsevere and severe forms of COPD-PH. In conclusion, iloprost improved pulmonary hemodynamics without detrimental effects on arterial oxygenation in patients with COPD-PH, even in those with severe PH. These findings suggest that the short-term use of iloprost in patients with COPD-PH is effective and well tolerated.
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Affiliation(s)
- Lan Wang
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yuan-Zhe Jin
- Department of Cardiology, The Fourth Affiliated Hospital of China Medical University, Liaoning, China
| | - Qin-Hua Zhao
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Rong Jiang
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wen-Hui Wu
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Su-Gang Gong
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jing He
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jin-Ming Liu
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Zhi-Cheng Jing
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China.,Thrombosis and Vascular Medicine Center, State Key Laboratory of Cardiovascular Disease, FuWai Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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54
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Marashi SM, Nasri-Nasrabadi Z. Is there a role for sildenafil in the management of paraquat-induced lung fibrosis? Arh Hig Rada Toksikol 2017; 67:167-8. [PMID: 27331304 DOI: 10.1515/aiht-2016-67-2804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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Kylhammar D, Rådegran G. The principal pathways involved in the in vivo modulation of hypoxic pulmonary vasoconstriction, pulmonary arterial remodelling and pulmonary hypertension. Acta Physiol (Oxf) 2017; 219:728-756. [PMID: 27381367 DOI: 10.1111/apha.12749] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 06/10/2016] [Accepted: 07/04/2016] [Indexed: 12/13/2022]
Abstract
Hypoxic pulmonary vasoconstriction (HPV) serves to optimize ventilation-perfusion matching in focal hypoxia and thereby enhances pulmonary gas exchange. During global hypoxia, however, HPV induces general pulmonary vasoconstriction, which may lead to pulmonary hypertension (PH), impaired exercise capacity, right-heart failure and pulmonary oedema at high altitude. In chronic hypoxia, generalized HPV together with hypoxic pulmonary arterial remodelling, contribute to the development of PH. The present article reviews the principal pathways in the in vivo modulation of HPV, hypoxic pulmonary arterial remodelling and PH with primary focus on the endothelin-1, nitric oxide, cyclooxygenase and adenine nucleotide pathways. In summary, endothelin-1 and thromboxane A2 may enhance, whereas nitric oxide and prostacyclin may moderate, HPV as well as hypoxic pulmonary arterial remodelling and PH. The production of prostacyclin seems to be coupled primarily to cyclooxygenase-1 in acute hypoxia, but to cyclooxygenase-2 in chronic hypoxia. The potential role of adenine nucleotides in modulating HPV is unclear, but warrants further study. Additional modulators of the pulmonary vascular responses to hypoxia may include angiotensin II, histamine, serotonin/5-hydroxytryptamine, leukotrienes and epoxyeicosatrienoic acids. Drugs targeting these pathways may reduce acute and/or chronic hypoxic PH. Endothelin receptor antagonists and phosphodiesterase-5 inhibitors may additionally improve exercise capacity in hypoxia. Importantly, the modulation of the pulmonary vascular responses to hypoxia varies between species and individuals, with hypoxic duration and age. The review also define how drugs targeting the endothelin-1, nitric oxide, cyclooxygenase and adenine nucleotide pathways may improve pulmonary haemodynamics, but also impair pulmonary gas exchange by interference with HPV in chronic lung diseases.
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Affiliation(s)
- D. Kylhammar
- Department of Clinical Sciences Lund, Cardiology; Faculty of Medicine; Lund University; Lund Sweden
- The Section for Heart Failure and Valvular Disease; VO Heart and Lung Medicine; Skåne University Hospital; Lund Sweden
| | - G. Rådegran
- Department of Clinical Sciences Lund, Cardiology; Faculty of Medicine; Lund University; Lund Sweden
- The Section for Heart Failure and Valvular Disease; VO Heart and Lung Medicine; Skåne University Hospital; Lund Sweden
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56
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Pulmonary Hypertension Associated with Idiopathic Pulmonary Fibrosis: Current and Future Perspectives. Can Respir J 2017; 2017:1430350. [PMID: 28286407 PMCID: PMC5327768 DOI: 10.1155/2017/1430350] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 01/19/2017] [Indexed: 12/12/2022] Open
Abstract
Pulmonary hypertension (PH) is commonly present in patients with chronic lung diseases such as Chronic Obstructive Pulmonary Disease (COPD) or Idiopathic Pulmonary Fibrosis (IPF) where it is classified as Group III PH by the World Health Organization (WHO). PH has been identified to be present in as much as 40% of patients with COPD or IPF and it is considered as one of the principal predictors of mortality in patients with COPD or IPF. However, despite the prevalence and fatal consequences of PH in the setting of chronic lung diseases, there are limited therapies available for patients with Group III PH, with lung transplantation remaining as the most viable option. This highlights our need to enhance our understanding of the molecular mechanisms that lead to the development of Group III PH. In this review we have chosen to focus on the current understating of PH in IPF, we will revisit the main mediators that have been shown to play a role in the development of the disease. We will also discuss the experimental models available to study PH associated with lung fibrosis and address the role of the right ventricle in IPF. Finally we will summarize the current available treatment options for Group III PH outside of lung transplantation.
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57
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Panagiotou M, Church AC, Johnson MK, Peacock AJ. Pulmonary vascular and cardiac impairment in interstitial lung disease. Eur Respir Rev 2017; 26:26/143/160053. [PMID: 28096284 PMCID: PMC9488566 DOI: 10.1183/16000617.0053-2016] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 08/02/2016] [Indexed: 12/19/2022] Open
Abstract
Pulmonary vascular and cardiac impairment is increasingly appreciated as a major adverse factor in the natural history of interstitial lung disease. This clinically orientated review focuses on the current concepts in the pathogenesis, pathophysiology and implications of the detrimental sequence of increased pulmonary vascular resistance, pre-capillary pulmonary hypertension and right heart failure in interstitial lung disease, and provides guidance on its management. Development of pulmonary hypertension is a major adverse factor in the natural history of interstitial lung diseasehttp://ow.ly/nJB0302XAmD
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Affiliation(s)
- Marios Panagiotou
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
| | - Alistair C Church
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
| | - Martin K Johnson
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
| | - Andrew J Peacock
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
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58
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Abstract
Perioperative management of severe pulmonary hypertension (PH) is challenging. Anaesthesiologists come across perioperative management of such cases during incidental surgeries, surgery for various congenital heart diseases and valvular heart diseases and for caesarean section or painless labour in pregnant patient with Eisenmenger syndrome. Knowledge of pathophysiology of PH and novel drugs acting through different mechanisms is paramount in managing such patients. This review will help understanding pathophysiology of PH, anaesthetising patients with PH, use of novel drugs for PH and use of new mechanical devices for rescue of failing right ventricle.
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Affiliation(s)
- Ajay Kumar
- Department of Anaesthesiology, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Praveen Kumar Neema
- Department of Anaesthesiology, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
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59
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King CS, Nathan SD. Idiopathic pulmonary fibrosis: effects and optimal management of comorbidities. THE LANCET RESPIRATORY MEDICINE 2017; 5:72-84. [DOI: 10.1016/s2213-2600(16)30222-3] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 07/07/2016] [Accepted: 07/15/2016] [Indexed: 12/30/2022]
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60
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Shlobin OA, Brown AW, Nathan SD. Pulmonary Hypertension in Diffuse Parenchymal Lung Diseases. Chest 2016; 151:204-214. [PMID: 27554299 DOI: 10.1016/j.chest.2016.08.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 07/29/2016] [Accepted: 08/05/2016] [Indexed: 10/21/2022] Open
Abstract
Pulmonary hypertension (PH) can be triggered by any number of disease processes that result in increased pulmonary vascular resistance. Although historically associated with idiopathic pulmonary arterial hypertension (PAH), most patients with PH do not have the idiopathic subtype, but rather PH associated with another underlying diagnosis, such as left heart or lung disease. The World Health Organization (WHO) classification of PH helps conceptualize the different categories based on presumed etiology. WHO group 3 is PH associated with lung disease. This review focuses on PH in diffuse parenchymal lung diseases (DPLDs), such as the idiopathic interstitial pneumonias and other more rare forms of DPLD. Although there are clear associations of PH with DPLD, the exact pathophysiologic mechanisms and full clinical significance remain uncertain. Treatment of PH related to DPLD remains investigational, but an area of great interest given the negative prognostic implications and the growing number of available pulmonary vasoactive agents.
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Affiliation(s)
- Oksana A Shlobin
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular Institute, Inova Fairfax Hospital, Falls Church, VA.
| | - A Whitney Brown
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular Institute, Inova Fairfax Hospital, Falls Church, VA
| | - Steven D Nathan
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular Institute, Inova Fairfax Hospital, Falls Church, VA
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61
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Richter MJ, Gall H, Grimminger J, Grimminger F, Ghofrani HA. Selexipag for the treatment of pulmonary arterial hypertension. Expert Opin Pharmacother 2016; 17:1825-34. [DOI: 10.1080/14656566.2016.1215429] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Manuel Jonas Richter
- Department of Internal Medicine, University of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany, member of the German Center of Lung Research (DZL)
- Department of Pneumology, Kerckhoff Heart and Thoracic Center, Bad Nauheim, Germany
| | - Henning Gall
- Department of Internal Medicine, University of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany, member of the German Center of Lung Research (DZL)
| | - Jan Grimminger
- Department of Internal Medicine, University of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany, member of the German Center of Lung Research (DZL)
- Center for Pulmonary Hypertension, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Friedrich Grimminger
- Department of Internal Medicine, University of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany, member of the German Center of Lung Research (DZL)
| | - Hossein-Ardeschir Ghofrani
- Department of Internal Medicine, University of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany, member of the German Center of Lung Research (DZL)
- Department of Pneumology, Kerckhoff Heart and Thoracic Center, Bad Nauheim, Germany
- Department of Medicine, Imperial College London, London, UK
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62
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Parikh KS, Rajagopal S, Fortin T, Tapson VF, Poms AD. Safety and Tolerability of High-dose Inhaled Treprostinil in Pulmonary Hypertension. J Cardiovasc Pharmacol 2016; 67:322-5. [PMID: 26828324 PMCID: PMC4824653 DOI: 10.1097/fjc.0000000000000357] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Pulmonary arterial hypertension (PAH) has emerging therapeutic options including prostacyclin analogs. Inhaled therapy offers advantages compared with alternative routes of administration. We aimed to determine the safety and tolerability of inhaled treprostinil (iTRE) titrated to target maintenance dose higher than the labeled dose for PAH. Our study included 80 consecutive patients (69% female, 70% White) followed at the Duke University Medical Center prescribed iTRE at dose >9 breaths (54 μg). Etiology of pulmonary hypertension was most frequently PAH (51%) or secondary to lung disease (35%). Median follow-up was 20.3 months (interquartile range 14.2-33.2). Most patients (91%) had titrated iTRE dose to 12 breaths (72 μg) four times daily. Common side effects reported with drug initiation were cough (41%), headache (28%), and throat irritation (8%); most of the side effects improved at follow-up. Overall, 25% patients discontinued iTRE: 9 transitioned to parenteral therapy, 4 had untolerable side effects, 3 died, and 4 had other reasons. Overall, iTRE taken at a higher dose than approved for use in PAH was safe and well-tolerated in our cohort of pulmonary hypertension patients.
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Affiliation(s)
- Kishan S. Parikh
- Department of Medicine, Duke University Medical Center, Durham, USA
| | | | - Terry Fortin
- Department of Medicine, Duke University Medical Center, Durham, USA
| | - Victor F. Tapson
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Abby D. Poms
- Department of Medicine, Duke University Medical Center, Durham, USA
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63
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Bryant AJ, Scott EW. "A small leak will sink a great ship": hypoxia-inducible factor and group III pulmonary hypertension. ACTA ACUST UNITED AC 2016; 3. [PMID: 27446973 PMCID: PMC4950984 DOI: 10.14800/rci.1213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Pulmonary hypertension complicating idiopathic pulmonary fibrosis, also known as secondary pulmonary hypertension, represents a major source of morbidity and mortality in affected patients. While the study of primary pulmonary arterial hypertension has yielded several therapies, the same is not true for the treatment of pulmonary hypertension secondary to pulmonary fibrosis. Recent studies have indicated an important role of hypoxia-inducible factor (HIF) - a regulatory protein that is vital in adaptation to hypoxic conditions - in the development of secondary pulmonary hypertension. HIF influences development of hypoxia-induced pulmonary hypertension through alteration in voltage-gated potassium channels and homeostatic calcium regulation, resulting in disruption of endothelial cell-cell communication, and eventual vascular remodeling. This article summarizes salient literature related to HIF and secondary pulmonary hypertension, in addition to proposing a final common pathway in known mechanistic pathways that result in endothelial barrier integrity loss - vascular "leak" - primarily through a shared endothelial-epithelial signaling protein family, CCN.
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Affiliation(s)
- Andrew J Bryant
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida College of Medicine, Gainesville, FL 32610-0225, USA
| | - Edward W Scott
- Department of Molecular Genetics & Microbiology, University of Florida College of Medicine, Gainesville, FL 32610-0225, USA
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64
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Rowan SC, Keane MP, Gaine S, McLoughlin P. Hypoxic pulmonary hypertension in chronic lung diseases: novel vasoconstrictor pathways. THE LANCET RESPIRATORY MEDICINE 2016; 4:225-36. [PMID: 26895650 DOI: 10.1016/s2213-2600(15)00517-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 12/03/2015] [Accepted: 12/07/2015] [Indexed: 11/29/2022]
Abstract
Pulmonary hypertension is a well recognised complication of chronic hypoxic lung diseases, which are among the most common causes of death and disability worldwide. Development of pulmonary hypertension independently predicts reduced life expectancy. In chronic obstructive pulmonary disease, long-term oxygen therapy ameliorates pulmonary hypertension and greatly improves survival, although the correction of alveolar hypoxia and pulmonary hypertension is only partial. Advances in understanding of the regulation of vascular smooth muscle tone show that chronic vasoconstriction plays a more important part in the pathogenesis of hypoxic pulmonary hypertension than previously thought, and that structural vascular changes contribute less. Trials of existing vasodilators show that pulmonary hypertension can be ameliorated and systemic oxygen delivery improved in carefully selected patients, although systemic hypotensive effects limit the doses used. Vasoconstrictor pathways that are selective for the pulmonary circulation can be blocked to reduce hypoxic pulmonary hypertension without causing systemic hypotension, and thus provide potential targets for novel therapeutic strategies.
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Affiliation(s)
- Simon C Rowan
- UCD School of Medicine, Conway Institute, Dublin, Ireland
| | - Michael P Keane
- UCD School of Medicine, Respiratory Medicine, St Vincent's University Hospital, Dublin, Ireland
| | - Seán Gaine
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
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65
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Bryant AJ, Carrick RP, McConaha ME, Jones BR, Shay SD, Moore CS, Blackwell TR, Gladson S, Penner NL, Burman A, Tanjore H, Hemnes AR, Karwandyar AK, Polosukhin VV, Talati MA, Dong HJ, Gleaves LA, Carrier EJ, Gaskill C, Scott EW, Majka SM, Fessel JP, Haase VH, West JD, Blackwell TS, Lawson WE. Endothelial HIF signaling regulates pulmonary fibrosis-associated pulmonary hypertension. Am J Physiol Lung Cell Mol Physiol 2015; 310:L249-62. [PMID: 26637636 DOI: 10.1152/ajplung.00258.2015] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 12/01/2015] [Indexed: 01/12/2023] Open
Abstract
Pulmonary hypertension (PH) complicating chronic parenchymal lung disease, such as idiopathic pulmonary fibrosis, results in significant morbidity and mortality. Since the hypoxia-inducible factor (HIF) signaling pathway is important for development of pulmonary hypertension in chronic hypoxia, we investigated whether HIF signaling in vascular endothelium regulates development of PH related to pulmonary fibrosis. We generated a transgenic model in which HIF is deleted within vascular endothelial cells and then exposed these mice to chronic intraperitoneal bleomycin to induce PH associated with lung fibrosis. Although no differences in the degree of fibrotic remodeling were observed, we found that endothelial HIF-deficient mice were protected against development of PH, including right ventricle and pulmonary vessel remodeling. Similarly, endothelial HIF-deficient mice were protected from PH after a 4-wk exposure to normobaric hypoxia. In vitro studies of pulmonary vascular endothelial cells isolated from the HIF-targeted mice and controls revealed that endothelial HIF signaling increases endothelial cell expression of connective tissue growth factor, enhances vascular permeability, and promotes pulmonary artery smooth muscle cell proliferation and wound healing ability, all of which have the potential to impact the development of PH in vivo. Taken together, these studies demonstrate that vascular endothelial cell HIF signaling is necessary for development of hypoxia and pulmonary fibrosis associated PH. As such, HIF and HIF-regulated targets represent a therapeutic target in these conditions.
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Affiliation(s)
- Andrew J Bryant
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida College of Medicine, Gainesville, Florida
| | - Ryan P Carrick
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Melinda E McConaha
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Brittany R Jones
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Sheila D Shay
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Christy S Moore
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Thomas R Blackwell
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Santhi Gladson
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Niki L Penner
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Ankita Burman
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Harikrishna Tanjore
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Anna R Hemnes
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Ayub K Karwandyar
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Vasiliy V Polosukhin
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Megha A Talati
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Hui-Jia Dong
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida College of Medicine, Gainesville, Florida
| | - Linda A Gleaves
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Erica J Carrier
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Christa Gaskill
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Edward W Scott
- Department of Molecular Genetics & Microbiology, University of Florida College of Medicine, Gainesville, Florida; and
| | - Susan M Majka
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Joshua P Fessel
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Volker H Haase
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - James D West
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Timothy S Blackwell
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee; Department of Cell and Developmental Biology, Vanderbilt University School of Medicine, Nashville, Tennessee; Department of Cancer Biology, Vanderbilt University School of Medicine, Nashville, Tennessee; and Department of Veterans Affairs Medical Center, Nashville, Tennessee; and
| | - William E Lawson
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee; Department of Veterans Affairs Medical Center, Nashville, Tennessee; and
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66
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Liu QQ, Jing ZC. The limits of oral therapy in pulmonary arterial hypertension management. Ther Clin Risk Manag 2015; 11:1731-41. [PMID: 26648729 PMCID: PMC4664513 DOI: 10.2147/tcrm.s49026] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a devastating disease in which remodeling of the small pulmonary arteries leads to a progressive increase in pulmonary vascular resistance and right-sided heart failure. Over the past decade, new treatments for PAH, such as the use of ERAs, PDE-5 inhibitors and prostacyclin analogs, have brought about dramatic improvements in clinical outcomes. Epoprostenol infusion therapy has been shown to improve hemodynamics, functional status, and survival, and it remains the gold standard for treatment of patients with severe PAH. Many agents, approved for PAH are always delivered in pill form. Although oral therapy occupies an important position, it has some drawbacks and limitations in PAH management. For patients in World Health Organization functional class IV and with severe right heart failure, there are few data on the long-term survival of patients treated with oral medications. Further research, exploration, and clinical experience with oral therapy in severe PAH and combination therapy will redefine its position in PAH management.
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Affiliation(s)
- Qian-Qian Liu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China ; Department of Echocardiography, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Zhi-Cheng Jing
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China ; State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
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Raghu G, Rochwerg B, Zhang Y, Garcia CAC, Azuma A, Behr J, Brozek JL, Collard HR, Cunningham W, Homma S, Johkoh T, Martinez FJ, Myers J, Protzko SL, Richeldi L, Rind D, Selman M, Theodore A, Wells AU, Hoogsteden H, Schünemann HJ. An Official ATS/ERS/JRS/ALAT Clinical Practice Guideline: Treatment of Idiopathic Pulmonary Fibrosis. An Update of the 2011 Clinical Practice Guideline. Am J Respir Crit Care Med 2015; 192:e3-19. [DOI: 10.1164/rccm.201506-1063st] [Citation(s) in RCA: 1242] [Impact Index Per Article: 138.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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Lange TJ, Baron M, Seiler I, Arzt M, Pfeifer M. Outcome of patients with severe PH due to lung disease with and without targeted therapy. Cardiovasc Ther 2015; 32:202-8. [PMID: 24909193 DOI: 10.1111/1755-5922.12084] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Pulmonary hypertension (PH) can occur in patients with lung disease and worsen prognosis. Endothelin receptor antagonists, phosphodiesterase 5-inhibitors, and prostacyclin analogs, referred to as targeted therapy, have not been shown in a limited number of controlled clinical studies to improve exercise capacity in these patients. Possibly targeted therapy could be of benefit in patients with severe PH due to lung disease, but this subgroup is not well studied. AIMS To analyze influence of PH severity and use of targeted therapy on exercise capacity and survival in patients with PH due to lung disease. METHODS Consecutive patients with PH (mean pulmonary artery pressure ≥25 mmHg at rest) due to lung disease diagnosed by right heart catheterization between 1/2005 and 9/2011 were retrospectively included. Severe PH was defined as mean pulmonary artery pressure ≥35 mmHg. Patients were followed until 4/2012 for exercise capacity, survival, and targeted therapy use. RESULTS Patients with severe PH (n = 40) received significantly more often targeted therapy compared to the 32 patients with less severe PH (65% vs. 25%, P = 0.001). Survival was not significantly different between these groups (P = 0.310). Patients on targeted therapy were older, more often female, and had worse hemodynamic impairment, but significantly higher estimated 1-, 3-, and 5-year survival rates compared to untreated patients (97%, 81%, and 75% vs. 83%, 54%, and 19%, respectively; P = 0.002). This effect was mainly driven by the patients with severe PH, in whom the survival advantage was statistically significant on subgroup analysis (HR 0.182, P = 0.002). Exercise capacity was not significantly altered in any patient group. CONCLUSION Patients with severe PH due to lung disease may have a survival benefit from targeted therapy compared to untreated patients with less severe PH. Prospective clinical trials utilizing targeted therapy and long-term endpoints are justified in this patient group.
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Affiliation(s)
- Tobias J Lange
- Department of Internal Medicine II, Division of Pneumology, University Medical Center Regensburg, Regensburg, Germany
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Richter MJ, Ghofrani HA, Voswinckel R, Seeger W, Schulz R, Reichenberger F, Gall H. Acute hemodynamic effects of nebulized iloprost via the I-neb Adaptive Aerosol Delivery system in pulmonary hypertension. Pulm Circ 2015; 5:162-70. [PMID: 25992279 DOI: 10.1086/679722] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 09/09/2014] [Indexed: 01/19/2023] Open
Abstract
Inhaled iloprost has proven to be an effective therapy in patients with pulmonary hypertension (PH). However, the acute hemodynamic effect of nebulized iloprost delivered via the I-neb Adaptive Aerosol Delivery (AAD) system remains unclear and needs to be assessed. In this study, 126 patients with PH were classified according to current guidelines (59, 34, 29, and 4 patients in groups 1/1', 3, 4, and 5, respectively; 20 patients had idiopathic pulmonary arterial hypertension [iPAH]), were randomly assigned to inhale iloprost 2.5 [Formula: see text]g (n = 67) or 5.0 [Formula: see text]g (n = 59) via the I-neb AAD system, and were assessed by right heart catheterization. In seven patients with iPAH, iloprost plasma levels were measured. The two iloprost doses caused decreases from baseline in pulmonary vascular resistance (PVR; 2.5 [Formula: see text]g: -14.7%; 5.0 [Formula: see text]g: -15.6%) and mean pulmonary arterial pressure (mPAP; 2.5 [Formula: see text]g: -11.0%; 5.0 [Formula: see text]g: -10.1%) while cardiac index (CI) increased (2.5 [Formula: see text]g: +6.5%; 5.0 [Formula: see text]g: +6.4%). The subset with iPAH also showed decreases from baseline in PVR and mPAP and an increase in CI. Peak iloprost plasma levels showed no significant difference after inhalation of 2.5 [Formula: see text]g or 5.0 [Formula: see text]g iloprost (95.5 pg/mL vs. 73.0 pg/mL; P = 0.06). In summary, nebulized iloprost delivered via the I-neb AAD system reduced mPAP and PVR and increased CI from baseline in a heterogeneous group of patients with PH and in the subset with iPAH. In patients with iPAH, inhalation of 2.5 [Formula: see text]g or 5.0 [Formula: see text]g iloprost resulted in broadly similar peak iloprost plasma levels.
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Affiliation(s)
- Manuel J Richter
- Department of Pneumology, Kerckhoff Heart and Thoracic Center, Bad Nauheim, Germany ; Department of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center, Germany, and German Center for Lung Research
| | - Hossein A Ghofrani
- Department of Pneumology, Kerckhoff Heart and Thoracic Center, Bad Nauheim, Germany ; Department of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center, Germany, and German Center for Lung Research
| | - Robert Voswinckel
- Department of Pneumology, Kerckhoff Heart and Thoracic Center, Bad Nauheim, Germany ; Department of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center, Germany, and German Center for Lung Research ; Department of Lung Development and Remodeling, Max Planck Institute for Heart and Lung Research, Bad Nauheim, Germany
| | - Werner Seeger
- Department of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center, Germany, and German Center for Lung Research ; Department of Lung Development and Remodeling, Max Planck Institute for Heart and Lung Research, Bad Nauheim, Germany
| | - Richard Schulz
- Department of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center, Germany, and German Center for Lung Research
| | - Frank Reichenberger
- Department of Pneumology, Asklepios Hospital, Munich-Gauting, Germany, and German Center for Lung Research
| | - Henning Gall
- Department of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center, Germany, and German Center for Lung Research
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Chen X, Tang S, Liu K, Li Q, Kong H, Zeng X, Xie W, Wang H. Therapy in stable chronic obstructive pulmonary disease patients with pulmonary hypertension: a systematic review and meta-analysis. J Thorac Dis 2015; 7:309-19. [PMID: 25922708 DOI: 10.3978/j.issn.2072-1439.2015.02.08] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2014] [Accepted: 12/25/2014] [Indexed: 12/25/2022]
Abstract
Pulmonary hypertension (PH) is a common complication of chronic obstructive pulmonary disease (COPD) without effective drugs to treat. We conducted a systematic review and meta-analysis in order to evaluate whether PH specific therapies were effective for stable COPD patients. Data were extracted from PubMed, Cochrane Central Register of Controlled Trials and China Knowledge Resource Integrated Database. Randomized controlled trials (RCTs) with PH specific therapy treated more than 4 weeks in COPD were selected. The main outcome was exercise capacity; meanwhile pulmonary arterial pressure (PAP), hypoxemia and health related life quality were also measured. We included nine trials involving 365 subjects, among which two were treated with bosentan and seven with sildenafil. The study time varied from 4 weeks to 18 months and mostly it was 12 weeks. In a pooled analysis of nine trials, exercise capacity of COPD patients was improved by PH-specific therapy [mean difference (MD) 66.39 m, 95% confidence intervals (CI): 59.44-73.34]. COPD with severe PH (mean PAP >35 mmHg by right heart catheterization or systolic PAP >50 mmHg by echocardiography) improved the exercise capacity (MD 67.24 m, 95% CI: 60.26-74.23), but COPD without PH at rest did not (MD -9.24 m, 95% CI: -75.08 to 56.31). Meanwhile PAP was decreased (MD -9.02 mmHg, 95% CI: -10.71 to -7.34 mmHg). Although hypoxemia and life quality were not improved, the dyspnea was alleviated or at least not aggravated (Borg dyspnea index, MD -0.86, 95% CI: -1.86 to 0.14). In conclusion, PH specific drugs (especially sildenafil) could improve exercise capacity and decrease PAP in COPD patients with severe PH.
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Affiliation(s)
- Xuesong Chen
- 1 Department of Respiratory, First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China ; 2 Department of Epidemiology & Biostatistics, School of Public Health, Nanjing Medical University, Nanjing 210029, China ; 3 Department of Respiratory, Xuzhou No. 1 Hospital, Xuzhou 221002, China
| | - Shaowen Tang
- 1 Department of Respiratory, First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China ; 2 Department of Epidemiology & Biostatistics, School of Public Health, Nanjing Medical University, Nanjing 210029, China ; 3 Department of Respiratory, Xuzhou No. 1 Hospital, Xuzhou 221002, China
| | - Kouying Liu
- 1 Department of Respiratory, First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China ; 2 Department of Epidemiology & Biostatistics, School of Public Health, Nanjing Medical University, Nanjing 210029, China ; 3 Department of Respiratory, Xuzhou No. 1 Hospital, Xuzhou 221002, China
| | - Qinling Li
- 1 Department of Respiratory, First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China ; 2 Department of Epidemiology & Biostatistics, School of Public Health, Nanjing Medical University, Nanjing 210029, China ; 3 Department of Respiratory, Xuzhou No. 1 Hospital, Xuzhou 221002, China
| | - Hui Kong
- 1 Department of Respiratory, First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China ; 2 Department of Epidemiology & Biostatistics, School of Public Health, Nanjing Medical University, Nanjing 210029, China ; 3 Department of Respiratory, Xuzhou No. 1 Hospital, Xuzhou 221002, China
| | - Xiaoning Zeng
- 1 Department of Respiratory, First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China ; 2 Department of Epidemiology & Biostatistics, School of Public Health, Nanjing Medical University, Nanjing 210029, China ; 3 Department of Respiratory, Xuzhou No. 1 Hospital, Xuzhou 221002, China
| | - Weiping Xie
- 1 Department of Respiratory, First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China ; 2 Department of Epidemiology & Biostatistics, School of Public Health, Nanjing Medical University, Nanjing 210029, China ; 3 Department of Respiratory, Xuzhou No. 1 Hospital, Xuzhou 221002, China
| | - Hong Wang
- 1 Department of Respiratory, First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China ; 2 Department of Epidemiology & Biostatistics, School of Public Health, Nanjing Medical University, Nanjing 210029, China ; 3 Department of Respiratory, Xuzhou No. 1 Hospital, Xuzhou 221002, China
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Elphick M, von Hollen D, Pritchard JN, Nikander K, Hardaker LEA, Hatley RHM. Factors to consider when selecting a nebulizer for a new inhaled drug product development program. Expert Opin Drug Deliv 2015; 12:1375-87. [DOI: 10.1517/17425247.2015.1014339] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
A thorough, often multidisciplinary assessment to determine extrathoracic versus intrathoracic disease activity and degrees of impairment is needed to optimize the management of connective tissue disease (CTD)-associated interstitial lung disease (ILD). Pharmacologic intervention with immunosuppression is the mainstay of therapy for all forms of CTD-ILD, but should be reserved for those that show clinically significant and/or progressive disease. The management of CTD-ILD is not yet evidence based and there is a need for controlled trials across the spectrum of CTD-ILD. Nonpharmacologic management strategies and addressing comorbidities or aggravating factors should be included in the comprehensive treatment plan for CTD-ILD.
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74
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Fallah F. Recent strategies in treatment of pulmonary arterial hypertension, a review. Glob J Health Sci 2015; 7:307-22. [PMID: 25946920 PMCID: PMC4802183 DOI: 10.5539/gjhs.v7n4p307] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 01/06/2015] [Accepted: 10/26/2014] [Indexed: 01/21/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a disease characterized by an elevation in pulmonary artery pressure that can lead to right ventricular failure and death. The pulmonary circulation has to accommodate the entire cardiac output in each cardiac cycle and evolution has adapted to this by making it a low-pressure high-flow system. However, pathology can affect both the arterial and venous components of this system. Pulmonary venous hypertension mainly refers to diseases that result in elevated venous pressure and occurs mainly from mitral valve and left-sided heart disease. Standard treatment options include oral anticoagulation, diuretics, oxygen supplementation, and for a small percentage of patients, calcium channel blockers. Newer treatments include prostacyclin analogues, endothelin receptor antagonists, and phosphodiesterase type 5 inhibitors. This article reviews the current treatments strategies for PAH and provides guidelines for its management.
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Affiliation(s)
- Flora Fallah
- Assistant Professor of Cardiology, Shahid Sadoughi University of Medical Sciences & Health Services, Yazd, Iran..
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76
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[Pulmonary hypertension in chronic respiratory diseases]. Presse Med 2014; 43:945-56. [PMID: 25123317 DOI: 10.1016/j.lpm.2014.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 07/09/2014] [Indexed: 11/23/2022] Open
Abstract
Pulmonary hypertension is frequent in advanced chronic respiratory diseases, with an estimated prevalence at the time of pulmonary transplantation of 30-50 % in idiopathic pulmonary fibrosis, 30-50 % in chronic obstructive pulmonary disease, 50 % in combined pulmonary fibrosis and emphysema, 75 % in sarcoidosis, and more than 75 % of cases in pulmonary Langerhans cell histiocytosis. Histologic features include varying degrees of pulmonary arterial remodeling (prominent), vascular rarefaction (emphysema), fibrosis or specific involvement of the pulmonary arteries (idiopathic pulmonary fibrosis, sarcoidosis, lymphangioleiomyomatosis, pulmonary Langerhans cell histiocytosis), in situ thrombosis, and frequently associated involvement of the pulmonary veins (idiopathic pulmonary fibrosis, sarcoidosis). Pulmonary hypertension is usually detected using echocardiography with Doppler, however right heart catheterisation is required to confirm precapillary pulmonary hypertension defined by pulmonary artery pressure ≥ 25 mm Hg, with pulmonary artery wedge pressure ≤ 15 mm Hg. When present, it is associated with decreased exercise capacity and worse mortality. Pulmonary hypertension in chronic respiratory disease is almost invariably multifactorial; hypoxia is one of its main determinants, however supplemental oxygen therapy rarely reverses pulmonary hypertension. Management of pulmonary hypertension in chronic respiratory disease is mostly based on the optimal treatment of the underlying disease. Available data do not support the use of drug therapies specific for pulmonary hypertension in the setting of chronic respiratory diseases, however very few clinical studies have been conducted so far specifically in this context.
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Shino MY, Lynch Iii JP, Fishbein MC, McGraw C, Oyama J, Belperio JA, Saggar R. Sarcoidosis-associated pulmonary hypertension and lung transplantation for sarcoidosis. Semin Respir Crit Care Med 2014; 35:362-71. [PMID: 25007088 DOI: 10.1055/s-0034-1376863] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Pulmonary hypertension (PH) is a significant complication of sarcoidosis, occurring in approximately 6 to > 20% of cases, and markedly increases mortality among these patients. The clinician should exercise a high index of suspicion for sarcoidosis-associated PH (SAPH) given the nonspecific symptomatology and the limitations of echocardiography in this patient population. The pathophysiology of PH in sarcoidosis is complex and multifactorial. Importantly, there are inherent differences in the pathogenesis of SAPH compared with idiopathic pulmonary arterial hypertension, making the optimal management of SAPH controversial. In this article, we review the epidemiology, diagnosis, prognosis, and treatment considerations for SAPH. Lung transplantation (LT) is a viable therapeutic option for sarcoid patients with severe pulmonary fibrocystic sarcoidosis or SAPH refractory to medical therapy. We discuss the role for LT in patients with sarcoidosis, review the global experience with LT in this population, and discuss indications and contraindications to LT.
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Affiliation(s)
- Michael Y Shino
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Joseph P Lynch Iii
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Michael C Fishbein
- Department of Pathology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Charles McGraw
- Department of Radiological Sciences, UCLA Medical Center, Los Angeles, California
| | - Jared Oyama
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - John A Belperio
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Rajan Saggar
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
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Abstract
PURPOSE OF REVIEW This review discusses the current impact of pulmonary hypertension on the outcome and treatment of cystic fibrosis (CF). RECENT FINDINGS Pulmonary hypertension is commonly encountered in advanced lung diseases such as CF. The prevalence of pulmonary hypertension in CF patients varies based on disease severity and methodology used for diagnosis. Chronic alveolar hypoxia is the most likely cause. The majority of recent studies have shown worse survival in CF patients who develop pulmonary hypertension. The impact of pulmonary hypertension-specific therapies on symptomatology and outcomes in CF patients has not been well studied. SUMMARY Pulmonary hypertension is common in patients with CF and it occurs largely because of hypoxemia. The presence of pulmonary hypertension in patients with CF is likely associated with worse outcome; however, it remains unknown whether treatment with pulmonary hypertension-specific therapies would be beneficial.
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Groves DS, Blum FE, Huffmyer JL, Kennedy JL, Ahmad HB, Durieux ME, Kern JA. Effects of Early Inhaled Epoprostenol Therapy on Pulmonary Artery Pressure and Blood Loss During LVAD Placement. J Cardiothorac Vasc Anesth 2014; 28:652-60. [DOI: 10.1053/j.jvca.2013.05.028] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Indexed: 11/11/2022]
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Saggar R, Khanna D, Vaidya A, Derhovanessian A, Maranian P, Duffy E, Belperio JA, Weigt SS, Dua S, Shapiro SS, Goldin JG, Abtin F, Lynch JP, Ross DJ, Forfia PR, Saggar R. Changes in right heart haemodynamics and echocardiographic function in an advanced phenotype of pulmonary hypertension and right heart dysfunction associated with pulmonary fibrosis. Thorax 2014; 69:123-9. [PMID: 24431095 DOI: 10.1136/thoraxjnl-2013-204150] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Pulmonary hypertension (PH)-targeted therapy in the setting of pulmonary fibrosis (PF) is controversial; the main clinical concern is worsening of systemic hypoxaemia. We sought to determine the effects of gentle initiation and chronic administration of parenteral treprostinil on right heart function in patients with PF associated with an advanced PH phenotype. METHODS Open-label, prospective analysis of patients with PF-PH referred for lung transplantation (LT). Advanced PH was defined as mean pulmonary artery pressure (mPAP) ≥35 mm Hg. We compared haemodynamics, Doppler echocardiography (DE), oxygenation, dyspnoea and quality of life indices, and 6 min walk distance (6MWD) before and 12 weeks after parenteral treprostinil. RESULTS 15 patients were recruited in the study. After therapy, there were significant improvements in right heart haemodynamics (right atrial pressure (9.5 ± 3.4 vs 6.0 ± 3.7); mPAP (47 ± 8 vs 38.9 ± 13.4); CI (2.3 ± 0.5 vs 2.7 ± 0.6); pulmonary vascular resistance (698 ± 278 vs 496 ± 229); transpulmonary gradient (34.7 ± 8.7 vs 28.5 ± 10.3); mvO2 (65 ± 7.2 vs 70.9 ± 7.4); and stroke volume index (29.2 ± 6.7 vs 33 ± 7.3)) and DE parameters reflecting right heart function (right ventricular (RV) end diastolic area (36.4 ± 5.2 vs 30.9 ± 8.2 cm(2)), left ventricular eccentricity index (1.7 ± 0.6 vs 1.3 ± 0.5), tricuspid annular planar systolic excursion (1.6 ± 0.5 vs 1.9 ± 0.2 cm)). These changes occurred without significant alteration in systemic oxygenation, heart rate, or mean systemic arterial pressure. In addition, improvements were seen in 6MWD (171 ± 93 vs 230 ± 114), 36-Item Short Form Health Survey Mental Component Summary aggregate (38 ± 11 vs 44.2 ± 10.7), University of California, San Diego Shortness of Breath Questionnaire (87 ± 17.1 vs 73.1 ± 21), and brain natriuretic peptide (558 ± 859 vs 228 ± 340). CONCLUSIONS PH-targeted therapy may improve right heart haemodynamics and echocardiographic function without affecting systemic oxygen saturation in an advanced PH phenotype associated with RV dysfunction in the setting of PF.
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Affiliation(s)
- Rajeev Saggar
- Thoracic Transplantation, Heart-Lung Institute, St Joseph Hospital & Medical Center, , Phoenix, Arizona, USA
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81
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Abstract
Chronic obstructive lung disease (COPD) and diffuse parenchymal lung diseases (DPLD), including idiopathic pulmonary fibrosis (IPF) and sarcoidosis, are associated with a high incidence of pulmonary hypertension (PH), which is linked with exercise limitation and a worse prognosis. Patients with combined pulmonary fibrosis and emphysema (CPFE) are particularly prone to the development of PH. Echocardiography and right heart catheterization are the principal modalities for the diagnosis of COPD and DPLD. For discrimination between group 1 PH patients with concomitant respiratory abnormalities and group 3 PH patients (PH caused by lung disease), patients should be transferred to a center with expertise in both PH and lung diseases for comprehensive evaluation. The task force encompassing the authors of this article provided criteria for this discrimination and suggested using the following definitions for group 3 patients, as exemplified for COPD, IPF, and CPFE: COPD/IPF/CPFE without PH (mean pulmonary artery pressure [mPAP] <25 mm Hg); COPD/IPF/CPFE with PH (mPAP ≥25 mm Hg); PH-COPD, PH-IPF, and PH-CPFE); COPD/IPF/CPFE with severe PH (mPAP ≥35 mm Hg or mPAP ≥25 mm Hg with low cardiac index [CI <2.0 l/min/m(2)]; severe PH-COPD, severe PH-IPF, and severe PH-CPFE). The "severe PH group" includes only a minority of chronic lung disease patients who are suspected of having strong general vascular abnormalities (remodeling) accompanying the parenchymal disease and with evidence of an exhausted circulatory reserve rather than an exhausted ventilatory reserve underlying the limitation of exercise capacity. Exertional dyspnea disproportionate to pulmonary function tests, low carbon monoxide diffusion capacity, and rapid decline of arterial oxygenation upon exercise are typical clinical features of this subgroup with poor prognosis. Studies evaluating the effect of pulmonary arterial hypertension drugs currently not approved for group 3 PH patients should focus on this severe PH group, and for the time being, these patients should be transferred to expert centers for individualized patient care.
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Sumida H, Asano Y, Hatano M, Aozasa N, Toyama T, Akamata K, Miyazaki M, Taniguchi T, Takahashi T, Ichimura Y, Noda S, Kuwano Y, Yanaba K, Sato S. Effect of ambrisentan on peripheral circulation in patients with systemic sclerosis. Mod Rheumatol 2014; 26:454-7. [PMID: 24593173 DOI: 10.3109/14397595.2014.885377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Systemic sclerosis (SSc) is characterized by disturbed blood circulation. The effect of ambrisentan, an endothelin-A receptor-selective antagonist, on impaired peripheral circulation in SSc remains largely elusive. Here we show SSc patients, whose clinical symptoms such as cyanosis and Raynaud's phenomenon, were ameliorated by the treatment with ambrisentan. Additionally, objective evaluations with thermography showed improvement of hand coldness in steady-state and cold challenge tests. Ambrisentan might have a potential to improve peripheral circulation in SSc.
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Affiliation(s)
- Hayakazu Sumida
- a Department of Dermatology , Faculty of Medicine, The University of Tokyo , Tokyo , Japan
| | - Yoshihide Asano
- a Department of Dermatology , Faculty of Medicine, The University of Tokyo , Tokyo , Japan
| | - Masaru Hatano
- b Department of Cardiovascular Medicine , Graduate School of Medicine, The University of Tokyo , Tokyo , Japan
| | - Naohiko Aozasa
- a Department of Dermatology , Faculty of Medicine, The University of Tokyo , Tokyo , Japan
| | - Tetsuo Toyama
- a Department of Dermatology , Faculty of Medicine, The University of Tokyo , Tokyo , Japan
| | - Kaname Akamata
- a Department of Dermatology , Faculty of Medicine, The University of Tokyo , Tokyo , Japan
| | - Miki Miyazaki
- a Department of Dermatology , Faculty of Medicine, The University of Tokyo , Tokyo , Japan
| | - Takashi Taniguchi
- a Department of Dermatology , Faculty of Medicine, The University of Tokyo , Tokyo , Japan
| | - Takehiro Takahashi
- a Department of Dermatology , Faculty of Medicine, The University of Tokyo , Tokyo , Japan
| | - Yohei Ichimura
- a Department of Dermatology , Faculty of Medicine, The University of Tokyo , Tokyo , Japan
| | - Shinji Noda
- a Department of Dermatology , Faculty of Medicine, The University of Tokyo , Tokyo , Japan
| | - Yoshihiro Kuwano
- a Department of Dermatology , Faculty of Medicine, The University of Tokyo , Tokyo , Japan
| | - Koichi Yanaba
- a Department of Dermatology , Faculty of Medicine, The University of Tokyo , Tokyo , Japan
| | - Shinichi Sato
- a Department of Dermatology , Faculty of Medicine, The University of Tokyo , Tokyo , Japan
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Abstract
Pulmonary hypertension, an elevation of the mean pulmonary artery pressure ≥25 mmHg, ultimately leads to premature death due to right ventricular dysfunction. Ten treatments from three classes of drugs are licensed for the management of pulmonary arterial hypertension. These treatments have improved exercise capacity but median survival is still poor. Additionally there are no licensed therapies for the other groups of pulmonary hypertension. Riociguat is a novel drug that stimulates soluble guanylate cyclase independently of nitric oxide and in synergy with nitric oxide. This review summarises the available evidence for riociguat in the treatment across all groups of pulmonary hypertension with a focus on pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension.
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Affiliation(s)
- John E Cannon
- Pulmonary Vascular Disease Unit, Papworth Hospital, Papworth Everard, Cambridge, CB23 3RE, UK
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84
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Ohtsuka T, Flaherty KR, Lin J, Lama VN, Reddy RM, Orringer MB, Chan KM, Chang AC. Preoperative pulmonary artery pressure and mortality after lung transplantation. Asian Cardiovasc Thorac Ann 2014; 21:326-30. [PMID: 24570500 DOI: 10.1177/0218492312459972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The purpose of this study was to determine the influence of changes in pulmonary artery pressure during the waiting period on survival after lung transplantation for pulmonary fibrosis. METHODS We identified 65 patients with pulmonary fibrosis who underwent lung transplantation from 2003 to 2010. Pulmonary artery pressure determined at listing was compared with intraoperative pressure. The primary outcome was overall survival. Co-variates included type of transplantation (single or bilateral), ischemic time, recipient and donor age and sex. RESULTS The median age of the 65 patients undergoing transplantation was 58 years, and 27 (43%) underwent bilateral sequential transplantation. Twenty-two (35%) patients presented at transplantation with a mean pulmonary artery pressure increased by at least 10% compared to the initial pressure at the time of listing. Rising pulmonary artery pressure at transplantation was associated with increased mortality (p = 0.022). Other factors including type of operation, ischemic time, age, and sex, were not significantly associated with mortality. Post-transplantation survival was worse among recipients who had pulmonary artery pressure increased by at least 10% at transplantation (p = 0.003, logrank). CONCLUSIONS Increasing pulmonary artery pressure while awaiting lung transplantation is associated with worse long-term survival following transplantation, and is a sign of progressively worsening disease for which greater urgency of donor organ allocation should be considered.
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Affiliation(s)
- Takashi Ohtsuka
- Departments of Surgery and Medicine, University of Michigan Medical Center, Ann Arbor, Michigan, USA
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85
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Abstract
Idiopathic pulmonary arterial hypertension is a rare but serious and life-threatening disease that leads to right heart failure and death within 2.8 years without specific treatment. This review focuses on the stable prostacyclin analog iloprost, its biologic action and pharmacology and, finally, on its clinical development, efficacy and safety in patients with idiopathic pulmonary arterial hypertension, which led to its approval for this indication. Furthermore, this review assesses the role of iloprost compared with other newly developed drugs, such as the endothelin receptor antagonist bosentan and the phosphodiesterase-5 inhibitor sildenafil, as well as other modes of application of prostacyclin and its analogs for the treatment of idiopathic pulmonary arterial hypertension. Based on the different modes of action of these substances, a combination of these treatments could be most promising for the future.
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Affiliation(s)
- Hanno H Leuchte
- Ludwig Maximilians University, Division of Pulmonary Diseases, Department of Internal Medicine I, Klinikum Grosshadern, Marchioninistr. 15, 81377 Munich, Germany.
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86
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87
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Abstract
Pulmonary hypertension (PH) is a well-recognized complication of interstitial lung disease, including idiopathic pulmonary fibrosis (IPF). The underlying pathogenesis was initially hypothesized to be inflammatory but now is characterized as an over exuberant fibroproliferative process. The prevalence of PH in the setting of IPF has not been well described in the literature, with a reported occurrence from 32% to 85%. Diagnostically, recognizing underlying PH in the setting of IPF remains challenging because of nonspecific clinical symptoms and unrevealing ancillary testing. A high degree of clinical suspicion is paramount. The only reliable diagnostic tool for PH is right heart catheterization. The treatment of PH, in patients with IPF, is based on multiple factors, including disease severity, functional status and degree of hypoxemia. Medications currently approved to treat PH have been administered for PH in the setting of IPF, such as phosphodiesterase-5 inhibitors, nonselective endothelin receptor antagonists and prostacyclin analogues. The treatment of PH in the setting of IPF may also be difficult due to worsening ventilation-perfusion mismatch induced by selective pulmonary artery vasodilator therapy. Lung transplantation should be considered with patients refractory to pharmacological treatment. Identification of PH in IPF patients is crucial, as functional status and prognosis are greatly reduced. Given the high mortality rate and propensity for acute decompensation, IPF and PH patients should be evaluated for transplant early in their disease course.
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88
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Andersen CU, Mellemkjær S, Nielsen-Kudsk JE, Bendstrup E, Hilberg O, Simonsen U. Pulmonary hypertension in chronic obstructive and interstitial lung diseases. Int J Cardiol 2013; 168:1795-804. [PMID: 23849967 DOI: 10.1016/j.ijcard.2013.06.033] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 04/25/2013] [Accepted: 06/20/2013] [Indexed: 12/27/2022]
Abstract
The purpose of the present review is to summarize the current knowledge on PH in relation to COPD and ILD from a clinical perspective with emphasis on diagnosis, biomarkers, prevalence, impact, treatment, and practical implications. PH in COPD and ILD is associated with a poor prognosis, and is considered one of the most frequent types of PH. However, the prevalence of PH among patients with COPD and ILD is not clear. The diagnosis of PH in chronic lung disease is often established by echocardiographic screening, but definitive diagnosis requires right heart catheterization, which is not systematically performed in clinical practice. Given the large number of patients with chronic lung disease, biomarkers to preclude or increase suspicion of PH are needed. NT-proBNP may be used as a rule-out test, but biomarkers with a high specificity for PH are still required. It is not known whether specific treatment with existent drugs effective in pulmonary arterial hypertension (PAH) is beneficial in lung disease related PH. Studies investigating existing PAH drugs in animal models of lung disease related PH have indicated a positive effect, and so have case reports and open label studies. However, treatment with systemically administered pulmonary vasodilators implies the risk of worsening the ventilation-perfusion mismatch in patients with lung disease. Inhaled vasodilators may be better suited for PH in lung disease, but new treatment modalities are also required.
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89
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Bourge RC, Tapson VF, Safdar Z, Benza RL, Channick RN, Rosenzweig EB, Shapiro S, White RJ, McSwain CS, Gotzkowsky SK, Nelsen AC, Rubin LJ. Rapid transition from inhaled iloprost to inhaled treprostinil in patients with pulmonary arterial hypertension. Cardiovasc Ther 2013; 31:38-44. [PMID: 22970909 PMCID: PMC3561685 DOI: 10.1111/1755-5922.12008] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background Inhaled treprostinil is a prostacyclin analog approved for the treatment of pulmonary arterial hypertension (PAH) that may provide a more convenient treatment option for patients receiving inhaled iloprost while maintaining the clinical benefit of inhaled prostacyclin therapy. Aims In this open-label safety study, 73 PAH patients were enrolled with primarily World Health Organization Class II (56%) or III (42%) symptoms. At baseline, most patients (93%) were receiving 5 μg of iloprost per dose but 38% of patients reported a dosing frequency below the labeled rate of 6–9 times daily. Patients initiated inhaled treprostinil at 3 breaths four times daily (qid) at the immediate next scheduled iloprost dose. The primary objective was to assess the safety of rapid transition from iloprost to inhaled treprostinil; clinical status and quality of life were also assessed. Results Most patients (84%) achieved the target treprostinil dose of 9 breaths qid and remained on study until transition to commercial therapy (89%). The most frequent adverse events (AEs) were cough (74%), headache (44%), and nausea (30%), and five patients prematurely discontinued study drug due to AE (n = 3), disease progression (n = 1), or death (n = 1). At week 12, the time spent on daily treatment activities was reduced compared to baseline, with a mean total savings of 1.4 h per day. Improvements were also observed at week 12 for 6-min walk distance (+16.0; P < 0.001), N-terminal pro-B-type natriuretic peptide (−74 pg/mL; P = 0.001), and the Cambridge Pulmonary Hypertension Outcome Review (all domains P < 0.001). Conclusions Pulmonary arterial hypertension patients can be safely transitioned from inhaled iloprost to inhaled treprostinil while maintaining clinical status.
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Affiliation(s)
- Robert C Bourge
- University of Alabama at Birmingham, Birmingham, AL 35294, USA.
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90
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Jing ZC, Parikh K, Pulido T, Jerjes-Sanchez C, White RJ, Allen R, Torbicki A, Xu KF, Yehle D, Laliberte K, Arneson C, Rubin LJ. Efficacy and Safety of Oral Treprostinil Monotherapy for the Treatment of Pulmonary Arterial Hypertension. Circulation 2013; 127:624-33. [DOI: 10.1161/circulationaha.112.124388] [Citation(s) in RCA: 249] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Pulmonary arterial hypertension (PAH) is a progressive, fatal disease with no cure. Parenteral and inhaled prostacyclin analogue therapies are effective for the treatment of PAH, but complicated administration requirements can limit the use of these therapies in patients with less severe disease. This study was designed to evaluate the safety and efficacy of the oral prostacyclin analogue treprostinil diolamine as initial treatment for de novo PAH.
Methods and Results—
Three hundred forty-nine patients (intent-to-treat population) not receiving endothelin receptor antagonist or phosphodiesterase type-5 inhibitor background therapy were randomized (treprostinil, n=233; placebo, n=116). The primary analysis population (modified intent-to-treat) included 228 patients (treprostinil, n=151; placebo, n=77) with access to 0.25-mg treprostinil tablets at randomization. The primary end point was change from baseline in 6-minute walk distance at week 12. Secondary end points included Borg dyspnea index, clinical worsening, and symptoms of PAH. The week 12 treatment effect for 6-minute walk distance (modified intent-to-treat population) was 23.0 m (
P
=0.0125). For the intent-to-treat population, 6-minute walk distance improvements were observed at peak (26.0 m;
P
=0.0001) and trough (17.0 m;
P
=0.0025) plasma study drug concentrations. Other than an improvement in the combined 6-minute walk distance/Borg dyspnea score, there were no significant changes in secondary end points. Oral treprostinil therapy was generally well tolerated; the most common adverse events (intent-to-treat) were headache (69%), nausea (39%), diarrhea (37%), and pain in jaw (25%).
Conclusions—
Oral treprostinil improves exercise capacity in PAH patients not receiving other treatment. Oral treprostinil could provide a convenient, first-line prostacyclin treatment option for PAH patients not requiring more intensive therapy.
Clinical Trial Registration:—
URL:
http://www.clinicaltrials.gov
. Unique identifier:
NCT00325403
.
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Affiliation(s)
- Zhi-Cheng Jing
- From Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China (Z.-C.J.); Care Institute of Medical Science, Ahmedabad, India (K.P.); Instituto Nacional de Cardiologia, Mexico City, Mexico (T.P.); Unidad de Investigacion Clinica en Medicina, Monterrey, Mexico (C.J.-S.); University of Rochester Medical Center, Rochester, NY (R.J.W.); UC Davis Medical Center, Sacramento, CA (R.A.); Medical Center of Postgraduate Education, ECZ – Otwock, Poland (A.T.); Peking Union Medical
| | - Keyur Parikh
- From Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China (Z.-C.J.); Care Institute of Medical Science, Ahmedabad, India (K.P.); Instituto Nacional de Cardiologia, Mexico City, Mexico (T.P.); Unidad de Investigacion Clinica en Medicina, Monterrey, Mexico (C.J.-S.); University of Rochester Medical Center, Rochester, NY (R.J.W.); UC Davis Medical Center, Sacramento, CA (R.A.); Medical Center of Postgraduate Education, ECZ – Otwock, Poland (A.T.); Peking Union Medical
| | - Tomas Pulido
- From Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China (Z.-C.J.); Care Institute of Medical Science, Ahmedabad, India (K.P.); Instituto Nacional de Cardiologia, Mexico City, Mexico (T.P.); Unidad de Investigacion Clinica en Medicina, Monterrey, Mexico (C.J.-S.); University of Rochester Medical Center, Rochester, NY (R.J.W.); UC Davis Medical Center, Sacramento, CA (R.A.); Medical Center of Postgraduate Education, ECZ – Otwock, Poland (A.T.); Peking Union Medical
| | - Carlos Jerjes-Sanchez
- From Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China (Z.-C.J.); Care Institute of Medical Science, Ahmedabad, India (K.P.); Instituto Nacional de Cardiologia, Mexico City, Mexico (T.P.); Unidad de Investigacion Clinica en Medicina, Monterrey, Mexico (C.J.-S.); University of Rochester Medical Center, Rochester, NY (R.J.W.); UC Davis Medical Center, Sacramento, CA (R.A.); Medical Center of Postgraduate Education, ECZ – Otwock, Poland (A.T.); Peking Union Medical
| | - R. James White
- From Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China (Z.-C.J.); Care Institute of Medical Science, Ahmedabad, India (K.P.); Instituto Nacional de Cardiologia, Mexico City, Mexico (T.P.); Unidad de Investigacion Clinica en Medicina, Monterrey, Mexico (C.J.-S.); University of Rochester Medical Center, Rochester, NY (R.J.W.); UC Davis Medical Center, Sacramento, CA (R.A.); Medical Center of Postgraduate Education, ECZ – Otwock, Poland (A.T.); Peking Union Medical
| | - Roblee Allen
- From Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China (Z.-C.J.); Care Institute of Medical Science, Ahmedabad, India (K.P.); Instituto Nacional de Cardiologia, Mexico City, Mexico (T.P.); Unidad de Investigacion Clinica en Medicina, Monterrey, Mexico (C.J.-S.); University of Rochester Medical Center, Rochester, NY (R.J.W.); UC Davis Medical Center, Sacramento, CA (R.A.); Medical Center of Postgraduate Education, ECZ – Otwock, Poland (A.T.); Peking Union Medical
| | - Adam Torbicki
- From Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China (Z.-C.J.); Care Institute of Medical Science, Ahmedabad, India (K.P.); Instituto Nacional de Cardiologia, Mexico City, Mexico (T.P.); Unidad de Investigacion Clinica en Medicina, Monterrey, Mexico (C.J.-S.); University of Rochester Medical Center, Rochester, NY (R.J.W.); UC Davis Medical Center, Sacramento, CA (R.A.); Medical Center of Postgraduate Education, ECZ – Otwock, Poland (A.T.); Peking Union Medical
| | - Kai-Feng Xu
- From Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China (Z.-C.J.); Care Institute of Medical Science, Ahmedabad, India (K.P.); Instituto Nacional de Cardiologia, Mexico City, Mexico (T.P.); Unidad de Investigacion Clinica en Medicina, Monterrey, Mexico (C.J.-S.); University of Rochester Medical Center, Rochester, NY (R.J.W.); UC Davis Medical Center, Sacramento, CA (R.A.); Medical Center of Postgraduate Education, ECZ – Otwock, Poland (A.T.); Peking Union Medical
| | - David Yehle
- From Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China (Z.-C.J.); Care Institute of Medical Science, Ahmedabad, India (K.P.); Instituto Nacional de Cardiologia, Mexico City, Mexico (T.P.); Unidad de Investigacion Clinica en Medicina, Monterrey, Mexico (C.J.-S.); University of Rochester Medical Center, Rochester, NY (R.J.W.); UC Davis Medical Center, Sacramento, CA (R.A.); Medical Center of Postgraduate Education, ECZ – Otwock, Poland (A.T.); Peking Union Medical
| | - Kevin Laliberte
- From Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China (Z.-C.J.); Care Institute of Medical Science, Ahmedabad, India (K.P.); Instituto Nacional de Cardiologia, Mexico City, Mexico (T.P.); Unidad de Investigacion Clinica en Medicina, Monterrey, Mexico (C.J.-S.); University of Rochester Medical Center, Rochester, NY (R.J.W.); UC Davis Medical Center, Sacramento, CA (R.A.); Medical Center of Postgraduate Education, ECZ – Otwock, Poland (A.T.); Peking Union Medical
| | - Carl Arneson
- From Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China (Z.-C.J.); Care Institute of Medical Science, Ahmedabad, India (K.P.); Instituto Nacional de Cardiologia, Mexico City, Mexico (T.P.); Unidad de Investigacion Clinica en Medicina, Monterrey, Mexico (C.J.-S.); University of Rochester Medical Center, Rochester, NY (R.J.W.); UC Davis Medical Center, Sacramento, CA (R.A.); Medical Center of Postgraduate Education, ECZ – Otwock, Poland (A.T.); Peking Union Medical
| | - Lewis J. Rubin
- From Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China (Z.-C.J.); Care Institute of Medical Science, Ahmedabad, India (K.P.); Instituto Nacional de Cardiologia, Mexico City, Mexico (T.P.); Unidad de Investigacion Clinica en Medicina, Monterrey, Mexico (C.J.-S.); University of Rochester Medical Center, Rochester, NY (R.J.W.); UC Davis Medical Center, Sacramento, CA (R.A.); Medical Center of Postgraduate Education, ECZ – Otwock, Poland (A.T.); Peking Union Medical
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91
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Abstract
Idiopathic pulmonary fibrosis (IPF) is a fatal lung disease with a variable natural history. Pulmonary hypertension (PH) is frequently found in patients with IPF and is associated with an almost 3-fold increase in the risk of death. Pulmonary hypoxic vasoconstriction plays an important role in the pathogenesis of PH in IPF (PH-IPF), although it has become clear that it is not the only mechanism involved. While invasive right heart catheterization is the gold standard modality of hemodynamic assessment, there has been increasing interest in noninvasive testing, such as Doppler echocardiogram, as complementary methods of assessing right ventricular function in these patients. While the expanding array of pharmacologic options for the treatment of pulmonary arterial hypertension has engendered increased interest in the application of these therapies for PH-IPF, supportive evidence for benefit is lacking.
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92
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Boeck L, Tamm M, Grendelmeier P, Stolz D. Acute effects of aerosolized iloprost in COPD related pulmonary hypertension - a randomized controlled crossover trial. PLoS One 2012; 7:e52248. [PMID: 23300624 PMCID: PMC3531427 DOI: 10.1371/journal.pone.0052248] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Accepted: 11/16/2012] [Indexed: 12/02/2022] Open
Abstract
Background Inhaled iloprost potentially improves hemodynamics and gas exchange in patients with chronic obstructive pulmonary disease (COPD) and secondary pulmonary hypertension (PH). Objectives To evaluate acute effects of aerosolized iloprost in patients with COPD-associated PH. Methods A randomized, double blind, crossover study was conducted in 16 COPD patients with invasively confirmed PH in a single tertiary care center. Each patient received a single dose of 10 µg iloprost (low dose), 20 µg iloprost (high dose) and placebo during distinct study-visits. The primary end-point of the study was exercise capacity as assessed by the six minute walking distance. Results Both iloprost doses failed to improve six-minute walking distance (p = 0.36). Low dose iloprost (estimated difference of the means −1.0%, p = 0.035) as well as high dose iloprost (−2.2%, p<0.001) significantly impaired oxygenation at rest. Peak oxygen consumption and carbon dioxide production differed significantly over the three study days (p = 0.002 and p = 0.003, accordingly). As compared to placebo, low dose iloprost was associated with reduced peak oxygen consumption (−76 ml/min, p = 0.002), elevated partial pressure of carbon dioxide (0.27 kPa, p = 0.040) and impaired ventilation during exercise (−3.0l/min, p<0.001). Conclusions Improvement of the exercise capacity after iloprost inhalation in patients with COPD-associated mild to moderate PH is very unlikely. Trial Registration Controlled-Trials.com ISRCTN61661881
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Affiliation(s)
- Lucas Boeck
- Clinic of Pulmonary Medicine and Respiratory Cell Research, University Hospital Basel, Basel, Switzerland
| | - Michael Tamm
- Clinic of Pulmonary Medicine and Respiratory Cell Research, University Hospital Basel, Basel, Switzerland
| | - Peter Grendelmeier
- Clinic of Pulmonary Medicine and Respiratory Cell Research, University Hospital Basel, Basel, Switzerland
| | - Daiana Stolz
- Clinic of Pulmonary Medicine and Respiratory Cell Research, University Hospital Basel, Basel, Switzerland
- * E-mail:
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93
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Abstract
Pulmonary hypertension in the setting of parenchymal lung disease and conditions associated with chronic hypoxemia is commonly encountered in clinical practice and may adversely affect patients' function and mortality. Diagnosis of this subgroup of pulmonary hypertension has evolved but still requires right heart catheterization for confirmation. The primary treatment goal is optimization of the underlying parenchymal lung or hypoxemia-associated condition prior to consideration of pharmacologic therapy. Limited published experience with pulmonary hypertension-specific medications for treatment of WHO Group 3 pulmonary hypertension suggests symptomatic and functional benefit in selected individuals. The potential for worsening ventilation-perfusion matching must be considered in these cases, however, since there is a paucity of data regarding the optimal approach to treatment selection. Ongoing medication trials and further investigation of mechanisms of hypoxic pulmonary vasoconstriction provide hope for these patients who in the past often had only lung transplantation as a potential treatment option.
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Affiliation(s)
- Hooman D Poor
- New York Presbyterian Hospital, Columbia University College of Physicians and Surgeons, New York, NY, USA
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94
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LeVarge BL, Channick RN. Inhaled treprostinil for the treatment of pulmonary arterial hypertension. Expert Rev Respir Med 2012; 6:255-65. [PMID: 22788940 DOI: 10.1586/ers.12.23] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Treprostinil is a prostacyclin derivative approved for the treatment of pulmonary arterial hypertension by intravenous, subcutaneous and inhalational administration. Unlike its precursor epoprostenol, treprostinil is chemically stable at room temperature and neutral pH, and its plasma half-life is longer. In addition to promoting smooth muscle relaxation in the pulmonary vasculature, treprostinil has suppressive effects on platelet aggregation, smooth muscle proliferation and inflammation. A Phase III study, investigating the addition of inhaled treprostinil to oral bosentan or sildenafil, confirmed significant improvements in exercise capacity and quality of life. This review examines the pharmacodynamics, pharmacokinetics, clinical efficacy and safety of inhaled treprostinil for use in pulmonary arterial hypertension.
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Affiliation(s)
- Barbara L LeVarge
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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95
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Abstract
Pulmonary arterial hypertension (PAH) is a progressive disease of the pulmonary vascular system, which may lead to right-heart failure or early death in the absence of effective treatment. The current therapy for PAH mainly includes phosphodiesterase inhibitors, prostanoids and endothelin receptor antagonists. These, however, have adverse effects when administered via conventional routes. There is a clear and critical need for the development of a novel delivery system that can efficiently deliver the drug to lung vasculature and minimize adverse effects. This article summarizes the inhalation devices and recent patents in the area of inhalable therapy for the treatment of PAH. Various patents are discussed that describe the application of inhalable therapy to target lung vasculature and to reduce dose-related side effects in PAH treatment. Entry of some inhalable delivery approaches into clinical trials is the result of progress in inhalable therapies for the treatment of PAH.
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96
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Sherner J, Collen J, King CS, Nathan SD. Pulmonary hypertension in idiopathic pulmonary fibrosis: epidemiology, diagnosis and therapeutic implications. ACTA ACUST UNITED AC 2012. [DOI: 10.1007/s13665-012-0027-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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97
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Abstract
Pulmonary arterial hypertension (PAH) is a severe condition that markedly reduces exercise capacity and survival in the affected patient population. PAH includes primary pulmonary hypertension (PPH) and pulmonary hypertension associated with collagen vascular diseases, congenital systemic-to-pulmonary shunts, portal hypertension and HIV infection. All these conditions share virtually identical obstructive pathologic changes of the pulmonary microcirculation and probably similar pathobiologic processes. The pathophysiology is characterized by a progressive increase in pulmonary vascular resistance, leading to right ventricular failure and death. Prostacyclin is an endogenous substance that is produced by vascular endothelial cells and induces vasodilatation, inhibition of platelet activity, and antiproliferative effects. A dysregulation of prostacyclin metabolic pathways has been shown in patients with PAH and this represents the rationale for the exogenous therapeutic administration of this substance. The clinical use of prostacyclin in patients with PAH has been made possible by the synthesis of stable analogs that possess different pharmacokinetic properties but share similar pharmacodynamic effects. Experience in humans has been initially collected with epoprostenol, which is a synthetic salt of prostacyclin. Epoprostenol has a short half-life in the circulation and requires continuous administration by the intravenous route by means of infusion pumps and permanent tunnelized catheters. In addition, epoprostenol is unstable at room temperature, and the complex delivery system required is associated with several adverse effects and potentially serious complications. For these reasons, alternatives to intravenous epoprostenol have been sought and this has led to the development of analogs that can be administered subcutaneously (treprostinil), orally (beraprost sodium) or by inhalation (iloprost). Three unblinded clinical trials and several uncontrolled trials have shown that treatment with epoprostenol improved symptoms and exercise capacity in New York Heart Association (NYHA) class III and IV PAH patients and also survival in patients with PPH. Subcutaneous treprostinil improved symptoms, exercise, hemodynamics and clinical events in the largest clinical trial ever performed in PAH, but local infusion site reactions limited efficacy in a proportion of patients. Oral beraprost sodium improved exercise capacity only in patients with PPH and is the only prostacyclin analog that has also been tested in NYHA class II patients. Inhaled iloprost has improved symptoms, exercise capacity and clinical events in patients with PAH and inoperable chronic thromboembolic pulmonary hypertension. The favorable effects of prostanoids observed in all studies coupled with different profiles of adverse events and tolerability for each prostacyclin analog allow the unique opportunity to select the most appropriate compound for the individual patient with PAH.
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Affiliation(s)
- Nazzareno Galiè
- Institute of Cardiology, University of Bologna, Bologna, Italy.
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98
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Patel R, Aronow WS, Patel L, Gandhi K, Desai H, Kaul D, Sahgal SP. Treatment of pulmonary hypertension. Med Sci Monit 2012; 18:RA31-9. [PMID: 22460104 PMCID: PMC3560813 DOI: 10.12659/msm.882607] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a chronic progressive disease of the pulmonary vasculature characterized by elevated pulmonary arterial pressure and secondary right ventricular failure. PAH is considered a life-threatening condition unless treated. This article provides a comprehensive review of controlled and uncontrolled trials to define the risk-benefit for different therapeutic options of this clinical disorder. Relevant published articles were identified through searches of the National Center for Biotechnology PubMed database. All therapeutic measures for PAH were discussed. Six drugs have been approved in the United States for the treatment of PAH. Extensive medical advancement has been achieved in treatment of PAH. However, none of the approved therapies have shown ability to cure the disease. New research should be performed to develop promising new therapies.
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99
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Bishop BM, Mauro VF, Khouri SJ. Practical Considerations for the Pharmacotherapy of Pulmonary Arterial Hypertension. Pharmacotherapy 2012; 32:838-55. [DOI: 10.1002/j.1875-9114.2012.01114.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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100
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Aytemur ZA, Hacievliyagil SS, Iraz M, Samdanci E, Ozerol E, Kuku I, Nurkabulov Z, Yildiz K. Effects of iloprost on bleomycin-induced pulmonary fibrosis in rats compared with methyl-prednisolone. REVISTA PORTUGUESA DE PNEUMOLOGIA 2012; 18:272-7. [PMID: 22770817 DOI: 10.1016/j.rppneu.2012.04.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Revised: 04/17/2012] [Accepted: 04/29/2012] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE Prostacyclin (PGI2) has been shown to inhibit the expression of pro-inflammatory and pro-fibrotic mediators in pulmonary fibrosis. In this study, we aimed to test the preventive effects of intraperitoneally administered iloprost, a stable PGI2 analog, on bleomycin-induced pulmonary fibrosis in rats and to compare the effects of iloprost with the effects of methyl-prednisolone, a traditional therapy. METHODS Rats were randomly allocated into four groups: 1. Saline alone (n=6); 2. Bleomycin+placebo (n=7); 3. Bleomycin+methyl-prednisolone (n=7); 4. Bleomycin+iloprost (n=7). Fibrotic changes in the lungs were demonstrated by analyzing the cellular composition of bronchoalveolar lavage fluid, histological evaluation and lung hydroxyproline content. RESULTS Fibrosis was made in the lungs of rats by bleomycin experimentally. Fibrosis scores in the methyl-prednisolone and the iloprost groups were significantly lower than in the placebo group (p<0.05). Furthermore, the score of the iloprost group was significantly lower than the score of the methyl-prednisolone group. The hydroxyproline content was significantly less in the methyl-prednisolone and the iloprost groups (p<0.05). In the placebo group, the neutrophil percentage in bronchoalveolar lavage was significantly higher than in the other groups, whereas the macrophage percentage in placebo group was significantly lower (p<0.05). CONCLUSION Iloprost has protective effect on the pulmonary fibrosis induced by bleomycin and it may be more effective in decreasing fibrotic changes than methyl-prednisolone.
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Affiliation(s)
- Z A Aytemur
- Department of Pulmonary Disease, Inonu University Medical Faculty, Malatya, Turkey
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