1
|
Wu X, Wang X, Zhang L, Pan Z, Chen F, Chen SL, Kan J, Wei Y. Pulmonary artery denervation versus conventional therapies for PAH: a systematic review and updated network meta-analysis. ESC Heart Fail 2024. [PMID: 38783684 DOI: 10.1002/ehf2.14842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 01/12/2024] [Accepted: 04/24/2024] [Indexed: 05/25/2024] Open
Abstract
AIMS A recent guideline presented by the ESC Congress in 2022 had indicated a novel therapy targeted at pulmonary artery hypertension, known as pulmonary artery denervation (PADN), which get inspired from a laboratorial trial that could lowering the pulmonary artery pressure through the intervention on the animals. Our aim is to conduct a network meta-analysis to compare the efficacy and safety of PADN from six aspects with the current conventional therapies. METHODS AND RESULTS According to the PRISMA guidance, databases including Ovid, ClinicalTrials.gov, Medline, Embase, and PubMed were searched from inception to 22 August 2023, along with a full assessment of the previous five meta-analyses. Data were extracted and curated for Bayesian network meta-analysis. The primary outcome was the change in the 6-min walking distance (6MWD) from baseline with a secondary outcome called change in mean pulmonary artery pressure (mPAP) from baseline. The four safety outcomes included risk of clinical worsening, hospitalization, mortality and severe adverse events (SAEs). The comparison is structured on a contrast model based on 65 randomized controlled trials (RCTs) on PADN and the other conventional mainstream drugs. PADN had a better effect in improving 6MWD than Placebo (-77.76 m, 95% CI: -102.04 to -54.34 m), Macitentan (-65.32 m, 95% CI: -95.34 to -36.1 m), Bosentan (-64.5 m, 95% CI: -94.7 to -35.07 m), Iloprost (-62.66 m, 95% CI: -99.48 to -27.13 m), Oxygen (-62.42 m, 95% CI: -100.01 to -25.78 m), Treprostinil (-62.01 m, 95% CI: -89.04 to -35.61 m), Riociguat (-60.59 m, 95% CI: -86.11 to -35.98 m), Selexipag (-47.2 m, 95% CI: -85.61 to -10.19 m), Sildenafil (-44.92 m, 95% CI: -74.43 to -16.15 m), or Sitaxsentan (-39.53 m, 95% CI: -78.99 to -0.76 m). PADN had a better antihypertensive effect than placebo and showed statistical significant lower risks to induce clinical worsening and re-hospitalization than treprostinil, riociguat, and placebo groups. No statistically significant difference in risk of mortality and severe adverse events was observed between PADN versus the other interventions. CONCLUSIONS Compared with 16 types of conventional therapies and Placebo, PADN has advantage over nine single therapies and Placebo in improving 6MWD and appears to be better than two types of dual-drug combined therapies while with no statistical significance. PADN shows a favourable antihypertensive effect on mPAP and has a lower risk to trigger clinical worsening or hospitalization, while its risk on mortality and severe adverse events is still inconclusive.
Collapse
Affiliation(s)
- Xiaoyu Wu
- Department of Biostatistics, School of Public Health, Center of Global Health, Nanjing Medical University, Nanjing, China
| | - Xiang Wang
- Department of Biostatistics, School of Public Health, Center of Global Health, Nanjing Medical University, Nanjing, China
| | - Longyao Zhang
- Department of Biostatistics, School of Public Health, Center of Global Health, Nanjing Medical University, Nanjing, China
| | - Zoucheng Pan
- Department of Biostatistics, School of Public Health, Center of Global Health, Nanjing Medical University, Nanjing, China
| | - Feng Chen
- Department of Biostatistics, School of Public Health, Center of Global Health, Nanjing Medical University, Nanjing, China
| | - Shao-Liang Chen
- Department of Cardiology, Nanjing First Hospital, The Affiliated Nanjing Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Jing Kan
- Department of Cardiology, Nanjing First Hospital, The Affiliated Nanjing Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Yongyue Wei
- Department of Biostatistics, School of Public Health, Center of Global Health, Nanjing Medical University, Nanjing, China
- Center for Public Health and Epidemic Preparedness & Response, Peking University, Key Laboratory of Epidemiology of Major Diseases (Peking University), Ministry of Education, Beijing, China
| |
Collapse
|
2
|
Correale M, Tricarico L, Bevere EML, Chirivì F, Croella F, Severino P, Mercurio V, Magrì D, Dini F, Licordari R, Beltrami M, Dattilo G, Salzano A, Palazzuoli A. Circulating Biomarkers in Pulmonary Arterial Hypertension: An Update. Biomolecules 2024; 14:552. [PMID: 38785959 PMCID: PMC11117582 DOI: 10.3390/biom14050552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 04/25/2024] [Accepted: 05/01/2024] [Indexed: 05/25/2024] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare subtype of group 1 pulmonary hypertension (PH) diseases, characterized by high pulmonary artery pressure leading to right ventricular dysfunction and potential life-threatening consequences. PAH involves complex mechanisms: vasoconstriction, vascular remodeling, endothelial dysfunction, inflammation, oxidative stress, fibrosis, RV remodeling, cellular hypoxia, metabolic imbalance, and thrombosis. These mechanisms are mediated by several pathways, involving molecules like nitric oxide and prostacyclin. PAH diagnosis requires clinical evaluation and right heart catheterization, confirming a value of mPAP ≥ 20 mmHg at rest and often elevated pulmonary vascular resistance (PVR). Even if an early and accurate diagnosis is crucial, PAH still lacks effective biomarkers to assist in its diagnosis and prognosis. Biomarkers could contribute to arousing clinical suspicion and serve for prognosis prediction, risk stratification, and dynamic monitoring in patients with PAH. The aim of the present review is to report the main novelties on new possible biomarkers for the diagnosis, prognosis, and treatment monitoring of PAH.
Collapse
Affiliation(s)
- Michele Correale
- Cardiothoracic Department, Ospedali Riuniti University Hospital, 71100 Foggia, Italy
| | - Lucia Tricarico
- Department of Medical and Surgical Sciences, University of Foggia, 71100 Foggia, Italy; (L.T.); (E.M.L.B.); (F.C.)
| | - Ester Maria Lucia Bevere
- Department of Medical and Surgical Sciences, University of Foggia, 71100 Foggia, Italy; (L.T.); (E.M.L.B.); (F.C.)
| | - Francesco Chirivì
- Department of Medical and Surgical Sciences, University of Foggia, 71100 Foggia, Italy; (L.T.); (E.M.L.B.); (F.C.)
| | - Francesca Croella
- Cardiothoracic Vascular Department, Division of Provincial Cardiology, Santissima Annunziata Hospital and Delta Hospital, Azienda Unità Sanitaria Locale di Ferrara, 44121 Ferrara, Italy;
| | - Paolo Severino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 00185 Rome, Italy;
| | - Valentina Mercurio
- Department of Translational Medical Sciences, Federico II University, 80138 Naples, Italy;
| | - Damiano Magrì
- Department of Clinical and Molecular Medicine, Azienda Ospedaliera Sant’Andrea, “Sapienza” Università degli Studi di Roma, 00161 Rome, Italy;
| | - Frank Dini
- Istituto Auxologico IRCCS, Centro Medico Sant’Agostino, Via Temperanza, 6, 20127 Milan, Italy;
- Department of Public Health and Clinical Medicine, Umeå University, 901 87 Umeå, Sweden
| | - Roberto Licordari
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Section of Cardiology, University of Messina, 98122 Messina, Italy; (R.L.); (G.D.)
| | - Matteo Beltrami
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, 50134 Florence, Italy;
| | - Giuseppe Dattilo
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Section of Cardiology, University of Messina, 98122 Messina, Italy; (R.L.); (G.D.)
| | - Andrea Salzano
- Cardiology Unit, AORN A Cardarelli, 80131 Naples, Italy;
| | - Alberto Palazzuoli
- Cardiovascular Diseases Unit, Cardio-Thoracic and Vascular Department, S. Maria alle Scotte Hospital, University of Siena, 53100 Siena, Italy;
| |
Collapse
|
3
|
Novara ME, Di Martino E, Stephens B, Nayrouz M, Vitulo P, Carollo A, Provenzani A. Future Perspectives of Pulmonary Arterial Hypertension: A Review of Novel Pipeline Treatments and Indications. Drugs R D 2024; 24:13-28. [PMID: 38514585 PMCID: PMC11035521 DOI: 10.1007/s40268-024-00453-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2024] [Indexed: 03/23/2024] Open
Abstract
Pulmonary arterial hypertension is characterized by elevated blood pressure and pathological changes in the pulmonary arterioles, leading to the development of right-heart failure and potentially fatal outcomes if left untreated. This review aims to provide an overview of novel drugs or formulations and new drug indications for pulmonary arterial hypertension that are currently in phases II-III of randomized controlled trials, and describe the rationale for the use of these targeted therapies, as well as their efficacy, safety profile, and impact on quality of life and survival. The literature research was conducted using data from ClinicalTrials.gov for the period between 1 January 2016 up to 31 December 2022. The population of interest includes individuals aged ≥ 18 years who have been diagnosed with pulmonary arterial hypertension. The review selection criteria included trials with recruiting, enrolling by invitation, active, terminated or completed status in 2022 and 2023. A total of 24 studies were selected for evaluation based on the inclusion and exclusion criteria. This review summarizes the updated information from randomized clinical trials involving novel therapies for pulmonary arterial hypertension. However, larger clinical trials are required to validate their clinical safety and effects. In the future, clinicians should choose therapies based on the patient's individual situation and requirements when developing treatment strategies.
Collapse
Affiliation(s)
- Maria Eugenia Novara
- Clinical Pharmacy Service, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Enrica Di Martino
- Clinical Pharmacy Service, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Brandon Stephens
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, 15261, USA
| | - Mary Nayrouz
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, 15261, USA
| | - Patrizio Vitulo
- Pneumology Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Anna Carollo
- Clinical Pharmacy Service, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Alessio Provenzani
- Clinical Pharmacy Service, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy.
| |
Collapse
|
4
|
Rössler J, Cywinski JB, Argalious M, Ruetzler K, Khanna S. Anesthetic management in patients having catheter-based thrombectomy for acute pulmonary embolism: A narrative review. J Clin Anesth 2024; 92:111281. [PMID: 37813080 DOI: 10.1016/j.jclinane.2023.111281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/25/2023] [Accepted: 09/30/2023] [Indexed: 10/11/2023]
Abstract
Pulmonary embolism is the third leading cause of cardiovascular death. Novel percutaneous catheter-based thrombectomy techniques are rapidly becoming popular in high-risk pulmonary embolism - especially in the presence of contraindications to thrombolysis. The interventional nature of these procedures and the risk of sudden cardiorespiratory compromise requires the presence of an anesthesiologist. Facilitating catheter-based thrombectomy can be challenging since qualifying patients are often critically ill. The purpose of this narrative review is to provide guidance to anesthesiologists for the assessment and management of patients having catheter-based thrombectomy for acute pulmonary embolism. First, available techniques for catheter-based thrombectomy are reviewed. Then, we discuss definitions and application of common risk stratification tools for pulmonary embolism, and how to assess patients prior to the procedure. An adjudication of risks and benefits of anesthetic strategies for catheter-based thrombectomy follows. Specifically, we give guidance and rationale for use monitored anesthesia care and general anesthesia for these procedures. For both, we review strategies for assessing and mitigating hemodynamic perturbations and right ventricular dysfunction, ranging from basic monitoring to advanced inodilator therapy. Finally, considerations for management of right ventricular failure with mechanical circulatory support are discussed.
Collapse
Affiliation(s)
- Julian Rössler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jacek B Cywinski
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Maged Argalious
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kurt Ruetzler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Sandeep Khanna
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Cardiothoracic and Vascular Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
5
|
Khan S, Randhawa S, Patail H, Spira Y, Frishman WH, Aronow WS, Lanier GM. Pharmacological Update and Emerging Treatments of Pulmonary Hypertension. Cardiol Rev 2024:00045415-990000000-00192. [PMID: 38294225 DOI: 10.1097/crd.0000000000000647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
Pulmonary hypertension (PH) is defined as elevated pressures in the pulmonary artery and is associated with significant morbidity and mortality. The World Health Organization classifies PH into 5 distinct groups based on underlying etiology, pathology, and modality of treatment. Therapeutic approach may be challenging due to the extensive spectrum of causes and underlying mechanisms mediating PH. The 5 groups include pulmonary arterial hypertension (group 1), PH secondary to left heart disease (group 2), PH secondary to chronic lung disease (group 3), chronic thromboembolic pulmonary hypertension (group 4), and PH due to miscellaneous causes (group 5). Although significant progress has been made in the treatment of group 1 PH, there is a continued need to develop new therapies for all types of PH. Additionally, most treatments currently available improve functional capacity and symptoms but without a significant benefit in mortality. In this review, we aim to describe the various etiologies of PH and their established pharmacotherapies, as well as expand on emerging therapeutic options for each group.
Collapse
Affiliation(s)
- Shazli Khan
- From the Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Sukhbir Randhawa
- Department of Internal Medicine, Samaritan Medical Center, Watertown, NY
| | - Haris Patail
- Department of Internal Medicine, University of Connecticut School of Medicine, Hartford, CT
| | - Yaakov Spira
- Department of Internal Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - William H Frishman
- Department of Internal Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Wilbert S Aronow
- From the Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Gregg M Lanier
- From the Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY
| |
Collapse
|
6
|
Kochanski JJ, Feinstein JA, Ogawa M, Ritter V, Hopper RK, Adamson GT. Younger age at initiation of subcutaneous treprostinil is associated with better response in pediatric Group 1 pulmonary arterial hypertension. Pulm Circ 2024; 14:e12328. [PMID: 38348195 PMCID: PMC10860541 DOI: 10.1002/pul2.12328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 10/31/2023] [Accepted: 11/24/2023] [Indexed: 02/15/2024] Open
Abstract
Children with severe Group 1 pulmonary arterial hypertension (PAH) have an unpredictable response to subcutaneous treprostinil (TRE) therapy, which may be influenced by age, disease severity, or other unknown variables at time of initiation. In this retrospective single-center cohort study, we hypothesized that younger age at TRE initiation, early hemodynamic response (a decrease in pulmonary vascular resistance by ≥30% at follow-up catheterization), and less severe baseline hemodynamics (Rp:Rs < 1.1) would each be associated with better clinical outcomes. In 40 pediatric patients with Group I PAH aged 17 days-18 years treated with subcutaneous TRE, younger age (cut-off of 6-years of age, AUC 0.824) at TRE initiation was associated with superior 5-year freedom from adverse events (94% vs. 39%, p = 0.002), better WHO functional class (I or II: 88% vs. 39% p = 0.003), and better echocardiographic indices of right ventricular function at most recent follow-up. Neither early hemodynamic response nor less severe baseline hemodynamics were associated with better outcomes. Patients who did not have a significant early hemodynamic response to TRE by first follow-up catheterization were unlikely to show subsequent improvement in PVRi (1/8, 13%). These findings may help clinicians counsel families and guide clinical decision making regarding the timing of advanced therapies.
Collapse
Affiliation(s)
- Justin J. Kochanski
- Department of Pediatrics (Cardiology)Stanford University School of MedicinePalo AltoCaliforniaUSA
| | - Jeffrey A. Feinstein
- Department of Pediatrics (Cardiology)Stanford University School of MedicinePalo AltoCaliforniaUSA
| | - Michelle Ogawa
- Department of Pediatrics (Cardiology)Stanford University School of MedicinePalo AltoCaliforniaUSA
| | - Victor Ritter
- Stanford University School of MedicineQuantitative Sciences UnitPalo AltoCaliforniaUSA
| | - Rachel K. Hopper
- Department of Pediatrics (Cardiology)Stanford University School of MedicinePalo AltoCaliforniaUSA
| | - Gregory T. Adamson
- Department of Pediatrics (Cardiology)Stanford University School of MedicinePalo AltoCaliforniaUSA
| |
Collapse
|
7
|
Weatherald J, Varughese RA, Liu J, Humbert M. Management of Pulmonary Arterial Hypertension. Semin Respir Crit Care Med 2023; 44:746-761. [PMID: 37369218 DOI: 10.1055/s-0043-1770118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
Pulmonary arterial hypertension (PAH) is a rare pulmonary vascular disease characterized by progressive pulmonary arterial remodeling, increased pulmonary vascular resistance, right ventricular dysfunction, and reduced survival. Effective therapies have been developed that target three pathobiologic pathways in PAH: nitric oxide, endothelin-1, and prostacyclin. Approved therapies for PAH include phosphodiesterase type-5 inhibitors, soluble guanylate cyclase stimulators, endothelin receptor antagonists, prostacyclin analogs, and prostacyclin receptor agonists. Management of PAH in the modern era incorporates multidimensional risk assessment to guide the use of these medications. For patients with PAH and without significant comorbidities, current guidelines recommend two oral medications (phosphodiesterase type-5 inhibitor and endothelin receptor antagonist) for low- and intermediate-risk patients, with triple therapy including a parenteral prostacyclin to be considered in those at high or intermediate-high risk. Combination therapy may be poorly tolerated and less effective in patients with PAH and cardiopulmonary comorbidities. Thus, a single-agent approach with individualized decisions to add-on other PAH therapies is recommended in older patients and those with significant comorbid conditions. Management of PAH is best performed in multidisciplinary teams located in experienced centers. Other core pillars of PAH management include supportive and adjunctive treatments including oxygen, diuretics, rehabilitation, and anticoagulation in certain patients. Patients with PAH who progress despite optimal treatment or who are refractory to best medical care should be referred for lung transplantation, if eligible. Despite considerable progress, PAH is often fatal and new therapies that reverse the disease and improve outcomes are desperately needed.
Collapse
Affiliation(s)
- Jason Weatherald
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Rhea A Varughese
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Jonathan Liu
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, Canada
| | - Marc Humbert
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- Hôpital Marie Lannelongue, Le Plessis Robinson, INSERM UMR_S 999, France
| |
Collapse
|
8
|
Miller CE, Franco V, Smith JS, Balasubramanian V, Kingrey J, Zolty R, Melendres-Groves L, Huston J, Elwing JM, Ravichandran A, Cella D, Shen E, Seaman S, Thrasher CM, Broderick M, Oudiz RJ. Parenteral treprostinil induction for rapid attainment of therapeutic doses of oral treprostinil. Respir Med 2023; 218:107374. [PMID: 37532157 DOI: 10.1016/j.rmed.2023.107374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/27/2023] [Accepted: 07/25/2023] [Indexed: 08/04/2023]
Abstract
RATIONALE Oral treprostinil slows disease progression and improves exercise capacity in pulmonary arterial hypertension; however, titration can be prolonged. Published data suggests prostacyclin-naïve patients achieve total daily oral treprostinil doses of about 6 mg by Week 16, while those on prior parenteral treprostinil reach higher doses at the same timepoint. OBJECTIVES EXPEDITE (NCT03497689), a single-arm, multicenter study, assessed the efficacy of rapid parenteral treprostinil induction to quickly reach higher doses of oral treprostinil for the treatment of pulmonary arterial hypertension. METHODS Parenteral treprostinil was titrated for 2-8 weeks, followed by cross-titration of oral treprostinil. The primary endpoint was percentage of patients reaching ≥12 mg daily of oral treprostinil at Week 16. Secondary endpoints included clinical changes from baseline to Week 16. RESULTS Twenty-nine prostacyclin-naïve patients were included in efficacy analyses. At Week 16, the mean daily oral treprostinil dose was 16.4 mg; 79% of patients met the primary endpoint. From baseline to Week 16, median REVEAL Lite 2 score improved (decreased) from 6 to 3.5 (p = 0.0006). Statistically significant improvements were also seen in World Health Organization Functional Class, N-terminal-pro brain natriuretic peptide levels, 6-minute walk distance, right atrial area, Borg Dyspnea Score, and emPHasis-10 score. Favorable trends were seen in risk stratification, echocardiography parameters, disease symptoms, and treatment satisfaction. CONCLUSION Short-course parenteral treprostinil induction resulted in oral treprostinil doses over twice those reported in de novo initiations and may be a useful approach to quickly achieve the therapeutic benefits of oral treprostinil.
Collapse
Affiliation(s)
| | | | | | | | - John Kingrey
- Integris Baptist NZTI, Oklahoma City, OK, 73112, USA
| | - Ronald Zolty
- University of Nebraska Medical Center, Omaha, NE, USA
| | | | | | | | | | - Dana Cella
- United Therapeutics Corporation, Research Triangle Park, NC, USA
| | - Eric Shen
- United Therapeutics Corporation, Research Triangle Park, NC, USA
| | - Scott Seaman
- United Therapeutics Corporation, Research Triangle Park, NC, USA
| | | | | | - Ronald J Oudiz
- Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| |
Collapse
|
9
|
Alqarni AA, Aldhahir AM, Alghamdi SA, Alqahtani JS, Siraj RA, Alwafi H, AlGarni AA, Majrshi MS, Alshehri SM, Pang L. Role of prostanoids, nitric oxide and endothelin pathways in pulmonary hypertension due to COPD. Front Med (Lausanne) 2023; 10:1275684. [PMID: 37881627 PMCID: PMC10597708 DOI: 10.3389/fmed.2023.1275684] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 09/19/2023] [Indexed: 10/27/2023] Open
Abstract
Pulmonary hypertension (PH) due to chronic obstructive pulmonary disease (COPD) is classified as Group 3 PH, with no current proven targeted therapies. Studies suggest that cigarette smoke, the most risk factor for COPD can cause vascular remodelling and eventually PH as a result of dysfunction and proliferation of pulmonary artery smooth muscle cells (PASMCs) and pulmonary artery endothelial cells (PAECs). In addition, hypoxia is a known driver of pulmonary vascular remodelling in COPD, and it is also thought that the presence of hypoxia in patients with COPD may further exaggerate cigarette smoke-induced vascular remodelling; however, the underlying cause is not fully understood. Three main pathways (prostanoids, nitric oxide and endothelin) are currently used as a therapeutic target for the treatment of patients with different groups of PH. However, drugs targeting these three pathways are not approved for patients with COPD-associated PH due to lack of evidence. Thus, this review aims to shed light on the role of impaired prostanoids, nitric oxide and endothelin pathways in cigarette smoke- and hypoxia-induced pulmonary vascular remodelling and also discusses the potential of using these pathways as therapeutic target for patients with PH secondary to COPD.
Collapse
Affiliation(s)
- Abdullah A. Alqarni
- Department of Respiratory Therapy, Faculty of Medical Rehabilitation Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
- Respiratory Therapy Unit, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Abdulelah M. Aldhahir
- Respiratory Therapy Department, Faculty of Applied Medical Sciences, Jazan University, Jazan, Saudi Arabia
| | - Sara A. Alghamdi
- Respiratory Care Department, Al Murjan Hospital, Jeddah, Saudi Arabia
| | - Jaber S. Alqahtani
- Department of Respiratory Care, Prince Sultan Military College of Health Sciences, Dammam, Saudi Arabia
| | - Rayan A. Siraj
- Department of Respiratory Care, College of Applied Medical Sciences, King Faisal University, Al Ahsa, Saudi Arabia
| | - Hassan Alwafi
- Faculty of Medicine, Umm Al-Qura University, Mecca, Saudi Arabia
| | - Abdulkareem A. AlGarni
- King Abdulaziz Hospital, The Ministry of National Guard Health Affairs, Al Ahsa, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, College of Applied Medical Sciences, Al Ahsa, Saudi Arabia
| | - Mansour S. Majrshi
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
| | - Saad M. Alshehri
- Department of Respiratory Therapy, King Fahad General Hospital, Jeddah, Saudi Arabia
| | - Linhua Pang
- Respiratory Medicine Research Group, Academic Unit for Translational Medical Sciences, University of Nottingham School of Medicine, Nottingham, United Kingdom
| |
Collapse
|
10
|
Humbert M, Sitbon O, Guignabert C, Savale L, Boucly A, Gallant-Dewavrin M, McLaughlin V, Hoeper MM, Weatherald J. Treatment of pulmonary arterial hypertension: recent progress and a look to the future. THE LANCET. RESPIRATORY MEDICINE 2023; 11:804-819. [PMID: 37591298 DOI: 10.1016/s2213-2600(23)00264-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 07/03/2023] [Accepted: 07/06/2023] [Indexed: 08/19/2023]
Abstract
Pulmonary arterial hypertension (PAH) is a severe but treatable form of pre-capillary pulmonary hypertension caused by pulmonary vascular remodelling. As a result of basic science discoveries, randomised controlled trials, studies of real-world data, and the development of clinical practice guidelines, considerable progress has been made in the treatment options and outcomes for patients with PAH, underscoring the importance of seamless translation of information from bench to bedside and, ultimately, to patients. However, PAH still carries a high mortality rate, which emphasises the urgent need for transformative innovations in the field. In this Series paper, written by a group of clinicians, researchers, and a patient with PAH, we review therapeutic approaches and treatment options for PAH. We summarise current knowledge of the cellular and molecular mechanisms of PAH, with an emphasis on emerging treatable pathways and optimisation of current management strategies. In considering future directions for the field, our ambition is to identify therapies with the potential to stall or reverse pulmonary vascular remodelling. We highlight novel therapeutic approaches, the important role of patients as partners in research, and innovative approaches to PAH clinical trials.
Collapse
Affiliation(s)
- Marc Humbert
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, ERN-LUNG, Le Kremlin-Bicêtre, France.
| | - Olivier Sitbon
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, ERN-LUNG, Le Kremlin-Bicêtre, France
| | - Christophe Guignabert
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, ERN-LUNG, Le Kremlin-Bicêtre, France
| | - Laurent Savale
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, ERN-LUNG, Le Kremlin-Bicêtre, France
| | - Athénaïs Boucly
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, ERN-LUNG, Le Kremlin-Bicêtre, France
| | | | - Vallerie McLaughlin
- Department of Internal Medicine, Division of Cardiology, Frankel Cardiovascular Center University of Michigan Medical School, Ann Arbor, MI, USA
| | - Marius M Hoeper
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Hannover, Germany; Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hanover (BREATH), Hannover, Germany
| | - Jason Weatherald
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
11
|
Alqarni AA, Aldhahir AM, Bintalib HM, Alqahtani JS, Siraj RA, Majrshi M, AlGarni AA, Naser AY, Alghamdi SA, Alwafi H. Inhaled therapies targeting prostacyclin pathway in pulmonary hypertension due to COPD: systematic review. Front Med (Lausanne) 2023; 10:1217156. [PMID: 37706024 PMCID: PMC10496018 DOI: 10.3389/fmed.2023.1217156] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 08/08/2023] [Indexed: 09/15/2023] Open
Abstract
Background Pulmonary hypertension due to chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD) is classified as group 3 pulmonary hypertension. Inhaled treprostinil, a prostaglandin I2 analogue also known as prostacyclin, has recently been approved as a first drug for patients with pulmonary hypertension secondary to ILD. However, due to a lack of evidence, no therapies are currently approved for those with COPD-associated pulmonary hypertension. Thus, this systematic review aims to summarise the current evidence to assess the impact of inhaled prostaglandin I2 analogue use on the pulmonary hemodynamics, exercise function, lung function, and gas exchange in patients with pulmonary hypertension due to COPD. Methods We systematically searched the electronic databases of Medline, Embase, Scopus and Cochrane from inception to 1 February 2023. Studies of adult patients with a confirmed diagnosis of COPD-associated pulmonary hypertension who received inhaled drugs targeting the prostacyclin pathway were included in the systematic review. Case reports, systematic reviews, conference abstracts with no full text, non-full-text articles, non-English manuscripts and book chapters were excluded from this systematic review. A risk-of-bias assessment was carried out for the studies included in this review, using two different Cochrane risk-of-bias tools for randomised and non-randomised clinical trials. Results A total of four studies met our inclusion criteria and were included in this systematic review. The results of one prospective clinical trial showed an improvement in the pulmonary hemodynamics (e.g., cardiac index, cardiac output and mean pulmonary artery pressure) in response to inhaled prostacyclin use in patients with pulmonary hypertension secondary to COPD. However, the severity of dyspnoea, lung function, exercise capacity and gas exchange were not affected when inhaled prostacyclin was used for patients with COPD-related pulmonary hypertension. Conclusion This systematic review demonstrated that although inhaled prostacyclin does not seem to improve COPD-related outcomes (e.g., lung function and exercise capacity), short-term use of inhaled prostacyclin has the potential to reduce mean pulmonary artery pressure and pulmonary vascular resistance without impairing ventilation-perfusion mismatch. Further studies with larger sample sizes are warranted. Systematic review registration CRD42022372803, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=372803.
Collapse
Affiliation(s)
- Abdullah A. Alqarni
- Department of Respiratory Therapy, Faculty of Medical Rehabilitation Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
- Respiratory Therapy Unit, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Abdulelah M. Aldhahir
- Respiratory Therapy Department, Faculty of Applied Medical Sciences, Jazan University, Jazan, Saudi Arabia
| | - Heba M. Bintalib
- Department of Respiratory Care, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Centre, Jeddah, Saudi Arabia
| | - Jaber S. Alqahtani
- Department of Respiratory Care, Prince Sultan Military College of Health Sciences, Dammam, Saudi Arabia
| | - Rayan A. Siraj
- Department of Respiratory Care, College of Applied Medical Sciences, King Faisal University, Al Ahsa, Saudi Arabia
| | - Mansour Majrshi
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
| | - Abdulkareem A. AlGarni
- King Abdulaziz Hospital, The Ministry of National Guard Health Affairs, Al Ahsa, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, College of Applied Medical Sciences, Al Ahsa, Saudi Arabia
| | - Abdallah Y. Naser
- Department of Applied Pharmaceutical Sciences and Clinical Pharmacy, Faculty of Pharmacy, Isra University, Amman, Jordan
| | - Sara A. Alghamdi
- Respiratory Care Department, Mediclinic Almurjan Hospital, Jeddah, Saudi Arabia
| | - Hassan Alwafi
- Faculty of Medicine, Umm Al-Qura University, Mecca, Saudi Arabia
| |
Collapse
|
12
|
Harutyunova S, Benjamin N, Eichstaedt C, Marra AM, Xanthouli P, Nagel C, Grünig E, Egenlauf B. Long-Term Safety, Outcome, and Clinical Effects of Subcutaneous and Intravenous Treprostinil Treatment in Patients with Severe Chronic Pulmonary Arterial Hypertension. Respiration 2023; 102:579-590. [PMID: 37544296 DOI: 10.1159/000531169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/16/2023] [Indexed: 08/08/2023] Open
Abstract
BACKGROUND Current guidelines recommend treatment with parenteral prostacyclin analogs in patients with severe pulmonary arterial hypertension (PAH), who have insufficient response to treatment. Real-life data are sought to help physicians in treatment decisions and clinical care of patients. OBJECTIVE This study analyzed safety, clinical effects, and long-term outcomes of subcutaneous (sc) and/or intravenous (iv) treprostinil via different pump systems in consecutive patients with PAH. METHODS Thirty-seven patients with severe progressive PAH despite dual combination therapy (20 female, mean age: 52.3 ± 15 years, mean pulmonary vascular resistance: 12.1 ± 5.1 WU) were initiated with add-on treprostinil sc and were routinely clinically assessed. Changes in clinical parameters, adverse events, and outcome were analyzed retrospectively. RESULTS In 24 of 37 patients, treprostinil administration was continued iv via implantation of LENUS Pro® pump after 3 ± 1.3 months, 6 patients continued with sc therapy, and 7 discontinued treatment. After 3, 6, 9, and 12 months of treprostinil treatment, patients showed a significant improvement in mean 6-min walk distance and tricuspid annular plane systolic excursion compared to baseline. In 8 of the 24 patients, iv pumps required surgical revision. During a mean follow-up of 2.82 ± 1.95 years, 12 patients died, four received lung transplantation. Transplant-free survival after 1, 2, and 3 years was 85.7%, 69.2%, and 65.3%, respectively. CONCLUSION sc treprostinil as add-on to double combination treatment significantly improved exercise capacity and right heart function. In most patients, treprostinil could be continued via more tolerable iv administration approach (LENUS Pro® pump), showing reasonable overall survival with respect to the severity of PAH.
Collapse
Affiliation(s)
- Satenik Harutyunova
- Center for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany,
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany,
| | - Nicola Benjamin
- Center for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Christina Eichstaedt
- Center for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
- Institute of Human Genetics, Laboratory for Molecular Genetic Diagnostics, Heidelberg University, Heidelberg, Germany
| | - Alberto M Marra
- Center for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
- Internal Medicine Section, Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Panagiota Xanthouli
- Center for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Christian Nagel
- Center for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
- Department of Pneumology, Clinic Baden-Baden, Baden-Baden, Germany
- Practice of Pneumology, Max Grundig Clinic Bühlerhöhe, Bühl, Germany
| | - Ekkehard Grünig
- Center for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Benjamin Egenlauf
- Center for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| |
Collapse
|
13
|
Steringer-Mascherbauer R, Huber C, Fröschl U, Engleder D, Függer R, Lummersdorfer M, Lenhard R, Martinek M. Intravenous Treprostinil in Severe Inoperable Chronic Thromboembolic Pulmonary Hypertension Using Implantable Pumps-Single-Center Experience over More Than a Decade. J Cardiovasc Dev Dis 2023; 10:318. [PMID: 37623331 PMCID: PMC10455634 DOI: 10.3390/jcdd10080318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/14/2023] [Accepted: 07/19/2023] [Indexed: 08/26/2023] Open
Abstract
The management of chronic thromboembolic pulmonary hypertension has significantly changed over the last decade with the availability of both specific therapies and interventional treatments. In parallel, implantable pumps for intravenous administration of treprostinil have broadened the spectrum of continuous prostanoid infusion. We evaluated the course of 17 consecutive patients with inoperable chronic thromboembolic pulmonary hypertension treated with treprostinil by means of an implantable infusion pump between 2011 and 2023 at our center. Complications associated with the infusion system were rare, leading to 0.4 unplanned surgical interventions during 17,160 patient days. No additional safety signals were detected, and clinical benefits achieved with subcutaneous treprostinil before pump implantation could be maintained in all patients. No catheter-related infections or thromboembolic events were observed. Implantable infusion pumps offer an attractive alternative to subcutaneous treprostinil for patients intolerant to the subcutaneous route, including those with chronic thromboembolic pulmonary hypertension.
Collapse
Affiliation(s)
| | - Charlotte Huber
- Department of Cardiology, Ordensklinikum Linz GmbH Elisabethinen, 4020 Linz, Austria; (C.H.)
| | - Uwe Fröschl
- Department of Surgery, Ordensklinikum Linz GmbH Elisabethinen, 4020 Linz, Austria; (U.F.); (R.F.)
| | - Dagmar Engleder
- Institute for Anesthesiology and Intensive Care, Ordensklinikum Linz GmbH Elisabethinen, 4020 Linz, Austria
| | - Reinhold Függer
- Department of Surgery, Ordensklinikum Linz GmbH Elisabethinen, 4020 Linz, Austria; (U.F.); (R.F.)
| | - Maria Lummersdorfer
- Institute for Anesthesiology and Intensive Care, Ordensklinikum Linz GmbH Elisabethinen, 4020 Linz, Austria
| | | | - Martin Martinek
- Department of Cardiology, Ordensklinikum Linz GmbH Elisabethinen, 4020 Linz, Austria; (C.H.)
| |
Collapse
|
14
|
Garcia MVF, Coz-Yataco A, Al-Jaghbeer MJ. Pulmonary arterial hypertension trials put to the test: Using the fragility index to assess trials robustness. Heart Lung 2023; 61:147-152. [PMID: 37271106 DOI: 10.1016/j.hrtlng.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/29/2023] [Accepted: 05/30/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND Randomized clinical trials (RCTs) are considered the gold standard for evidence-based medicine. The Fragility Index (FI) is a tool to assess the robustness of RCT results. FI was validated for dichotomous outcomes and recent work expanded its use to continuous outcomes. Studying the robustness of RCTs in Pulmonary Arterial Hypertension (PAH) treatments is crucial due to the severity and mortality risks associated with this rare condition. OBJECTIVES Analyze FI and Fragility quotient (FQ) of significant primary outcomes in PAH RCTs and study FI correlation with sample size and journal impact factor. METHODS FI and FQ calculation followed by Spearman correlation to assess the correlation between FI and sample size, and FI and impact factor. RESULTS The median sample size of the 21 trials was 202 patients (IQR 106-267), with 6 trials reporting primary outcomes as dichotomous and 15 reporting continuous primary outcomes. The median FI was 10 (IQR 3-20), and the median FQ was 0.044 (0.026-0.097). A moderate correlation was found between FI and sample size, with r = 0.56; P = 0.008 and FI and journal impact factor (r=0.50; P=0.019). The FI for continuous outcomes was similar to that for dichotomous outcomes. CONCLUSIONS This study represents the first analysis of the FI and FQ of PAH treatment RCTs, and expands the use of FI to continuous outcomes in this context. The moderate correlation between FI and sample size suggests that increasing sample size alone is partially correlated to a higher FI. The similarity between FI for continuous and dichotomous outcomes supports the broader use of FI in PAH RCTs.
Collapse
Affiliation(s)
| | - Angel Coz-Yataco
- Cleveland Clinic Foundation, Fairview Hospital, 18101 Lorain Ave, Cleveland, OH 44111, United States; Respiratory Institute, Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Mohammed J Al-Jaghbeer
- Cleveland Clinic Foundation, Fairview Hospital, 18101 Lorain Ave, Cleveland, OH 44111, United States; Respiratory Institute, Cleveland Clinic Foundation, Cleveland, OH, United States; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States
| |
Collapse
|
15
|
Cox-Flaherty K, Moutchia J, Krowka MJ, Al-Naamani N, Fallon MB, DuBrock H, Forde KA, Krok K, Doyle MF, Kawut SM, Ventetuolo CE. Six-Minute walk distance predicts outcomes in liver transplant candidates. Liver Transpl 2023; 29:521-530. [PMID: 36691988 PMCID: PMC10101910 DOI: 10.1097/lvt.0000000000000071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 12/06/2022] [Indexed: 01/25/2023]
Abstract
A 6-minute walk test is a simple tool for assessing submaximal exercise capacity. We sought to determine whether a 6-minute walk distance (6MWD) predicts outcomes in patients with cirrhosis. The Pulmonary Vascular Complications of Liver Disease 2 study is a multicenter, prospective cohort study that enrolled adults with portal hypertension during liver transplantation evaluation. We excluded subjects with an incident or prevalent portopulmonary hypertension. The 6-minute walk test was performed using standardized methods. Cox proportional hazards modeling and multivariable linear regression analysis were performed to determine the relationship between baseline 6MWD and outcomes. The study sample included 352 subjects. The mean 6MWD was 391±101 m. For each 50-meter decrease in 6MWD, there was a 25% increase in the risk of death (HR 1.25, 95% CI [1.11, 1.41], p < 0.001) after adjustment for age, gender, body mass index, MELD-Na, and liver transplant as a time-varying covariate. In a multistate model, each 50-meter decrease in 6MWD was associated with an increased risk of death before the liver transplant ( p < 0.001) but not after the transplant. 6MWD was similar to MELD-Na in discriminating mortality. Each 50-meter decrease in 6MWD was associated with an increase in all-cause ( p < 0.001) and transplant-free hospitalizations ( p < 0.001) in multivariable models for time-to-recurrent events. Shorter 6MWD was associated with worse Short Form-36 physical ( p < 0.001) and mental component scores ( p = 0.05). In conclusion, shorter 6MWD is associated with an increased risk of death, hospitalizations, and worse quality of life in patients evaluated for liver transplantation. The 6-minute walk distance may be a useful adjunct for risk assessment in patients undergoing liver transplant evaluation.
Collapse
Affiliation(s)
| | - Jude Moutchia
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Nadine Al-Naamani
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - Kimberly A. Forde
- Department of Medicine, Lewis Katz School of Medicine at Temple University, PA, USA
| | - Karen Krok
- Department of Medicine, Penn State Health Milton S. Hershey Medical Center
| | | | - Steven M. Kawut
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Corey E. Ventetuolo
- Departments of Medicine, Brown University, Providence, RI, USA
- Health Services, Policy and Practice, Brown University, Providence, RI, USA
| |
Collapse
|
16
|
Camara RP, Coelho FDN, Cruz-Martins N, Marques-Alves P, Castro G, Baptista R, Ferreira F. Incidence of Bloodstream Infection in Patients with Pulmonary Hypertension under Intravenous Epoprostenol or Iloprost—A Multicentre, Retrospective Study. Int J Mol Sci 2023; 24:ijms24076434. [PMID: 37047407 PMCID: PMC10094981 DOI: 10.3390/ijms24076434] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 03/11/2023] [Accepted: 03/21/2023] [Indexed: 03/31/2023] Open
Abstract
Intravenous synthetic prostacyclin analogs (iPCAs), such as epoprostenol, treprostinil and iloprost have been widely used for the treatment of pulmonary arterial hypertension (PAH). Despite having good outcomes, continuous infusion of iPCAs has been associated with some adverse effects. Bloodstream infection (BSI) is one of the most severe complications, although poorly recognized, especially under iloprost administration, which few studies have addressed. This study aimed to compare the BSI incidence rates between intravenous iloprost and epoprostenol administration. Patients with pulmonary hypertension (PH) functional class III or IV receiving intravenous iloprost or epoprostenol through Hickman catheter, between 2004 and 2019, were retrospectively selected from two PH treatment centers. From a total of 36 patients (13 for iloprost and 23 for epoprostenol), 75% (n = 27) fulfilled the PAH criteria, mainly belonging to the idiopathic group. Overall BSI rate was 1.5/1000 days of treatment (3.38 and 0.09/1000 days for iloprost and epoprostenol, respectively). Patients receiving iloprost were at a higher risk of developing BSI than those receiving epoprostenol (HR: 12.5; 95% CI: 1.569–99.092). A higher mortality rate from BSI was also identified in the iloprost group (p = 0.04). Twenty-seven patients developed BSI, with 92% of them requiring hospitalization. A total of 29 agents were found, 10 Gram-positive (mainly Staphylococcus aureus; n = 5) and 19 Gram-negative (mainly Pseudomonas aeruginosa; n = 6) bacteria. Iloprost administration was linked to a significantly higher incidence of BSI, worse prognosis, and more BSI-related deaths than epoprostenol. BSI due to Gram-negative, commensal, low-virulence bacteria was also higher in the iloprost group. In short, physicians should be aware when prescribing iPCA to guarantee their patients’ safety and best medical care.
Collapse
Affiliation(s)
- Raquel Paulinetti Camara
- Cardiology Departament, Hospital Garcia de Orta, 2805-267 Almada, Portugal
- Pulmonology Department, Hospital Nossa Senhora do Rosário, Centro Hospitalar Barreiro-Montijo, 2830-003 Barreiro, Portugal
- Correspondence: (R.P.C.); (N.C.-M.)
| | - Francisco das Neves Coelho
- Cardiology Departament, Hospital Garcia de Orta, 2805-267 Almada, Portugal
- Polyvalent Intensive Care Unit, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, 1349-019 Lisbon, Portugal
| | - Natália Cruz-Martins
- Faculty of Medicine, University of Porto, 4099-002 Porto, Portugal
- Institute for Research and Innovation in Health (i3S), University of Porto, 4099-002 Porto, Portugal
- Institute of Research and Advanced Training in Health Sciences and Technologies (CESPU), Rua Central de Gandra, 4585-116 Gandra, Portugal
- TOXRUN—Toxicology Research Unit, University Institute of Health Sciences, CESPU, CRL, 4585-116 Gandra, Portugal
- Correspondence: (R.P.C.); (N.C.-M.)
| | - Patrícia Marques-Alves
- Pulmonary Vascular Disease Unit, Cardiology Department, Centro Hospitalar e Universitário de Coimbra, 3004-561 Coimbra, Portugal
| | - Graça Castro
- Pulmonary Vascular Disease Unit, Cardiology Department, Centro Hospitalar e Universitário de Coimbra, 3004-561 Coimbra, Portugal
| | - Rui Baptista
- Cardiology Department, Centro Hospitalar de Entre o Douro e Vouga, 4520-211 Santa Maria da Feira, Portugal
- Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
- ICBR—Institute for Clinical and Biomedical Research, Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), 3004-561 Coimbra, Portugal
| | - Filipa Ferreira
- Cardiology Departament, Hospital Garcia de Orta, 2805-267 Almada, Portugal
| |
Collapse
|
17
|
Zhu J, Yang L, Jia Y, Balistrieri A, Fraidenburg DR, Wang J, Tang H, Yuan JXJ. Pathogenic Mechanisms of Pulmonary Arterial Hypertension: Homeostasis Imbalance of Endothelium-Derived Relaxing and Contracting Factors. JACC. ASIA 2022; 2:787-802. [PMID: 36713766 PMCID: PMC9877237 DOI: 10.1016/j.jacasi.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 08/29/2022] [Accepted: 09/14/2022] [Indexed: 12/23/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a progressive and fatal disease. Sustained pulmonary vasoconstriction and concentric pulmonary vascular remodeling contribute to the elevated pulmonary vascular resistance and pulmonary artery pressure in PAH. Endothelial cells regulate vascular tension by producing endothelium-derived relaxing factors (EDRFs) and endothelium-derived contracting factors (EDCFs). Homeostasis of EDRF and EDCF production has been identified as a marker of the endothelium integrity. Impaired synthesis or release of EDRFs induces persistent vascular contraction and pulmonary artery remodeling, which subsequently leads to the development and progression of PAH. In this review, the authors summarize how EDRFs and EDCFs affect pulmonary vascular homeostasis, with special attention to the recently published novel mechanisms related to endothelial dysfunction in PAH and drugs associated with EDRFs and EDCFs.
Collapse
Key Words
- 5-HT, 5-hydroxytryptamine
- ACE, angiotensin-converting enzyme
- EC, endothelial cell
- EDCF, endothelium-derived contracting factor
- EDRF, endothelium-derived relaxing factor
- ET, endothelin
- PAH, pulmonary arterial hypertension
- PASMC, pulmonary artery smooth muscle cell
- PG, prostaglandin
- TPH, tryptophan hydroxylase
- TXA2, thromboxane A2
- cGMP, cyclic guanosine monophosphate
- endothelial dysfunction
- endothelium-derived relaxing factor
- pulmonary arterial hypertension
- vascular homeostasis
Collapse
Affiliation(s)
- Jinsheng Zhu
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangdong Key Laboratory of Vascular Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Lei Yang
- College of Veterinary Medicine, Northwest A&F University, Yangling, China
| | - Yangfan Jia
- College of Veterinary Medicine, Northwest A&F University, Yangling, China
| | - Angela Balistrieri
- Section of Physiology, Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California, San Diego, La Jolla, California, USA
| | - Dustin R. Fraidenburg
- Division of Pulmonary, Critical Care, Sleep, and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Jian Wang
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangdong Key Laboratory of Vascular Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China,Section of Physiology, Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California, San Diego, La Jolla, California, USA
| | - Haiyang Tang
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangdong Key Laboratory of Vascular Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China,Addresses for correspondence: Dr Haiyang Tang, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 195 West Dongfeng Road, Guangzhou, Guangdong 510120, China.
| | - Jason X-J Yuan
- Section of Physiology, Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California, San Diego, La Jolla, California, USA,Dr Jason X.-J. Yuan, Section of Physiology, Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California-San Diego, 9500 Gilman Drive, MC 0856, La Jolla, California 92093-0856, USA.
| |
Collapse
|
18
|
Nathan SD, Fernandes P, Psotka M, Vitulo P, Piccari L, Antoniou K, Nikkho SM, Stockbridge N. Pulmonary hypertension in interstitial lung disease: Clinical trial design and endpoints: A consensus statement from the Pulmonary Vascular Research Institute's Innovative Drug Development Initiative-Group 3 Pulmonary Hypertension. Pulm Circ 2022; 12:e12178. [PMID: 36578976 PMCID: PMC9780699 DOI: 10.1002/pul2.12178] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Pulmonary hypertension (PH) associated with interstitial lung disease (ILD) is an attractive target for clinical trials of PH medications. There are many factors that need to be considered to prime such studies for success. The patient phenotype most likely to respond to the intervention requires weighing the extent of the parenchymal lung disease against the severity of the hemodynamic impairment. The inclusion criteria should not be too restrictive, thus enabling recruitment. The trial should be of sufficient duration to meet the chosen endpoint which should reflect how the patient feels, functions, or survives. This paper summarizes prior studies in PH-ILD and provides a framework of the type of studies to be considered. Inclusion criteria, clinical trial endpoints, and pharmacovigilance in the context of PH-ILD trials are also addressed. Through lessons learnt from prior studies, suggestions and guidance for future clinical trials in PH-ILD are also provided.
Collapse
Affiliation(s)
- Steven D. Nathan
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular InstituteFalls ChurchVirginiaUSA
| | - Peter Fernandes
- Bellerophon Therapeutics Inc., Regulatory, Safety and Quality DepartmentWarrenNew JerseyUSA
| | - Mitchell Psotka
- Division of Cardiology and Nephrology, Food and Drug AdministrationSilver SpringMarylandUSA
| | - Patrizio Vitulo
- Department of Pulmonary Medicine, IRCCS Mediterranean Institute for Transplantation and Advanced Specialized, TherapiesPalermoSiciliaItaly
| | - Lucilla Piccari
- Hospital del Mar, Pulmonary Hypertension Unit, Department of Pulmonary MedicineBarcelonaCatalunya, ESSpain
| | - Katerina Antoniou
- University of Crete School of Medicine, Department of Thoracic MedicineHeraklionCreteGreece
| | | | - Norman Stockbridge
- US Food and Drug Administration, Division of Cardiology and NephrologySilver SpringMarylandUSA
| |
Collapse
|
19
|
Pitre T, Su J, Cui S, Scanlan R, Chiang C, Husnudinov R, Khalid MF, Khan N, Leung G, Mikhail D, Saadat P, Shahid S, Mah J, Mielniczuk L, Zeraatkar D, Mehta S. Medications for the treatment of pulmonary arterial hypertension: a systematic review and network meta-analysis. Eur Respir Rev 2022; 31:31/165/220036. [PMID: 35948391 DOI: 10.1183/16000617.0036-2022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 05/30/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND There is no consensus on the most effective treatments of pulmonary arterial hypertension (PAH). Our objective was to compare effects of medications for PAH. METHODS We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials and Clinicaltrials.gov from inception to December 2021. We performed a frequentist random-effects network meta-analysis on all included trials. We rated the certainty of the evidence using the Grades of Recommendation, Assessment, Development, and Evaluation approach. RESULTS We included 53 randomised controlled trials with 10 670 patients. Combination therapy with endothelin receptor antagonist (ERA) plus phosphodiesterase-5 inhibitors (PDE5i) reduced clinical worsening (120.7 fewer events per 1000, 95% CI 136.8-93.4 fewer; high certainty) and was superior to either ERA or PDE5i alone, both of which reduced clinical worsening, as did riociguat monotherapy (all high certainty). PDE5i (24.9 fewer deaths per 1000, 95% CI 35.2 fewer to 2.1 more); intravenous/subcutaneous prostanoids (18.3 fewer deaths per 1000, 95% CI 28.6 fewer deaths to 0) and riociguat (29.1 fewer deaths per 1000, 95% CI 38.6 fewer to 8.7 more) probably reduce mortality as compared to placebo (all moderate certainty). Combination therapy with ERA+PDE5i (49.9 m, 95% CI 25.9-73.8 m) and riociguat (49.5 m, 95% CI 17.3-81.7 m) probably increase 6-min walk distance as compared to placebo (moderate certainty). CONCLUSION Current PAH treatments improve clinically important outcomes, although the degree and certainty of benefit vary between treatments.
Collapse
Affiliation(s)
- Tyler Pitre
- Division of Internal Medicine, McMaster University, Hamilton, ON, Canada.,Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Johnny Su
- Division of Internal Medicine, McMaster University, Hamilton, ON, Canada.,Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sonya Cui
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ryan Scanlan
- Division of Internal Medicine, McMaster University, Hamilton, ON, Canada.,Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Christopher Chiang
- Division of Internal Medicine, McMaster University, Hamilton, ON, Canada.,Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Renata Husnudinov
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Nadia Khan
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Gareth Leung
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - David Mikhail
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Pakeezah Saadat
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Shaneela Shahid
- Health Research Methods Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Jasmine Mah
- Dept of Medicine, Dalhousie University, Halifax, NS, Canada
| | | | - Dena Zeraatkar
- Health Research Methods Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Harvard Medical School, Harvard University, Boston, MA, USA.,D. Zeraatkar and S. Mehta contributed equally to this article as senior authors and supervised the work
| | - Sanjay Mehta
- Southwest Ontario PH Clinic, Division of Respirology, Dept of Medicine, Lawson Health Research Institute, London Health Sciences Centre, Schulich School of Medicine, Western University, London, ON, Canada.,PHA Canada, Vancouver, BC, Canada.,D. Zeraatkar and S. Mehta contributed equally to this article as senior authors and supervised the work
| |
Collapse
|
20
|
Yang Y, Zeng Q, Gao J, Yang B, Zhou J, Li K, Li L, Wang A, Li X, Liu Z, Luo Q, Zhao Z, Liu B, Xue J, Jiang X, Konerman MC, Zheng L, Xiong C. High-circulating gut microbiota-dependent metabolite trimethylamine N-oxide is associated with poor prognosis in pulmonary arterial hypertension. EUROPEAN HEART JOURNAL OPEN 2022; 2:oeac021. [PMID: 36071697 PMCID: PMC9442843 DOI: 10.1093/ehjopen/oeac021] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/17/2022] [Indexed: 12/30/2022]
Abstract
Aims We aimed to examine the hypothesis that circulating trimethylamine-N-oxide (TMAO) levels serve as a biomarker in pulmonary arterial hypertension (PAH), and to determine whether 3,3-dimethyl-1-butanol (DMB), a TMAO inhibitor, exerted a protective effect in monocrotaline (MCT)-induced PAH rats. Methods and results In-patients with PAH were prospectively recruited from the Fuwai Hospital. Fasting blood samples were obtained to assess the TMAO levels and other laboratory values during the initial and second hospitalization. In a MCT-induced PAH rat, a normal diet and water supplemented with or without 1% DMB were administered for 4 weeks. The TMAO levels, haemodynamic examinations, changes in organ-tissue, and molecular levels were evaluated. In total, 124 patients with PAH were enrolled in this study. High TMAO levels were correlated with increased disease severity and poor prognosis even after adjusting for confounders. The TMAO levels in the rats decreased in the MCT + DMB group, accompanied by improved haemodynamic parameters, decreased right ventricular hypertrophy, and amelioration of pulmonary vascular remodelling. The decrease in abnormal apoptosis, excessive cell proliferation, transforming growth factor-β expression, and restoration of endothelial nitric oxide synthase after DMB treatment further explained the amelioration of PAH. Conclusion Increased TMAO levels were associated with poor prognosis in patients with PAH, and DMB played a protective effect in MCT-induced PAH rat.
Collapse
Affiliation(s)
- Yicheng Yang
- Center of Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Qixian Zeng
- Center of Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Jianing Gao
- The Institute of Cardiovascular Sciences and Institute of Systems Biomedicine, School of Basic Medical Sciences, Key Laboratory of Molecular Cardiovascular Sciences of Ministry of Education, NHC Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Health Science Center, Peking University , Beijing , China
| | - Beilan Yang
- Center of Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Jingjing Zhou
- Center of Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Ke Li
- China National Clinical Research Center for Neurological Diseases, Tiantan Hospital, Advanced Innovation Center for Human Brain Protection, The Capital Medical University , Beijing , China
| | - Li Li
- Department of Pathology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Tiantan Hospital, Advanced Innovation Center for Human Brain Protection, The Capital Medical University , Beijing , China
| | - Xin Li
- Center of Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Zhihong Liu
- Center of Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Qin Luo
- Center of Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Zhihui Zhao
- Center of Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Bingyang Liu
- Center of Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Jing Xue
- China National Clinical Research Center for Neurological Diseases, Tiantan Hospital, Advanced Innovation Center for Human Brain Protection, The Capital Medical University , Beijing , China
| | - Xue Jiang
- China National Clinical Research Center for Neurological Diseases, Tiantan Hospital, Advanced Innovation Center for Human Brain Protection, The Capital Medical University , Beijing , China
| | - Matthew C Konerman
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Institute for Health Care Policy and Innovation, University of Michigan , Ann Arbor, MI , USA
- VA Center for Clinical Management Research , Ann Arbor, MI , USA
| | - Lemin Zheng
- The Institute of Cardiovascular Sciences and Institute of Systems Biomedicine, School of Basic Medical Sciences, Key Laboratory of Molecular Cardiovascular Sciences of Ministry of Education, NHC Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Health Science Center, Peking University , Beijing , China
- China National Clinical Research Center for Neurological Diseases, Tiantan Hospital, Advanced Innovation Center for Human Brain Protection, The Capital Medical University , Beijing , China
| | - Changming Xiong
- Center of Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| |
Collapse
|
21
|
Santos-Gomes J, Gandra I, Adão R, Perros F, Brás-Silva C. An Overview of Circulating Pulmonary Arterial Hypertension Biomarkers. Front Cardiovasc Med 2022; 9:924873. [PMID: 35911521 PMCID: PMC9333554 DOI: 10.3389/fcvm.2022.924873] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/21/2022] [Indexed: 11/16/2022] Open
Abstract
Pulmonary arterial hypertension (PAH), also known as Group 1 Pulmonary Hypertension (PH), is a PH subset characterized by pulmonary vascular remodeling and pulmonary arterial obstruction. PAH has an estimated incidence of 15-50 people per million in the United States and Europe, and is associated with high mortality and morbidity, with patients' survival time after diagnosis being only 2.8 years. According to current guidelines, right heart catheterization is the gold standard for diagnostic and prognostic evaluation of PAH patients. However, this technique is highly invasive, so it is not used in routine clinical practice or patient follow-up. Thereby, it is essential to find new non-invasive strategies for evaluating disease progression. Biomarkers can be an effective solution for determining PAH patient prognosis and response to therapy, and aiding in diagnostic efforts, so long as their detection is non-invasive, easy, and objective. This review aims to clarify and describe some of the potential new candidates as circulating biomarkers of PAH.
Collapse
Affiliation(s)
- Joana Santos-Gomes
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Inês Gandra
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Rui Adão
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Frédéric Perros
- Paris-Porto Pulmonary Hypertension Collaborative Laboratory (3PH), UMR_S 999, INSERM, Université Paris-Saclay, Paris, France
- Université Paris–Saclay, AP-HP, INSERM UMR_S 999, Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital de Bicêtre, Le Kremlin Bicêtre, France
| | - Carmen Brás-Silva
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
- Faculty of Nutrition and Food Sciences, University of Porto, Porto, Portugal
| |
Collapse
|
22
|
Song C, Kunovszki P, Beaudet A. Comparison of Healthcare Encounters and Drug Persistence in Patients With Pulmonary Arterial Hypertension Receiving Oral Selexipag, Inhaled Iloprost, or Parenteral Treprostinil: A Retrospective Database Analysis. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2022; 9:151-160. [PMID: 35800882 PMCID: PMC9178228 DOI: 10.36469/001c.35246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 05/13/2022] [Indexed: 06/15/2023]
Abstract
Background: Agents targeting the prostacyclin (PGI2) pathway are important in managing pulmonary arterial hypertension (PAH). No head-to-head clinical trials have compared outcomes between the 3 different PGI2-pathway drugs most commonly available in countries with advanced healthcare: oral selexipag, inhaled iloprost, and parenteral (subcutaneous or intravenous) treprostinil. Objectives: To conduct retrospective database analyses to describe characteristics of patients with PAH initiating therapy with these agents and compare the rate and risk of healthcare facility encounters and drug persistence. Methods: Data were obtained from the Optum™ Clinformatics® Data Mart and Truven™ Health Analytics® MarketScan® Commercial Claims and Encounters databases from July 1, 2008, to September 30, 2020 (Optum™), or October 31, 2020 (Truven™). Patients were categorized into index-drug cohorts based on first pharmacy claims for selexipag, inhaled iloprost, or parenteral treprostinil. Eligible patients were ≥18 years of age with ≥1 ICD-9-CM or ICD-10-CM diagnosis code indicating pulmonary hypertension and no diagnosis code suggesting Group 3-5 pulmonary hypertension. Rates of hospitalization (inpatient admissions), emergency room visits, or outpatient visits per person-year were calculated. Drug persistence was measured as time to discontinuation of index drug. Multivariable analyses were performed to compare outcomes with selexipag vs inhaled iloprost and parenteral treprostinil, adjusting for baseline characteristics using inverse probability of treatment weighting. Results: Overall, 583 patients were included in the Optum™ sample and 482 in the Truven™ sample. Mean (SD) age was 61.7 (14.5) and 49.3 (11.3) years, respectively; 74.4% and 75.7% of patients, respectively, were women. In the pooled samples, after adjustment for baseline characteristics, selexipag had a lower risk than inhaled iloprost or parenteral treprostinil for hospitalization (relative rate ratio [95% CI], 0.40 [0.22, 0.75], and 0.26 [0.17, 0.39]) and outpatient visits (0.66 [0.56, 0.78] and 0.76 [0.66, 0.88]). Trends toward lower risk of emergency room visits did not attain statistical significance. Drug discontinuation risk was 16% and 36% lower with selexipag vs parenteral treprostinil and inhaled iloprost, respectively. Conclusions: In real-world use, selexipag appears to be associated with lower rates of hospitalization and outpatient visits than inhaled iloprost or parenteral treprostinil. Further research is required to identify factors underlying these differences.
Collapse
Affiliation(s)
- Ci Song
- Janssen Global Commercial Strategy Organization
| | | | | |
Collapse
|
23
|
Maligireddy AR, Shore S, Sreenivas Kumar A, Harikrishnan S, Ajit Mullasari S, Sastry BK, Gupta S, Choudhary N, Atreya AR, Arora S, Moles VM, Mclaughlin VV, Aggarwal V. Current Status and Barriers in Pulmonary Hypertension Care Delivery in India: A Qualitative Analysis. Pulm Circ 2022; 12:e12094. [PMID: 35770278 PMCID: PMC9210552 DOI: 10.1002/pul2.12094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/26/2022] [Accepted: 05/06/2022] [Indexed: 11/18/2022] Open
Abstract
Although pulmonary hypertension (PH) is widely prevalent in India, care delivery for this condition has unique challenges in a lower middle‐income country (LMIC). To describe care delivery for patients with PH and associated barriers in India. We interviewed physicians across eight healthcare systems in India about PH clinical care using semi‐structured enquiries to understand care delivery and associated challenges in their specific practice as well as the associated health system. Qualitative analysis was performed using content analysis methodology. Physicians reported that common causes for PH in their practice were rheumatic mitral valve disease, coronary artery disease, and congenital heart disease (CHD). No center had a dedicated PH program. Only one center had a specific protocol for PH management. Diagnostic evaluations were limited, and right heart catheterizations were recommended for patients with CHD. Pulmonary vasodilator therapy was used for severe symptoms or markers of severe disease. Agents used to treat PH were widely variable across physicians and prostacyclins are unavailable in India. Barriers included limited training in PH for physicians, lack of consensus guidelines for PH specific to LMIC, and lack of financial incentives for health care systems to organize dedicated PH programs. Other barriers included poor patient health literacy and socioeconomic barriers that limit ability to test and treat PH. PH care delivery in India is variable with widely differing clinical practices. Dedicated training in PH management and establishing guidelines specific to LMIC like India can form the first step forward.
Collapse
Affiliation(s)
| | - Supriya Shore
- Division of Cardiology (Frankel Cardiovascular Center) Department of Internal Medicine, University of Michigan Medical School Ann Arbor MI USA
| | | | - S. Harikrishnan
- Sree Chitra Tirunal Institute for Medical Sciences and Technology Thiruvananthapuram India
| | | | | | | | | | - Auras R. Atreya
- Institute of Cardiac Sciences and Research AIG Hospitals Hyderabad India
| | - Sonali Arora
- Institute of Heart and Lung Transplant KIMS Hospital Hyderabad India
| | - Victor M. Moles
- Division of Cardiology (Frankel Cardiovascular Center) Department of Internal Medicine, University of Michigan Medical School Ann Arbor MI USA
| | - Vallerie V. Mclaughlin
- Division of Cardiology (Frankel Cardiovascular Center) Department of Internal Medicine, University of Michigan Medical School Ann Arbor MI USA
| | - Vikas Aggarwal
- Division of Cardiology (Frankel Cardiovascular Center) Department of Internal Medicine, University of Michigan Medical School Ann Arbor MI USA
- Division of Cardiology Veteran Affairs Hospital Ann Arbor MI USA
| |
Collapse
|
24
|
Ewert R, Habedank D, Halank M, Stubbe B, Opitz CF. Strategies for optimizing intravenous prostacyclin-analog therapy in patients with pulmonary arterial hypertension. Expert Rev Respir Med 2021; 16:57-66. [PMID: 34846985 DOI: 10.1080/17476348.2022.2011220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Intravenous prostacyclin-analogs (PCA, e.g. epoprostenol, treprostinil, iloprost) have become an essential part in the therapy of patients with pulmonary hypertension (PH), mainly pulmonary arterial hypertension (PAH). They show considerable differences in pharmacology. A combination therapy including intravenous drugs is regarded as the 'gold standard' in most of PAH patients. AREAS COVERED This review discusses and summarizes the studies and concepts on which this therapy is based. To date, intravenous prostacyclin-analogs are mainly administered when standard therapy fails to improve patients to low-risk status. However, preliminary data from uncontrolled studies suggest that an 'upfront triple' therapy including intravenous or subcutaneous prostacyclin-analogs could be preferable in selected patients. EXPERT OPINION Various IV PCA have been evaluated in the treatment of patients with PAH. Today, combination therapy is the 'gold standard' for the majority of patients. Intravenous PCA is recommended from functional class III onwards. Timing of its initiation is still a point of discussion. An escalation of therapy to IV or SC PCA is always necessary if a low-risk status cannot be achieved with other targeted therapies. Preliminary data suggest that selected patients could benefit from an 'upfront triple' therapy. Controlled studies on which such recommendation could be based are lacking.
Collapse
Affiliation(s)
- Ralf Ewert
- Internal Medicine B, Pneumology, University Hospital Greifswald, Greifswald, Germany
| | - Dirk Habedank
- Internal Medicine, Cardiology, DRK Kliniken Berlin, Berlin, Germany
| | - Michael Halank
- Internal Medicine, Pneumology, University Hospital Dresden, Dresden, Germany
| | - Beate Stubbe
- Internal Medicine B, Pneumology, University Hospital Greifswald, Greifswald, Germany
| | | |
Collapse
|
25
|
Akwii RG, Mikelis CM. Targeting the Angiopoietin/Tie Pathway: Prospects for Treatment of Retinal and Respiratory Disorders. Drugs 2021; 81:1731-1749. [PMID: 34586603 PMCID: PMC8479497 DOI: 10.1007/s40265-021-01605-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2021] [Indexed: 12/21/2022]
Abstract
Anti-angiogenic approaches have significantly advanced the treatment of vascular-related pathologies. The ephemeral outcome and known side effects of the current vascular endothelial growth factor (VEGF)-based anti-angiogenic treatments have intensified research on other growth factors. The angiopoietin/Tie (Ang/Tie) family has an established role in vascular physiology and regulates angiogenesis, vascular permeability, and inflammatory responses. The Ang/Tie family consists of angiopoietins 1-4, their receptors, tie1 and 2 and the vascular endothelial-protein tyrosine phosphatase (VE-PTP). Modulation of Tie2 activation has provided a promising outcome in preclinical models and has led to clinical trials of Ang/Tie-targeting drug candidates for retinal disorders. Although less is known about the role of Ang/Tie in pulmonary disorders, several studies have revealed great potential of the Ang/Tie family members as drug targets for pulmonary vascular disorders as well. In this review, we summarize the functions of the Ang/Tie pathway in retinal and pulmonary vascular physiology and relevant disorders and highlight promising drug candidates targeting this pathway currently being or expected to be under clinical evaluation for retinal and pulmonary vascular disorders.
Collapse
Affiliation(s)
- Racheal Grace Akwii
- Department of Pharmaceutical Sciences, School of Pharmacy, Texas Tech University Health Sciences Center, 1406 S. Coulter St., Amarillo, TX, 79106, USA
| | - Constantinos M Mikelis
- Department of Pharmaceutical Sciences, School of Pharmacy, Texas Tech University Health Sciences Center, 1406 S. Coulter St., Amarillo, TX, 79106, USA.
| |
Collapse
|
26
|
Mouratoglou SA, Bayoumy AA, Noordegraaf AV. Prediction Models and Scores in Pulmonary Hypertension: A Review. Curr Pharm Des 2021; 27:1266-1276. [PMID: 33155897 DOI: 10.2174/1381612824999201105163437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 10/07/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a serious disease with increased morbidity and mortality. The need for an individualized patient treatment approach necessitates the use of risk assessment in PAH patients. That may include a range of hemodynamic, clinical, imaging and biochemical parameters derived from clinical studies and registry data. OBJECTIVE In the current systematic review, we summarize the available data on risk prognostic models and scores in PAH and we explore the possible concordance amongst different risk stratification tools in PAH. METHODS PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines aided the performance of this systematic review. Eligible studies were identified through a literature search in the electronic databases PubMed, Science Direct, Google Scholar and Cochrane with the use of various combinations of MeSH and non-MeSH terms, with a focus on PAH. RESULTS Overall, 25 studies were included in the systematic review; out of them, 9 were studies deriving prognostic equations and risk scores and 16 were validating studies of an existing score. The majority of risk stratification scores use hemodynamic data for the assessment of prognosis, while others also include clinical and demographic variables in their equations. The risk discrimination in the overall PAH population was adequate, especially in differentiating the low versus high-risk patients, but their discrimination ability in the intermediate groups remained lower. Current ESC/ERS proposed risk stratification score utilizes a limited number of parameters with prognostic significance, whose prognostic ability has been validated in European patient populations. CONCLUSION Despite improvement in risk estimation of prognostic tools of the disease, PAH morbidity and mortality remain high, necessitating the need for the risk scores to undergo periodic re-evaluation and refinements to incorporate new data into predictors of disease progression and mortality and, thereby, maintain their clinical utility.
Collapse
Affiliation(s)
- Sophia Anastasia Mouratoglou
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Ahmed A Bayoumy
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| |
Collapse
|
27
|
Fu W, He W, Li Y, Chen Y, Liang J, Lei H, Fu L, Chen Y, Ren N, Jiang Q, Shen Y, Ma R, Wang T, Wang X, Zhang N, Xiao D, Liu C. Efficacy and safety of novel-targeted drugs in the treatment of pulmonary arterial hypertension: a Bayesian network meta-analysis. Drug Deliv 2021; 28:1007-1019. [PMID: 34060401 PMCID: PMC8172220 DOI: 10.1080/10717544.2021.1927243] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background: Pulmonary arterial hypertension (PAH) is a severe and fatal clinical syndrome characterized by high blood pressure and vascular remodeling in the pulmonary arterioles, which is also a rapidly progressing disease of the lung vasculature with a poor prognosis. Although PAH medication made great advances in recent years, the efficacy and safety of the medication are unsatisfactory. Therefore, we aimed to update and expand previous studies to explore the efficacy and safety of PAH-targeted medications. Methods: Relevant articles were searched and selected from published or publicly available data in PubMed, Cochrane Library, CNKI, PsycInfo, and MEDLINE (from inception until October 1st, 2020). To assess the efficacy and safety of PAH therapies, five efficacy outcomes [6-minute walking distance (6MWD), mean pulmonary arterial pressure (mPAP), WHO functional class (WHO FC) improvement, clinical worsening, death] and two safety outcomes [adverse events (AEs), serious adverse events (SAEs)] were selected. And 6MWD was regarded as the primary efficacy outcome. Results: 50 trials included with 10 996participants were selected. In terms of efficacy, all targeted drugs were more effective than placebo. For 6MWD, Bosentan + Sildenafil, Sildenafil, Bosentan + Iloprost were better than others. Bosentan + Iloprost and Bosentan + Sildenafil were better for mPAP. Bosentan + Iloprost and Ambrisentan + Tadalafil were more effective in improving WHO FC. Bosentan + Tadalafil and Bosentan + Iloprost had the Ambrisentan probability to reduce the incidence of clinical worsening. It is demonstrated that Ambrisentan had clear benefits in reducing all-cause mortality. In terms of safety, no therapies had been shown to reduce the incidence of SAEs significantly, and Ambrisentan + Tadalafil significantly increased the incidence of AEs. Conclusions: Phosphodiesterase 5 inhibitor (PDE5i) + Endothelin Receptor Antagonists (ERA) seems to be better therapy for PAH. Prostacyclin analogs (ProsA) + ERA appear promising, though additional data is warranted. Registration PROSPERO CRD42020218818.
Collapse
Affiliation(s)
- Wenhai Fu
- Department of Medicine, First Clinical School, Guangzhou Medical University, Guangzhou, China
| | - Wenjun He
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangdong Key Laboratory of Vascular Disease, Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Yuexin Li
- Department of Medicine, First Clinical School, Guangzhou Medical University, Guangzhou, China
| | - Yangxiao Chen
- Department of Medicine, First Clinical School, Guangzhou Medical University, Guangzhou, China
| | - Jingyi Liang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangdong Key Laboratory of Vascular Disease, Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Hui Lei
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangdong Key Laboratory of Vascular Disease, Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Lin Fu
- Department of Medicine, First Clinical School, Guangzhou Medical University, Guangzhou, China
| | - Yanghang Chen
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangdong Key Laboratory of Vascular Disease, Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Ni Ren
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangdong Key Laboratory of Vascular Disease, Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Qian Jiang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangdong Key Laboratory of Vascular Disease, Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Yi Shen
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangdong Key Laboratory of Vascular Disease, Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Ran Ma
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangdong Key Laboratory of Vascular Disease, Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Tao Wang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangdong Key Laboratory of Vascular Disease, Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Xinni Wang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangdong Key Laboratory of Vascular Disease, Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Nuofu Zhang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangdong Key Laboratory of Vascular Disease, Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Dakai Xiao
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangdong Key Laboratory of Vascular Disease, Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Chunli Liu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangdong Key Laboratory of Vascular Disease, Guangzhou Institute of Respiratory Health, Guangzhou, China
| |
Collapse
|
28
|
Stubbe B, Opitz CF, Halank M, Habedank D, Ewert R. Intravenous prostacyclin-analogue therapy in pulmonary arterial hypertension - A review of the past, present and future. Respir Med 2021; 179:106336. [PMID: 33647836 DOI: 10.1016/j.rmed.2021.106336] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 02/03/2021] [Accepted: 02/06/2021] [Indexed: 02/02/2023]
Abstract
Therapy with intravenous prostacyclin analogues in patients with pulmonary arterial hypertension (PAH) has been established for decades and is an integral component of the current guidelines for the treatment of pulmonary hypertension. Initially, these drugs were infused by external pump systems via tunnelled right atrial catheters with the need for cooling and frequent exchange of drug reservoirs. Associated complications included, among others, catheter-related infections. More recently, fully implantable pump systems have been developed with drug reservoirs that are filled transcutaneously, allowing intervals between refills of several weeks. This technique results in a low rate of infections. Epoprostenol, iloprost and treprostinil have all been used intravenously in PAH, but titration, dosing and dose escalation in long-term therapy are not standardized. Intravenous prostacyclin analogues are still under-used, despite available data suggesting that early and broad application of these therapies as part of risk-oriented, guideline-directed combination therapy for patients with PAH may lead to a survival benefit. This review provides a detailed overview of the drugs, infusion systems and dosing strategies used for intravenous therapy in patients with PAH.
Collapse
Affiliation(s)
- Beate Stubbe
- Department of Internal Medicine B, University Hospital Greifswald, Greifswald, Germany.
| | - Christian F Opitz
- Department of Cardiology, DRK Kliniken Berlin and Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Halank
- Universitätsklinikum Carl Gustav Carus, Medizinische Klinik 1, Bereich Pneumologie, Dresden, Germany
| | - Dirk Habedank
- Department of Cardiology, DRK Kliniken Berlin and Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ralf Ewert
- Department of Internal Medicine B, University Hospital Greifswald, Greifswald, Germany
| |
Collapse
|
29
|
Steringer-Mascherbauer R, Maria L, Reinhold F, Elisabeth S, Charlotte H, Dagmar E, Uwe F, Josef A. Rapid Switch From Subcutaneous to Intravenous Treprostinil in Precapillary Pulmonary Hypertension by Pump Implantation. J Cardiovasc Pharmacol 2021; 77:38-42. [PMID: 33079830 DOI: 10.1097/fjc.0000000000000933] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 09/14/2020] [Indexed: 11/25/2022]
Abstract
ABSTRACT Limited data are available on the transition from subcutaneous to intravenous prostacyclin in precapillary pulmonary hypertension. We performed a retrospective analysis of all patients who were switched from subcutaneous to intravenous treprostinil with an implantable infusion pump. We included 85 consecutive, clinically stable patients (mean age 66 years and range 16-85), who had been treated with subcutaneous treprostinil for mean 9 months (range 1-78) before pump implantation. An interdisciplinary expert panel defined standards for this procedure before the first implantation. As the first patient experienced a significant hypotensive episode indicating treprostinil overdose postoperatively, the time span to stop subcutaneous treprostinil was reduced to 60 minutes for all following patients. No events associated with the switch from subcutaneous to intravenous treprostinil were observed during postoperative hospital stay in 84 (98.8%) patients. Taking into account a likely depot effect of subcutaneous treprostinil patients can safely be switched to the intravenous route by the implantation of an infusion pump.
Collapse
Affiliation(s)
| | - Lummerstorfer Maria
- Institute for Anesthesiology and Intensive Care, Ordensklinikum Linz GmbH Elisabethinen, Academic Teaching Center Linz, Linz, Austria ; and
| | - Függer Reinhold
- Department of Surgery, Ordensklinikum Linz GmbH Elisabethinen, Academic Teaching Center Linz, Linz, Austria
| | - Sigmund Elisabeth
- Department of Cardiology, Ordensklinikum Linz GmbH Elisabethinen, Academic Teaching Center Linz, Linz, Austria
| | - Huber Charlotte
- Department of Cardiology, Ordensklinikum Linz GmbH Elisabethinen, Academic Teaching Center Linz, Linz, Austria
| | - Engleder Dagmar
- Institute for Anesthesiology and Intensive Care, Ordensklinikum Linz GmbH Elisabethinen, Academic Teaching Center Linz, Linz, Austria ; and
| | - Fröschl Uwe
- Department of Surgery, Ordensklinikum Linz GmbH Elisabethinen, Academic Teaching Center Linz, Linz, Austria
| | - Aichinger Josef
- Department of Cardiology, Ordensklinikum Linz GmbH Elisabethinen, Academic Teaching Center Linz, Linz, Austria
| |
Collapse
|
30
|
Genecand L, Wacker J, Beghetti M, Lador F. Selexipag for the treatment of pulmonary arterial hypertension. Expert Rev Respir Med 2020; 15:583-595. [PMID: 33382345 DOI: 10.1080/17476348.2021.1866990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION : Pulmonary arterial hypertension (PAH) is a rare pulmonary vasculopathy. This review focuses on selexipag, a prostacyclin receptor agonist validated for the treatment of PAH. AREAS COVERED We review the structure, mechanisms of action, pharmacokinetics, and pharmacodynamics of selexipag. Clinical efficacy and tolerability are discussed using the main clinical trial published for selexipag (GRIPHON) and its post-hoc analysis. EXPERT OPINION Selexipag should be added as a triple oral combination therapy in case of insufficient response to oral combination therapy with endothelin receptor antagonist and phosphodiesterase 5 inhibitor. However, selexipag should not replace parenteral prostacyclin in high-risk patients.
Collapse
Affiliation(s)
- Léon Genecand
- Internal Medicine Department,Riviera Chablais Hospital, Rennaz, Switzerland.,Pulmonary Hypertension Program, Geneva University Hospitals, Geneva, Switzerland
| | - Julie Wacker
- Pulmonary Hypertension Program, Geneva University Hospitals, Geneva, Switzerland.,Paediatric Cardiology Unit, University Hospitals of Geneva, Switzerland; Centre Universitaire Romand De Cardiologie Et Chirurgie Cardiaque Pédiatrique, University of Geneva and Lausanne, Switzerland
| | - Maurice Beghetti
- Pulmonary Hypertension Program, Geneva University Hospitals, Geneva, Switzerland.,Paediatric Cardiology Unit, University Hospitals of Geneva, Switzerland; Centre Universitaire Romand De Cardiologie Et Chirurgie Cardiaque Pédiatrique, University of Geneva and Lausanne, Switzerland
| | - Frédéric Lador
- Pulmonary Hypertension Program, Geneva University Hospitals, Geneva, Switzerland.,Department of Medicine Specialties, Division of Pulmonary Diseases, Geneva University Hospitals, Geneva, Switzerland
| |
Collapse
|
31
|
Abstract
Purpose of Review This review focuses on the therapeutic management and individualized approach to Group 1 pulmonary arterial hypertension (PAH), utilizing Food and Drug Administration-approved PAH-specific therapies and various interventional and surgical options for PAH. Recent Findings The paradigm for the optimal management of PAH has shifted in recent years. Upfront combination therapy with an endothelin receptor antagonist and a phosphodiesterase 5 inhibitor is now widely accepted as standard of care. In addition, there is increasing emphasis on starting prostanoids early in order to delay time to clinical worsening. However, less is known regarding which prostanoid agent to initiate and the optimum time to do so. In order to facilitate shared decision-making, there is an increasing need for decision tools based on guidelines and collective clinical experiences to navigate between pharmacologic and interventional treatments, as well as explore innovative, therapeutic pathways for PAH. Summary The management of PAH has become increasingly complex. With a growing number of PAH-specific therapies, intimate knowledge of the therapeutics and the potential barriers to adherence are integral to providing optimal care for this high-risk patient population. While current PAH-specific therapies largely mediate their effects through pulmonary vasodilation, ongoing research efforts are focused on ways to disrupt the mechanisms leading to pulmonary vascular remodeling. By targeting aberrations identified in the metabolism and proliferative state of pulmonary vascular cells, novel PAH treatment pathways may be just on the horizon.
Collapse
|
32
|
Hemnes A, Rothman AMK, Swift AJ, Zisman LS. Role of biomarkers in evaluation, treatment and clinical studies of pulmonary arterial hypertension. Pulm Circ 2020; 10:2045894020957234. [PMID: 33282185 PMCID: PMC7682212 DOI: 10.1177/2045894020957234] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 08/19/2020] [Indexed: 12/13/2022] Open
Abstract
Pulmonary arterial hypertension is a complex disease resulting from the interplay of myriad biological and environmental processes that lead to remodeling of the pulmonary vasculature with consequent pulmonary hypertension. Despite currently available therapies, there remains significant morbidity and mortality in this disease. There is great interest in identifying and applying biomarkers to help diagnose patients with pulmonary arterial hypertension, inform prognosis, guide therapy, and serve as surrogate endpoints. An extensive literature on potential biomarker candidates is available, but barriers to the implementation of biomarkers for clinical use in pulmonary arterial hypertension are substantial. Various omic strategies have been undertaken to identify key pathways regulated in pulmonary arterial hypertension that could serve as biomarkers including genomic, transcriptomic, proteomic, and metabolomic approaches. Other biologically relevant components such as circulating cells, microRNAs, exosomes, and cell-free DNA have recently been gaining attention. Because of the size of the datasets generated by these omic approaches and their complexity, artificial intelligence methods are being increasingly applied to decipher their meaning. There is growing interest in imaging the lung with various modalities to understand and visualize processes in the lung that lead to pulmonary vascular remodeling including high resolution computed tomography, Xenon magnetic resonance imaging, and positron emission tomography. Such imaging modalities have the potential to demonstrate disease modification resulting from therapeutic interventions. Because right ventricular function is a major determinant of prognosis, imaging of the right ventricle with echocardiography or cardiac magnetic resonance imaging plays an important role in the evaluation of patients and may also be useful in clinical studies of pulmonary arterial hypertension.
Collapse
Affiliation(s)
- Anna Hemnes
- Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Andrew J Swift
- University of Sheffield and Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | | |
Collapse
|
33
|
Kopp G, Hachulla AL, Noble S, Bringard A, Soccal PM, Beghetti M, Lador F. Unexpected Acceleration in Treprostinil Delivery Administered by a Lenus Pro® Implantable Pump in Two Patients Treated for Pulmonary Arterial Hypertension. Front Med (Lausanne) 2020; 7:539707. [PMID: 33195292 PMCID: PMC7662390 DOI: 10.3389/fmed.2020.539707] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 09/28/2020] [Indexed: 12/02/2022] Open
Abstract
Intravenous treprostinil administration by an implantable pump is an attractive option for pulmonary arterial hypertension (PAH) treatment and is the subject of recent publications. Short-term studies are promising, but there is still a lack of long-term prospective data. We analyzed the treprostinil flow rate administered by the Lenus Pro® implantable pump in 2 patients suffering from PAH during follow-up times of respectively 4.2 and 3 years. The flow rate delivered by the pumps in these 2 patients exceeded the manufacturer admitted margin of error within 2 years and continued to increase to reach, respectively, 158 and 120% of the expected flow rate at the end of the follow up. In one case, the implantable pump had to be removed for this reason. The ex-vivo flow rate of the withdrawn pump determined in the laboratory reached 173% of the predicted value. This correlated with the in-vivo measurement, which suggests a continuous flow increase even after pump removal and without treprostinil use. Spontaneous flow increase from such an implantable pump is a potentially major pitfall, which needs to be identified and actively managed by the responsible clinicians.
Collapse
Affiliation(s)
- Garance Kopp
- Division of Pneumology, University Hospitals of Geneva, Genève, Switzerland
| | - Anne-Lise Hachulla
- Division of Radiology, University Hospitals of Geneva, Genève, Switzerland.,Pulmonary Hypertension Program, University Hospitals of Geneva, Genève, Switzerland
| | - Stéphane Noble
- Pulmonary Hypertension Program, University Hospitals of Geneva, Genève, Switzerland.,Division of Cardiology, University Hospitals of Geneva, Genève, Switzerland.,Medical Faculty, University of Geneva, Genève, Switzerland
| | - Aurélien Bringard
- Division of Pneumology, University Hospitals of Geneva, Genève, Switzerland.,Medical Faculty, University of Geneva, Genève, Switzerland.,Division of Anesthesiology, Pharmacology, and Intensive Care, University Hospitals of Geneva, Genève, Switzerland
| | - Paola M Soccal
- Division of Pneumology, University Hospitals of Geneva, Genève, Switzerland.,Pulmonary Hypertension Program, University Hospitals of Geneva, Genève, Switzerland.,Medical Faculty, University of Geneva, Genève, Switzerland
| | - Maurice Beghetti
- Pulmonary Hypertension Program, University Hospitals of Geneva, Genève, Switzerland.,Medical Faculty, University of Geneva, Genève, Switzerland.,Pediatric Cardiology Unit, Children's Hospital, University Hospitals of Geneva, Genève, Switzerland
| | - Frédéric Lador
- Division of Pneumology, University Hospitals of Geneva, Genève, Switzerland.,Division of Cardiology, University Hospitals of Geneva, Genève, Switzerland.,Medical Faculty, University of Geneva, Genève, Switzerland
| |
Collapse
|
34
|
Abstract
PURPOSE OF REVIEW Pulmonary arterial hypertension (PAH) is a disease that carries a significant mortality left untreated. This article aims to review pharmacotherapeutics for PAH. RECENT FINDINGS PAH-specific therapies have evolved over the last three decades and have expanded from one therapy in the 1990s to 14 FDA-approved medications. Current therapies are directed at restoring the imbalance of vasoactive mediators that include nitric oxide, endothelin and prostacyclin. Although these agents are effective as monotherapy, recent trials have promulgated the strategy of upfront combination therapy. The availability of oral prostacyclin agonists has also allowed for expanded treatment options. Risk assessment is vital in guiding therapy for PAH patients. There is ongoing focus on targeting pathological mechanisms of the disease via novel therapies and repurposing existing drugs. SUMMARY There is an array of medications available for the treatment of PAH. Prudent combination of therapies to maximize treatment effect can improve morbidity and mortality. This article reviews the data supporting these therapies and attempts to outline an approach to patient management.
Collapse
|
35
|
Sugiyama Y, Tahara N, Bekki M, Tahara A, Honda A, Maeda-Ogata S, Sun J, Igata S, Fukumoto Y. Long-term survival outcome for pre-capillary pulmonary hypertension at a Japanese single center. Can J Physiol Pharmacol 2020; 98:644-652. [DOI: 10.1139/cjpp-2019-0663] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In recent years, several treatment options for patients with pre-capillary pulmonary hypertension (PH) have improved the short-term prognosis. However, the long-term survival for pre-capillary PH has not been well investigated. This study sought to investigate the long-term survival for pre-capillary PH in Kurume University Hospital. A total of 144 patients with pre-capillary PH (110 women, mean age 55.1 ± 17.9 years) were enrolled. The maximal duration of followup was 15 years with a mean followup of 5.77 years. The 15 year survival was 59.1% for pre-capillary PH, 68.5% for pulmonary arterial hypertension (PAH), and 44.3% for chronic thromboembolic PH. The 5 year survival was 50.9% for PH due to lung disease (PH-LD), indicating the worst in the pre-capillary PH subgroups. The survival for portopulmonary hypertension was the lowest among PAH groups, and PAH associated with connective tissue disease and congenital heart disease decreased 10 years after diagnosis. A 6 min walk distance and elevated brain natriuretic peptide were significantly associated with survival outcome in pre-capillary PH patients and diastolic pulmonary arterial pressure was related to survival for PH-LD. The survivals were different among pre-capillary PH groups in our hospital. Above all, the long-term survival was better than in previous reports.
Collapse
Affiliation(s)
- Yoichi Sugiyama
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Kurume City, Japan
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Kurume City, Japan
| | - Nobuhiro Tahara
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Kurume City, Japan
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Kurume City, Japan
| | - Munehisa Bekki
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Kurume City, Japan
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Kurume City, Japan
| | - Atsuko Tahara
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Kurume City, Japan
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Kurume City, Japan
| | - Akihiro Honda
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Kurume City, Japan
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Kurume City, Japan
| | - Shoko Maeda-Ogata
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Kurume City, Japan
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Kurume City, Japan
| | - Jiahui Sun
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Kurume City, Japan
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Kurume City, Japan
| | - Sachiyo Igata
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Kurume City, Japan
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Kurume City, Japan
| | - Yoshihiro Fukumoto
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Kurume City, Japan
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Kurume City, Japan
| |
Collapse
|
36
|
Zolty R. Pulmonary arterial hypertension specific therapy: The old and the new. Pharmacol Ther 2020; 214:107576. [PMID: 32417272 DOI: 10.1016/j.pharmthera.2020.107576] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2020] [Indexed: 02/08/2023]
Abstract
Pulmonary arterial hypertension (PAH) is a vascular disorder associated with high morbidity and mortality rate and is characterized by pulmonary vascular remodeling and increased pulmonary vascular resistance, ultimately resulting in right ventricular failure and death. Over the past few decades, significant advances in the understanding of the epidemiology, pathogenesis, and pathophysiology of pulmonary arterial hypertension have occured. This has led to the development of disease specific treatment including prostanoids, endothelin receptor antagonists, phosphodiesterase inhibitors, and soluble guanylate cyclase stimulators. These therapies significantly improve exercise capacity, quality of life, pulmonary hemodynamics, but none of the current treatments are actually curative and long-term prognosis remains poor. Thus, there is a clear need to develop new therapies. Several potential pharmacologic agents for the treatment of pulmonary arterial hypertension are under clinical development and some promising results with these treatments have been reported. These agents include tyrosine protein kinase inhibitors, rho-kinase inhibitors, synthetically produced vasoactive intestinal peptide, antagonists of the 5-HT2 receptors, and others. This article will review several of these promising new therapies and will discuss the current evidence regarding their potential benefit in pulmonary arterial hypertension.
Collapse
Affiliation(s)
- Ronald Zolty
- Cardiovascular Divisions, 982265 Nebraska Medical Center, University of Nebraska Medical Center, Omaha, NE 68198, United States of America.
| |
Collapse
|
37
|
Guigui A, Mazet R, Blaise S, Cracowski C, Beau-Guillaumot M, Kotzki S, Roustit M, Cracowski JL. Treprostinil Hydrogel Iontophoresis in Systemic Sclerosis-Related Digital Skin Ulcers: A Safety Study. J Clin Pharmacol 2020; 60:758-767. [PMID: 32080862 DOI: 10.1002/jcph.1574] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 12/02/2019] [Indexed: 12/19/2022]
Abstract
Digital skin ulcers are a severe complication of systemic sclerosis. The first-line treatment is intravenous iloprost, but it induces dose-limiting adverse effects. Local administration of treprostinil through skin iontophoresis may be a safe alternative. We conducted a 2-stage, randomized, placebo-controlled single-ascending-dose study in healthy volunteers and patients with systemic sclerosis-related digital ulcer. We further explored the effect of the procedure on skin blood flux. In a first group of healthy subjects, treprostinil and placebo iontophoresis were performed at 3 locations (ie, 6 skin sites): the sole of the foot, the leg, and the fingers. We used a 1-mg/mL hydrogel of treprostinil. We then randomly treated systemic sclerosis-related digital ulcers in a 3:1 ratio of treprostinil or placebo. We used concentrations from 0.1 to 1 mg/mL. All adverse events were recorded and rated according to the Common Terminology Criteria for Adverse Events (CTCAE), whereas skin microvascular blood flux was recorded with laser speckle contrast imaging. Among the 12 healthy volunteers, we observed 60 local adverse effects: burns, skin pain, erythema, and pruritus, graded 1 or 2 on the 5-point CTCAE scale. Treprostinil iontophoresis significantly increased skin blood flux on the leg (AUC0-4 h at 88 460% ± 6436% versus 12 730% ± 3397% baseline flux.min respectively; P < .001) and on the sole of the foot (AUC0-3 h at 20 124% ± 6119% versus 3142% ± 3036% baseline flux.min, respectively; P = .018) with a trend on the finger. Among 5 patients with systemic sclerosis-related digital ulcer, 2 resolutive local adverse effects were reported. Iontophoresis of treprostinil hydrogel was safe in systemic sclerosis patients with digital ulcer.
Collapse
Affiliation(s)
- Alicia Guigui
- Grenoble Alpes University Hospital, Clinical Pharmacology, Grenoble, France.,Univ. Grenoble Alpes, Grenoble, France
| | - Roseline Mazet
- Grenoble Alpes University Hospital, Pharmacy, Grenoble, France.,Univ. Grenoble Alpes, DPM, UMR CNRS 5063, ICMG FR 2607, Saint Martin d'Hères, France
| | - Sophie Blaise
- Univ. Grenoble Alpes, Grenoble, France.,Grenoble Alpes University Hospital, Department of Vascular Medicine, Grenoble, France
| | - Claire Cracowski
- Grenoble Alpes University Hospital, Clinical Pharmacology, Grenoble, France.,Univ. Grenoble Alpes, Grenoble, France
| | | | | | - Matthieu Roustit
- Grenoble Alpes University Hospital, Clinical Pharmacology, Grenoble, France.,Univ. Grenoble Alpes, Grenoble, France
| | - Jean-Luc Cracowski
- Grenoble Alpes University Hospital, Clinical Pharmacology, Grenoble, France.,Univ. Grenoble Alpes, Grenoble, France
| |
Collapse
|
38
|
Lindegaard Pedersen M, Krüger M, Grimm D, Infanger M, Wehland M. The prostacyclin analogue treprostinil in the treatment of pulmonary arterial hypertension. Basic Clin Pharmacol Toxicol 2020; 126:32-42. [PMID: 31403254 DOI: 10.1111/bcpt.13305] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 08/06/2019] [Indexed: 01/19/2023]
Abstract
Pulmonary arterial hypertension (PAH) is a rare but life-threatening disease that progresses rapidly and is currently without a cure. Pharmacological treatments aim to slow down disease progression and to reduce symptoms by targeting the prostacyclin, the endothelin or the nitric oxide pathway. Drugs targeting the prostacyclin pathway have been shown to be favourable for PAH patients by causing vasodilatative, anti-proliferative as well as anti-inflammatory effects, but tend to be underused, partially due to adverse effects and difficulties associated with their intravenous administration. Treprostinil, a stable prostacyclin analogue, was FDA-approved in 2002 to improve exercise capacity in PAH patients and is available in intravenous, subcutaneous, inhaled and oral form. The four different possible ways of administration, a long half-life and its stability at room temperature give treprostinil an advantage over epoprostenol, iloprost and selexipag, the three other FDA-approved drugs targeting the prostacyclin pathway. In clinical trials, treprostinil improved exercise capacity, quality of life (QOL), functional class and clinical status. While the different forms of treprostinil lead to specific complications, its general adverse effects are dizziness, nausea, pain in the jaw and extremities, diarrhoea, flushing and headache. This MiniReview will assess the benefits and drawbacks of treprostinil in the treatment of PAH by examining its specific mechanism of action and pharmacological properties, such as pharmacokinetics, pharmacodynamics, adverse effects and interactions. In addition, we will analyse and discuss results from different clinical trials, comparing treprostinil's four different forms to each other as well as to other drugs targeting the prostacyclin pathway.
Collapse
Affiliation(s)
| | - Marcus Krüger
- Clinic for Plastic, Aesthetic and Hand Surgery, Otto-von-Guericke University, Magdeburg, Germany
| | - Daniela Grimm
- Institute of Biomedicine, Pharmacology, Aarhus University, Aarhus C, Denmark.,Clinic for Plastic, Aesthetic and Hand Surgery, Otto-von-Guericke University, Magdeburg, Germany
| | - Manfred Infanger
- Clinic for Plastic, Aesthetic and Hand Surgery, Otto-von-Guericke University, Magdeburg, Germany
| | - Markus Wehland
- Clinic for Plastic, Aesthetic and Hand Surgery, Otto-von-Guericke University, Magdeburg, Germany
| |
Collapse
|
39
|
Arvidsson M, Ahmed A, Bouzina H, Rådegran G. Matrix metalloproteinase 7 in diagnosis and differentiation of pulmonary arterial hypertension. Pulm Circ 2019; 9:2045894019895414. [PMID: 31908766 PMCID: PMC6935882 DOI: 10.1177/2045894019895414] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 11/19/2019] [Indexed: 01/15/2023] Open
Abstract
Pulmonary arterial hypertension is a severe disease for which diagnosis often is delayed. Matrix metalloproteinases have been suggested to play a role in vascular remodeling and pulmonary hypertension development. Our aim was therefore to investigate the potential role of matrix metalloproteinases as biomarkers in diagnosis and differentiation of pulmonary arterial hypertension in relation to various causes of dyspnea and pulmonary hypertension. Using proximity extension assays, 10 matrix metalloproteinases and associated proteins were analyzed in venous plasma from healthy controls (n = 20), as well as patients diagnosed with pulmonary arterial hypertension (n = 48), chronic thromboembolic pulmonary hypertension (n = 20), pulmonary hypertension due to heart failure with preserved (n = 33) or reduced (n = 36) ejection fraction, and heart failure with reduced ejection fraction and heart failure with preserved ejection fraction without pulmonary hypertension (n = 15). Plasma levels of matrix metalloproteinase-2, -7, -9, -12 and TIMP-4 were elevated (p < 0.01) in pulmonary arterial hypertension compared to controls. Plasma levels of matrix metalloproteinase-7 were furthermore lower (p < 0.0081) in pulmonary arterial hypertension than in all the other disease groups, but higher compared to controls (p < 0.0001). Receiver operating characteristic analysis of matrix metalloproteinase-7 resulted in sensitivity of 58.7% and a specificity of 83.3% for detecting pulmonary arterial hypertension among the other disease groups. Plasma matrix metalloproteinase-7 may provide a potential new diagnostic tool to differentiate pulmonary arterial hypertension from other causes of dyspnea, including heart failure with or without pulmonary hypertension and healthy controls. Matrix metalloproteinase-7 may furthermore be involved in the development of pulmonary hypertension and pulmonary arterial hypertension. Future studies investigating the clinical usefulness of matrix metalloproteinase-7 in the differentiation and earlier diagnosis of pulmonary arterial hypertension, as well as its relationship to pulmonary arterial hypertension pathogenesis, are encouraged.
Collapse
Affiliation(s)
- Mattias Arvidsson
- Department of Clinical Sciences Lund, Cardiology, Faculty of Medicine, Lund University, Lund, Sweden.,The Hemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Abdulla Ahmed
- Department of Clinical Sciences Lund, Cardiology, Faculty of Medicine, Lund University, Lund, Sweden.,The Hemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Habib Bouzina
- Department of Clinical Sciences Lund, Cardiology, Faculty of Medicine, Lund University, Lund, Sweden.,The Hemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Göran Rådegran
- Department of Clinical Sciences Lund, Cardiology, Faculty of Medicine, Lund University, Lund, Sweden.,The Hemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| |
Collapse
|
40
|
Petrovič M, Locatelli I. Comparative effectiveness of pulmonary arterial hypertension drugs in treatment-naive patients: a network meta-analysis. J Comp Eff Res 2019; 9:7-22. [PMID: 31845591 DOI: 10.2217/cer-2019-0037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: No network meta-analysis has been conducted to study efficacy of drug therapies specific for treatment of pulmonary arterial hypertension in treatment-naive patients only. Methods: Randomized controlled trials on pulmonary arterial hypertension-specific drug therapies were searched and a Bayesian network meta-analysis was performed. The 6-min walking distance (6MWD) and all-cause mortality were efficacy outcomes, whereas discontinuation due to adverse events was a safety-related outcome. Results: Analysis included 3.713 patients from 21 trials. Combination of ambrisentan and tadalafil showed the greatest impact on 6MWD, followed by epoprostenol and intravenous treprostinil (high dose). The latter two demonstrated marked effect size on mortality, although not statistically significant. Conclusion: According to 6MWD, ambrisentan/tadalafil combination was considered as most effective among all comparisons. Prospero ID: CRD42019110832.
Collapse
Affiliation(s)
- Maja Petrovič
- Krka, d. d., Novo mesto, Šmarješka c. 6, 8501 Novo mesto, Slovenia.,University of Ljubljana, Faculty of Pharmacy, Department of Social Pharmacy, Aškerčeva c. 7, 1000 Ljubljana, Slovenia
| | - Igor Locatelli
- University of Ljubljana, Faculty of Pharmacy, Department of Social Pharmacy, Aškerčeva c. 7, 1000 Ljubljana, Slovenia
| |
Collapse
|
41
|
Ozen G, Benyahia C, Mani S, Boukais K, Silverstein AM, Bayles R, Nelsen AC, Castier Y, Danel C, Mal H, Clapp LH, Longrois D, Norel X. Bronchodilation induced by PGE 2 is impaired in Group III pulmonary hypertension. Br J Pharmacol 2019; 177:161-174. [PMID: 31476020 DOI: 10.1111/bph.14854] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 08/20/2019] [Accepted: 08/22/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND PURPOSE In patients with pulmonary hypertension (PH) associated with lung disease and/or hypoxia (Group III), decreased pulmonary vascular tone and tissue hypoxia is therapeutically beneficial. PGE2 and PGI2 induce potent relaxation of human bronchi from non-PH (control) patients via EP4 and IP receptors, respectively. However, the effects of PGE2 /PGI2 and their mimetics on human bronchi from PH patients are unknown. Here, we have compared relaxant effects of several PGI2 -mimetics approved for treating PH Group I with several PGE2 -mimetics, in bronchial preparations derived from PH Group III and control patients. EXPERIMENTAL APPROACH Relaxation of bronchial muscle was assessed in samples isolated from control and PH Group III patients. Expression of prostanoid receptors was analysed by western blot and real-time PCR, and endogenous PGE2 , PGI2 , and cAMP levels were determined by ELISA. KEY RESULTS Maximal relaxations induced by different EP4 receptor agonists (PGE2 , L-902688, and ONO-AE1-329) were decreased in human bronchi from PH patients, compared with controls. However, maximal relaxations produced by PGI2 -mimetics (iloprost, treprostinil, and beraprost) were similar for both groups of patients. Both EP4 and IP receptor protein and mRNA expressions were significantly lower in human bronchi from PH patients. cAMP levels significantly correlated with PGI2 but not with PGE2 levels. CONCLUSION AND IMPLICATIONS The PGI2 -mimetics retained maximal bronchodilation in PH Group III patients, whereas bronchodilation induced by EP4 receptor agonists was decreased. Restoration of EP4 receptor expression in airways of PH Group III patients with respiratory diseases could bring additional therapeutic benefit.
Collapse
Affiliation(s)
- Gulsev Ozen
- INSERM U1148, Hôpital Bichat, Paris, France.,Faculty of Pharmacy, Department of Pharmacology, Istanbul University, Istanbul, Turkey
| | - Chabha Benyahia
- INSERM U1148, Hôpital Bichat, Paris, France.,Paris 13 University (USPC), Villetaneuse, France
| | - Salma Mani
- INSERM U1148, Hôpital Bichat, Paris, France.,Paris 13 University (USPC), Villetaneuse, France.,Institut Supérieur de Biotechnologie de Monastir (ISBM), Université de Monastir, Monastir, Tunisia
| | | | | | | | | | - Yves Castier
- Hôpital Bichat-Claude Bernard, AP-HP, Paris Diderot University, Université de Paris, Paris, France
| | - Claire Danel
- Hôpital Bichat-Claude Bernard, AP-HP, Paris Diderot University, Université de Paris, Paris, France
| | - Hervé Mal
- Hôpital Bichat-Claude Bernard, AP-HP, Paris Diderot University, Université de Paris, Paris, France
| | - Lucie H Clapp
- Institute of Cardiovascular Science, University College London, London, UK
| | - Dan Longrois
- INSERM U1148, Hôpital Bichat, Paris, France.,Paris 13 University (USPC), Villetaneuse, France.,Hôpital Bichat-Claude Bernard, AP-HP, Paris Diderot University, Université de Paris, Paris, France
| | - Xavier Norel
- INSERM U1148, Hôpital Bichat, Paris, France.,Paris 13 University (USPC), Villetaneuse, France
| |
Collapse
|
42
|
Abstract
Pulmonary arterial hypertension (PAH) is a condition associated with substantial morbidity and mortality. Over the last 25 years there has been a significant evolution in the therapies to treat PAH. These therapies are effective for patients with group I PAH and group IV PH [chronic thromboembolic pulmonary hypertension (CTEPH)]. PAH is characterized by an imbalance of nitric oxide, prostacyclin and endothelin levels, and current pharmacotherapy involves these three pathways. Earlier clinical trials involving PAH-specific therapies evaluated improvements in 6-minute walk time as a primary improvement whereas contemporary trials have been larger and focused on morbidity and mortality reductions. While there may be a role for monotherapy in disease management, most patients should be considered for dual or triple therapy.
Collapse
Affiliation(s)
- Vishal Parikh
- Texas Heart Institute, Baylor College of Medicine, Houston, TX, USA
| | - Anju Bhardwaj
- Center for Advanced Cardiopulmonary Therapies and Transplantation at McGovern Medical School, Houston, TX, USA
| | - Ajith Nair
- Winters Center for Heart Failure Research, Michael E. DeBakey VA Medical Center, Texas Heart Institute Educational Faculty, Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
43
|
Ivy DD, Feinstein JA, Yung D, Mullen MP, Kirkpatrick EC, Hirsch R, Austin ED, Fineman J, Truong U, Solum D, Deng CQ, Hopper RK. Oral treprostinil in transition or as add-on therapy in pediatric pulmonary arterial hypertension. Pulm Circ 2019; 9:2045894019856471. [PMID: 31215336 PMCID: PMC6628532 DOI: 10.1177/2045894019856471] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Treprostinil, a prostacyclin analogue, is approved for the treatment of pulmonary
arterial hypertension (PAH) in adults. Transition from parenteral to oral
treprostinil has been successfully accomplished in adults with PAH but not in
children. In this multicenter study, pediatric patients treated with parenteral
(Cohort 1) or inhaled (Cohort 2) treprostinil were transitioned to oral
treprostinil. Prostacyclin-naïve individuals on background oral PAH therapy
received oral treprostinil as add-on therapy (Cohort 3). Successful transition
was oral treprostinil dose maintenance through week 24. Patients were monitored
for adverse events (AEs), 6-min walk distance (6MWD), PAH symptoms, World Health
Organization (WHO) Functional Class (FC), cardiac magnetic resonance imaging
(cMRI), cardiopulmonary exercise testing (CPET), and quality of life through 24
weeks. A total of 32 patients were enrolled in the study; 23 (72%) were girls
(mean age = 12.2 years). All patients were on background oral PAH therapy.
Overall, patients (96.9%) maintained transition to oral treprostinil; one
patient (Cohort 1) transitioned to oral treprostinil, then back to parenteral
after experiencing syncope and WHO FC change from II to III. Cohorts 1, 2, and 3
received a final mean oral treprostinil dose of 5.6, 3.3, and 4.5 mg t.i.d.,
respectively. All cohorts had variable changes in 6MWD, cMRI, and CPET. Overall,
12 serious AEs were reported. All patients had drug-related AEs including
headache (81%), diarrhea (69%), nausea (66%), vomiting (66%), and flushing
(56%). Pediatric patients maintained transition to oral treprostinil with
preservation of exercise capacity and WHO FC. Prostanoid-related AEs were most
common and similar to those reported in adults.
Collapse
Affiliation(s)
- D Dunbar Ivy
- 1 Children's Hospital of Colorado, Aurora, CO, USA
| | - Jeffrey A Feinstein
- 2 Lucile Packard Children's Hospital Stanford and Stanford University School of Medicine, Palo Alto, CA, USA
| | | | | | | | - Russel Hirsch
- 6 Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Eric D Austin
- 7 Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Jeffrey Fineman
- 8 University of California San Francisco, San Francisco, CA, USA
| | - Uyen Truong
- 1 Children's Hospital of Colorado, Aurora, CO, USA
| | - Derek Solum
- 9 United Therapeutics, Research Triangle Park, NC, USA
| | - C Q Deng
- 9 United Therapeutics, Research Triangle Park, NC, USA
| | - Rachel K Hopper
- 2 Lucile Packard Children's Hospital Stanford and Stanford University School of Medicine, Palo Alto, CA, USA.,10 Children's Hospital of Philadelphia, Philadelphia, PA, USA
| |
Collapse
|
44
|
Schoenberg NC, Farber HW. Add-on parenteral therapy in pulmonary arterial hypertension: The good, the bad, and the ugly. J Heart Lung Transplant 2019; 38:1003-1005. [PMID: 31495406 DOI: 10.1016/j.healun.2019.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 07/03/2019] [Indexed: 01/20/2023] Open
Affiliation(s)
- Noah C Schoenberg
- Pulmonary and Critical Care Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Harrison W Farber
- Pulmonary and Critical Care Division, Tufts Medical Center, Boston, Massachusetts.
| |
Collapse
|
45
|
White RJ, Parikh K, Allen R, Feldman J, Jerjez-Sanchez C, Pan L, Keogh A, Vizza CD, Shapiro S, Gordon K, Broderick M, Bartolome S. EXPRESS: Long term study of oral treprostinil to treat pulmonary arterial hypertension: dosing, tolerability, and pharmacokinetics. Pulm Circ 2019; 10:2045894019866335. [PMID: 31290359 PMCID: PMC7731723 DOI: 10.1177/2045894019866335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 07/07/2019] [Indexed: 11/25/2022] Open
Abstract
Oral treprostinil may be an option for low- and intermediate-risk patients with pulmonary arterial hypertension, a rare lung vascular disease. This open-label extension study collected data on participants who completed previously reported, placebo-controlled oral treprostinil studies. Eligible participants had completed the prospective parent studies and took increasing doses of oral treprostinil twice daily; some later transitioned to three times daily dosing. Investigators measured 6-minute walk distance at Month 12 as the sole efficacy measure but collected adverse events throughout the study. A single center measured pharmacokinetics in 13 subjects who changed dosing from twice daily to three times daily. Eight hundred and ninety-four participants enrolled and 71% completed one year of therapy, with a median total daily dose of 7 mg and a median 6-minute walk distance increase of 22 m (interquartile range, −14 to 67 m). Subjects achieving higher doses had larger increases in 6-minute walk distance; 42% of participants completed three years of therapy. Adverse events were typical for prostacyclin class therapy, but prostacyclin-type adverse events may have been better tolerated with three times daily dosing in 105 participants. In 13 participants transitioned to three times daily dosing with pharmacokinetic measurements before and after, trough drug levels were higher with three times daily dosing. Oral treprostinil is associated with modest but durable, dose-responsive effects on exercise tolerance for those who remained on therapy at one year in this prospective, uncontrolled study. Three times daily dosing was associated with higher trough levels and better tolerability. The recently completed Freedom-EV study will provide further insights into the utility of oral treprostinil (https://clinicaltrials.gov/show/NCT01560624 ).
Collapse
Affiliation(s)
| | - Keyur Parikh
- Care Institute of Medical Science, Sola, Ahmedabad, India
| | | | | | | | - Lei Pan
- Beijing Shijitan Hospital, Beijing, China
| | | | - C. Dario Vizza
- Dipartimento di Scienze Cliniche Internistiche, Università La Sapienza Roma, Rome, Italy
| | - Shelley Shapiro
- David Geffen UCLA School of Medicine and West Los Angeles VA Healthcare Center, Los Angeles, USA
| | - Kathryn Gordon
- United Therapeutics Corporation, Research Triangle Park, USA
| | | | | |
Collapse
|
46
|
Light A, Heininger A, Wessman K, Frutiger K, White RJ. 8% Capsaicin Patch as Analgesia for Severe Treprostinil Infusion Site Pain. PAIN MEDICINE 2019; 18:2515-2517. [PMID: 28541429 PMCID: PMC5914427 DOI: 10.1093/pm/pnx119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Allison Light
- Department of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Mary Parkes Center for Asthma, Allergy, and Pulmonary Care, Rochester, New York, USA
| | - Antonia Heininger
- Department of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Mary Parkes Center for Asthma, Allergy, and Pulmonary Care, Rochester, New York, USA
| | - Kathleen Wessman
- Department of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Mary Parkes Center for Asthma, Allergy, and Pulmonary Care, Rochester, New York, USA
| | - Karen Frutiger
- Department of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Mary Parkes Center for Asthma, Allergy, and Pulmonary Care, Rochester, New York, USA
| | - R James White
- Department of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Mary Parkes Center for Asthma, Allergy, and Pulmonary Care, Rochester, New York, USA
| |
Collapse
|
47
|
Ishak Gabra NB, Mahmoud O, Ishikawa O, Shah V, Altshul E, Oron M, Mina B. Pulmonary Arterial Hypertension and Therapeutic Interventions. Int J Angiol 2019; 28:80-92. [PMID: 31384105 DOI: 10.1055/s-0039-1692452] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Pulmonary hypertension is an uncommon disease that carries a significant morbidity and mortality. Pulmonary arterial hypertension is a subtype of pulmonary hypertension that describes a group of disease entities that lead to an elevation in precapillary pulmonary artery pressure. Despite advances in the diagnosis and treatment of pulmonary arterial hypertension, it remains a difficult disease to recognize and manage. In this review article, we will discuss the definition and diagnosis of pulmonary arterial hypertension. Additionally, we will discuss the ever-expanding management options, their mechanisms and strategies, including combination therapy and the most recent advances and future directions.
Collapse
Affiliation(s)
- Nader B Ishak Gabra
- Department of Pulmonary and Critical Care Medicine, Lenox Hill Hospital, New York, New York
| | - Omar Mahmoud
- Department of Pulmonary and Critical Care Medicine, Lenox Hill Hospital, New York, New York
| | - Oki Ishikawa
- Department of Pulmonary and Critical Care Medicine, Lenox Hill Hospital, New York, New York
| | - Varun Shah
- Department of Pulmonary and Critical Care Medicine, Lenox Hill Hospital, New York, New York
| | - Erica Altshul
- Department of Pulmonary and Critical Care Medicine, Lenox Hill Hospital, New York, New York
| | - Maly Oron
- Department of Pulmonary and Critical Care Medicine, Lenox Hill Hospital, New York, New York
| | - Bushra Mina
- Department of Pulmonary and Critical Care Medicine, Lenox Hill Hospital, New York, New York
| |
Collapse
|
48
|
Barnes H, Yeoh H, Fothergill T, Burns A, Humbert M, Williams T. Prostacyclin for pulmonary arterial hypertension. Cochrane Database Syst Rev 2019; 5:CD012785. [PMID: 31042010 PMCID: PMC6492481 DOI: 10.1002/14651858.cd012785.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is characterised by pulmonary vascular changes, leads to elevated pulmonary artery pressures, dyspnoea, a reduction in exercise tolerance, right heart failure, and ultimately death.Prostacyclin analogue drugs mimic endogenous prostacyclin which leads to vasodilation, inhibition of platelet aggregation, and reversal of vascular remodelling. Prostacyclin's short half-life theoretically enhances selectivity for the pulmonary vascular bed by direct (via central venous catheter) administration. Initial continuous infusion prostacyclins were efficacious, but use of intravenous access increases the risk of adverse events. Newer and safer subcutaneous, oral and inhaled preparations are now available, though possibly less potent.Selexipag is an oral selective prostacyclin receptor (IP receptor) agonist that works similarly to prostacyclin, potentially more stable, with less complex administration and titration. OBJECTIVES To determine the efficacy and safety of prostacyclin, prostacyclin analogues or prostacyclin receptor agonists for PAH in adults and children. SEARCH METHODS We performed searches on CENTRAL, MEDLINE, and Embase up to 16 September 2018. We handsearched review articles, clinical trial registries, and reference lists of retrieved articles. SELECTION CRITERIA We included any randomised controlled trials (RCTs) which compared prostacyclin, prostacyclin analogues or prostacyclin receptor agonists to control (placebo, any other treatment or usual care) for at least six weeks. DATA COLLECTION AND ANALYSIS We used standard methods specified by Cochrane. Primary outcomes included change in World Health Organization (WHO) functional class, six-minute walk distance (6MWD), and mortality. MAIN RESULTS Seventeen trials with 3765 mostly adult participants were included; median trial duration was 12 weeks. Fifteen trials used prostacyclin analogues: intravenous (N = 4); subcutaneous (N = 1); oral (N = 5); inhaled (N = 5); two used oral prostacyclin receptor agonists. Three intravenous and two inhaled trials were open-label.Participants using prostacyclin had 2.39 times greater odds of improving by at least one WHO functional class (95% confidence interval (CI) 1.72 to 3.32; 24 per 100 (95% CI 18.5 to 30.4) with prostacyclin compared to 12 per 100 with control; 8 trials, 1066 participants; moderate-certainty evidence). Improvement occurred with intravenous (odds ratio (OR) 14.96, 95% CI 4.76 to 47.04), and inhaled (OR 2.94, 95% CI 1.53 to 5.66), but not with oral preparations. Participants using prostacyclin increased their 6MWD by 19.50 metres (95% CI 14.82 to 24.19; 13 trials, 2283 participants; low-certainty evidence), which was clinically significant with intravenous (mean difference (MD) 91.76 metres; 95% CI 58.97 to 124.55), but not with non-intravenous preparations (subcutaneous: MD 16.00 metres, 95% CI 7.38 to 24.62; oral: MD 14.76 metres, 95% CI 7.81 to 21.70; inhaled: MD 26.97 metres, 95% CI 17.21 to 36.73). Mortality was reduced in the intravenous (OR 0.29, 95% CI 0.12 to 0.69; risk of death 6 per 100 (95% CI 2.38 to 12.31) with prostacyclin compared to 17 per 100 with control; 4 trials, 255 participants), but not in the non-intravenous studies (OR 0.82, 95% CI 0.48 to 1.40; risk of death 21 per 1000 (95% CI 12.00 to 34.20) with prostacyclin compared to 25 per 1000 with control; moderate-certainty evidence; 12 trials, 2299 participants). We reduced the certainty of evidence due to few studies per subgroup and use of open-label trials.Prostacyclins improved cardiopulmonary haemodynamics (reduction in mean pulmonary artery pressure by 3.60 mmHg (95% CI -4.73 to -2.48); pulmonary vascular resistance by 2.81 WU (95% CI -3.80 to -1.82); right atrial pressure by 1.90 mmHg (95% CI -2.58 to -1.22), and increase in cardiac index by 0.31 L/min/m2 (95% CI 0.23 to 0.38); low-certainty evidence), improved dyspnoea (low-certainty evidence, and improved quality of life (moderate-certainty evidence), when compared to control. When only subcutaneous/inhaled trials were included the effect was still significant, but the magnitude was smaller. There was no difference across oral trials.Adverse events were increased in all prostacyclin preparations, including vasodilation (OR 5.03, 95% CI 3.84 to 6.58), headache (OR 3.16, 95% CI 2.62 to 3.80), jaw pain (OR 5.25, 95% CI 3.96 to 6.98), diarrhoea (OR 2.81, 95% CI 2.29 to 3.46), nausea/vomiting (OR 2.39, 95% CI 1.98 to 2.88), myalgias (OR 2.75, 95% CI 1.65 to 4.58), upper respiratory tract events (OR 1.61, 95% CI 1.22 to 2.13), extremity pain (OR 3.36, 95% CI 2.32 to 4.85), and infusion site reactions (OR 14.41, 95% CI 9.16 to 22.66). In the intravenous trials, there was a 12%-25% risk of serious non-fatal events including sepsis, haemorrhage, pneumothorax and pulmonary embolism.Two trials (1199 participants) compared oral selexipag to placebo; no trials compared selexipag with prostacyclin. There was a small 12.62 metre improvement in 6MWD (95% CI 1.90 to 23.34; high-certainty evidence), and weak evidence for haemodynamics. The effect was uncertain for WHO functional class. The risk of death with selexipag was five per 100 compared to three per 100 with placebo, though the CI crossed zero so the true effect is uncertain (risk difference (RD) 0.02 (95% CI -0.00 to 0.04). There was less clinical worsening with selexipag (OR 0.47, 95% CI 0.37 to 0.60), though more side effects, including vasodilation (OR 2.67, 95% CI 1.72 to 4.17), headache (OR 3.91, 95% CI 3.07 to 4.98), jaw pain (OR 5.33, 95% CI 3.64 to 7.81), diarrhoea (OR 3.11, 95% CI 2.39 to 4.05), nausea/vomiting (OR 2.92, 95% CI 2.29 to 3.73), pain in the extremities (OR 2.44, 95% CI 1.69 to 3.52), and myalgias (OR 3.05, 95% CI 2.02 to 4.58). AUTHORS' CONCLUSIONS This review demonstrates clinical and statistical benefit for intravenous prostacyclin (compared to control) with improved functional class, 6MWD, mortality, symptoms scores, and cardiopulmonary haemodynamics, but at a cost of adverse events. This may be due to a true effect, or may be overestimated due to the inclusion of small, short or open-label studies. There was a statistical and small clinical benefit in function and haemodynamics for inhaled prostacyclin, but the effect is uncertain for mortality. The effect of oral prostacyclins are less certain. Selexipag demonstrated less clinical worsening without discernable impact on survival, increased adverse events; and the effect on other outcomes is less certain. Real-world registry data may provide further information about clinical effect.
Collapse
Affiliation(s)
- Hayley Barnes
- The Alfred HospitalDepartment of Respiratory MedicineCommercial RdMelbourneAustralia3004
| | - Hui‐Ling Yeoh
- The Alfred HospitalDepartment of Respiratory MedicineCommercial RdMelbourneAustralia3004
| | | | | | - Marc Humbert
- Université Paris‐SaclayHôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Inserm U999, Univ. Paris‐SudLe Kremlin‐BicêtreFrance
| | - Trevor Williams
- The Alfred HospitalDepartment of Respiratory MedicineCommercial RdMelbourneAustralia3004
- Monash UniversityDepartment of MedicineMelbourneAustralia
| | | |
Collapse
|
49
|
Picken C, Fragkos KC, Eddama M, Coghlan G, Clapp LH. Adverse Events of Prostacyclin Mimetics in Pulmonary Arterial Hypertension: A Systematic Review and Meta-Analysis. J Clin Med 2019; 8:jcm8040481. [PMID: 30970653 PMCID: PMC6517977 DOI: 10.3390/jcm8040481] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/12/2019] [Accepted: 04/04/2019] [Indexed: 02/06/2023] Open
Abstract
Prostacyclin mimetics (PMs) are effective for the treatment of pulmonary arterial hypertension (PAH). However, their clinical use may be limited by their adverse events. This study aims to quantify the different PM adverse events (AEs) with regard to their selectivity towards the prostacyclin (IP) receptor and their administrative routes. The study included randomised, placebo-controlled trials comparing iloprost, beraprost, treprostinil, and selexipag to placebo (published 2002–2016). We report the group efficacy differences between treatment and placebo by weighted and standardised mean difference. The probability of adverse events was determined by the odds ratio (OR). Of the 14 randomised clinical trials involving 3518 PAH patients, outcome and adverse event data were meta-analysed by drug type and route of administration. Prostacyclin mimetics comparison demonstrated a more significant discontinuation of the IP-selective agonist, selexipag, due to an adverse event (OR = 2.2; 95% CI: 1.5, 3.3). Compared to placebo, site pain associated with subcutaneously administered treprostinil was the most significant likely adverse event (OR = 17.5; 95% CI: 11.1, 27.1). Parenteral PMs were associated with fewer adverse effects overall. The overall efficacy of PMs to improve 6-minute walk distance by 16.3 meters was significant (95% CI: 13.0, 19.7). Decreases in pulmonary vascular resistance index (SMD = -5.5; 95% CI: -10.1, -0.9; I² = 98%) and mean pulmonary arterial pressure (SMD = -1.0; 95% CI: -2.6, -0.7; I² = 99%) in treatment groups were found to be significant. Adverse event profiles varied in response to administration route and PM type but were not negated by use of a selective IP agonist. Prostacyclin mimetics exposure to non-target IP receptors may underpin some AEs reported.
Collapse
Affiliation(s)
- Christina Picken
- Institute of Cardiovascular Sciences, University College London, 5 University Street, London, WC1E 6JF, UK.
| | | | - Mohammad Eddama
- Division of Surgery and Interventional Sciences, University College London, 21 University Street, London, WC1E 6AU, UK.
| | - Gerry Coghlan
- Department of Cardiology, Royal Free hospital, London, NW3 2QG, UK.
| | - Lucie H Clapp
- Institute of Cardiovascular Sciences, University College London, 5 University Street, London, WC1E 6JF, UK.
| |
Collapse
|
50
|
Improving Survival in Patients with Pulmonary Arterial Hypertension: Focus on Intravenous Epoprostenol. Am J Cardiovasc Drugs 2019; 19:99-105. [PMID: 30671881 DOI: 10.1007/s40256-018-00319-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Pulmonary arterial hypertension represents a devastating disease, causing progressive increase of pulmonary vascular resistance leading to right ventricular dysfunction and death. Therapeutic management has rapidly advanced in recent years due to improved understanding of pathophysiology and new drugs have been developed; however, survival remains poor. Oral agents as phosphodiesterase type V inhibitors, the soluble guanylyl cyclase stimulator riociguat, the prostacyclin receptor agonist selexipag and the endothelin receptor antagonists have each achieved evidence-based validation and are recommended for pulmonary arterial hypertension. Initial oral monotherapy or combination therapy is recommended for patients with low or intermediate risk according to each patient's risk stratification. Intravenous epoprostenol is a synthetic prostacyclin and the first drug approved for the disease. Although it represents the only treatment shown to reduce mortality, it is underused. Survival rates for patients treated with oral combination drug therapies are lower than those for patients treated with initial combination therapies including intravenous epoprostenol. This raises the interesting question of whether intermediate risk pulmonary arterial hypertension patients should be routinely introduced to therapies including intravenous epoprostenol rather than combination oral therapies.
Collapse
|