Transition from prostacyclin analogue infusion to oral therapy in patients with pulmonary arterial hypertension: a 5-year follow-up

Impact of additional selexipag on prostacyclin infusion analogs in patients with pulmonary arterial hypertension

The effective therapy for pulmonary arterial hypertension (PAH) with inadequate clinical response is scarce except for lung transplantation when prostacyclin infusion is ineffective. The purpose of this study is to investigate the efficacy and safety of selexipag in addition to the infusion of prostacyclin. Nine patients [median 38 (36–49) years of age; 78% female] with PAH whose clinical response was inadequate despite the use of prostacyclin infusion analogs, were evaluated. Addition of selexipag significantly improved hemodynamics and no serious adverse events were observed. Selexipag with prostacyclin infusion analogs can be an effective therapeutic strategy for the PAH patients with inadequate clinical response.

Right ventricular afterload predicts long-term transition from parenteral to oral treprostinil in pulmonary arterial hypertension

Despite the increasing trends, reports on long-term follow-up are limited on transitioning from parenteral to oral treprostinil therapy in patients with pulmonary arterial hypertension (PAH). We investigated both the effectiveness of parenteral to oral treprostinil transition and the characteristics associated with transition failure over a duration of two years. The study included 37 Group I functional class I and II patients with PAH on combination therapy. Patients were excluded if cardiac index ≤2.2 L/min/m², right atrial pressure ≥11 mmHg, or 6-min walk distance ≤250 m. Patients were categorized as successful (_STransition) or unsuccessful (_UTransition) transition based on clinical stability, or a parenteral comparator (_CParenteral) if they remained on parenteral therapy (no transition). All patients underwent two right heart catheterizations, one at enrollment and a second post transition. Of 24 total transition patients, 46% were classified as _UTransition. _UTransition occurred on average 577 days post transition. Both _UTransition and _STransition had similar hemodynamics at diagnosis and treprostinil dose before and after transition. Before transition, the pulmonary vascular resistance (PVR) was significantly higher in the _UTransition (6.7 ± 2 WU) vs. _STransition group (3.5 ± 1.5 WU). At follow-up catheterization, the _UTransition group demonstrated further increases in PVR, greater than the _CParenteral group, without recovery despite “rescue” therapy in the _UTransition group. A pre-transition PVR of 4.16 WU discriminated the _UTransition from the _STransition group. While a subset of PAH patients on combination therapy may be safely transitioned from parenteral to oral treprostinil, caution should be exercised in patients with elevated baseline PVR to avoid irreversible destabilization.

Real-World Switching to Riociguat: Management and Practicalities in Patients with PAH and CTEPH

Purpose

A proportion of patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) do not achieve treatment goals or experience side effects on their current therapy. In such cases, switching patients to a new drug while discontinuing the first may be a viable and appropriate treatment option. CAPTURE was designed to investigate how physicians manage the switching of patients to riociguat in real-world clinical practice. Observations from the study were used to assess whether recommendations in the riociguat prescribing information are reflected in clinical practice.

Methods

CAPTURE was an international, multicenter, uncontrolled, retrospective chart review that collected data from patients with PAH or inoperable or persistent/recurrent CTEPH who switched to riociguat from another pulmonary hypertension (PH)-targeted medical therapy. The primary objective of the study was to understand the procedure undertaken in real-world clinical practice for patients switching to riociguat.

Results

Of 127 patients screened, 125 were enrolled in CAPTURE. The majority of patients switched from a phosphodiesterase type 5 inhibitor (PDE5i) to riociguat and the most common reason for switching was lack of efficacy. Physicians were already using the recommended treatment-free period when switching patients to riociguat from sildenafil, but a slightly longer period than recommended for tadalafil. In line with the contraindication, the majority of patients did not receive riociguat and PDE5i therapy concomitantly. Physicians also followed the recommended dose-adjustment procedure for riociguat.

Conclusion

Switching to riociguat from another PH-targeted therapy may be feasible in real-world clinical practice in the context of the current recommendations.

Electronic supplementary material

The online version of this article (10.1007/s00408-018-0100-3) contains supplementary material, which is available to authorized users.

A systematic review of transition studies of pulmonary arterial hypertension specific medications

Pulmonary arterial hypertension (PAH) is a progressive potentially fatal disease. Multiple pharmacologic options are now available, which facilitated transitions between different therapeutic options, although the evidence for such transitions has not been well described. We sought to review the evidence supporting the safety and/or efficacy of transitioning between PAH-specific medications. We performed a systematic review of all published studies in the Medline database between 1 January 2000 and 30 June 2016 reporting on any transition between the currently Food and Drug Administration (FDA)-approved PAH-specific medications. Studies reporting on three or more adult patients published in the English language reporting on transitions between FDA-approved PAH medications were extracted and tabulated. Forty-one studies met the selection criteria, nine of which included less than eight patients (and thus were reported separately in the supplement), for a total of 32 studies. Transitioning from parenteral epoprostenol to parenteral treprostinil appears to be safe and efficacious in patients who have less severe disease and more favorable hemodynamics. Transitioning from a prostacyclin analogue to an oral medication may be successful in patients who have favorable hemodynamics and stable disease. There is conflicting evidence supporting the transition from a parenteral to an inhaled prostacyclin analogue, even in patients who are on background oral therapy. Currently, the only evidence in support of transitioning between oral PDE5 inhibitors is from sildenafil to tadalafil. Patients on higher doses of sildenafil are more likely to fail. In patients with liver abnormalities due to bosentan or sitaxentan, the transition to ambrisentan appears to be safe and can result in clinical improvement. Studies regarding PAH medication transitions are limited. Patients who have less severe disease, better functional status, and are on lower medications doses may be more successful at transitioning.