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Usmani SUR, Hasan SU, Ali SH, Ahmed SH, Pervez N, Danial M, Khan O, Tucker DL, Zubair MM. Perioperative sildenafil therapy in pulmonary hypertension associated with congenital cardiac disease: An updated meta-analysis. Asian J Surg 2024; 47:2551-2557. [PMID: 38531747 DOI: 10.1016/j.asjsur.2024.03.003] [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: 09/07/2023] [Revised: 12/31/2023] [Accepted: 03/01/2024] [Indexed: 03/28/2024] Open
Abstract
To provide an updated meta-analysis to evaluate the efficacy and safety of sildenafil on pediatric patients with pulmonary hypertension (PH) associated with congenital heart disease (CHD). To assess the efficacy and safety of sildenafil, five outcomes, time duration of post-operative need for mechanical ventilation, time duration of post-operative ICU stay, length of hospitalization (LOH), the incidence of mortalities and pulmonary arterial pressure to aortic pressure ratio (PAP/AoP) were regarded as primary efficacy outcomes. Standardized mean difference (SMD) was calculated for continuous data. In comparison to the control group (CG), there was a significant decrease in the time duration of ICU stay in the sildenafil group (SG) (SMD = -0.61 [95% CI -1.17, 0.04]; P < 0.01, I2 = 85%). Length of hospitalization was assessed in the sildenafil and control groups (SMD = -0.18 [95% CI -0.67, 0.31] P = 0.05, I2 = 62%). However, there was no significant difference seen in mortality rates between the SG and CG (SMD = 0.53 [ 95% CI 0.13, 2.17] p = 0.61, I2 = 0%), in the time duration of postoperative mechanical ventilation between the SG and CG (SMD = -0.23 [95% CI -0.49, 0.03] p = 0.29, I2 = 19%), or PAP/AoP ratio between the SG and CG (SMD = -0.42 [95% CI -1.35, 0.51] P < 0.01, I2 = 90%). Based on our analysis, sildenafil has little to no effect in reducing postoperative morbidity and mortality due to PH in infants and children with CHD.
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Affiliation(s)
| | - Syed Umar Hasan
- Dow University of Health Sciences, Karachi, Sindh, Pakistan.
| | - Syed Hasan Ali
- Dow University of Health Sciences, Karachi, Sindh, Pakistan.
| | | | - Neha Pervez
- Dow University of Health Sciences, Karachi, Sindh, Pakistan.
| | - Muhammad Danial
- Dow University of Health Sciences, Karachi, Sindh, Pakistan.
| | - Owais Khan
- Dow University of Health Sciences, Karachi, Sindh, Pakistan.
| | | | - M Mujeeb Zubair
- Department of Cardiac Surgery, Cedars-Sinai Hospital, Los Angeles, CA, USA.
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Shams KA, Ellahony DM, Halima AF, Elzayat RS. Effect of phosphodiesterase type 5 inhibitors on surgical outcome of ventricular septal defect and pulmonary hypertension patients. Egypt Heart J 2024; 76:60. [PMID: 38771438 PMCID: PMC11109034 DOI: 10.1186/s43044-024-00475-5] [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: 02/02/2024] [Accepted: 04/07/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Children with ventricular septal defect (VSD) and large systemic-to-pulmonary shunts eventually develop pulmonary hypertension (PH). The perioperative management of patients with VSD and PH is quite troublesome and still debatable, especially in developing countries where the different management options and standardization of treatment is not available. Oral phosphodiesterase type 5 (PDE-5) inhibitors are good treatment options being widely available, cheap, easy administration and do not require extensive monitoring. The aim of our study was to evaluate the effect of the PDE-5 inhibitors when given orally, early preoperative and continued for 3 months postoperative on controlling postoperative PH with its effect on right ventricle (RV) functions. Fifty-one patients were randomly assigned to either sildenafil or tadalafil, 1 week before and continued for 3 months after corrective surgery. The control group received a placebo. RESULTS There was no significant difference in the improvement in the right ventricle systolic pressure (RVSP) between both groups, early in the postoperative period (P = 0.255) and in follow-up (P = 0.259). There was also no significant difference in the changes in mean pulmonary artery pressure (mPAP), postoperatively and on follow-up (P = 0.788 and 0.059, respectively). There was a drop in RV functions in both groups postoperatively which improved on follow-up; however, it was not significant between both groups. The length of intensive care unit (ICU) stay was similar between both groups (P = 0.143). CONCLUSION Perioperative administration of PDE-5 inhibitors does not have an impact on the clinical course as regards improvement in pulmonary artery (PA) pressure, ventricular functions and ICU stay.
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Affiliation(s)
- Khaled Ahmed Shams
- Cardiology Department, Faculty of Medicine, Helwan University, Helwan, Egypt.
- Adult Cardiology Department, Aswan Heart Centre, Magdi Yacoub Foundation, Aswân, Egypt.
| | - Dalia Monir Ellahony
- Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebein Elkom, Menoufia, Egypt
| | - Ahmed Fouad Halima
- Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebein Elkom, Menoufia, Egypt
| | - Rania Salah Elzayat
- Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebein Elkom, Menoufia, Egypt
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3
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Awad AK, Gad ER, Abdelgalil MS, Elsaeidy AS, Ahmed O, Elbadawy MA. Sildenafil for congenital heart diseases induced pulmonary hypertension, a meta-analysis of randomized controlled trials. BMC Pediatr 2023; 23:372. [PMID: 37474896 PMCID: PMC10360284 DOI: 10.1186/s12887-023-04180-1] [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: 07/19/2022] [Accepted: 07/05/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Sildenafil was first prescribed for angina pectoris and then for erectile dysfunction from its effects on vascular smooth muscle relaxation and vasodilatation. Recently, sildenafil has been proposed for congenital heart diseases induced pulmonary hypertension, which constitutes a huge burden on children's health and can attribute to fatal complications due to presence of unoxygenated blood in the systemic circulation. Therefore, our meta-analysis aims to further investigate the safety and efficacy of sildenafil on children population. METHODS We searched the following electronic databases: PubMed, Cochrane CENTRAL, WOS, Embase, and Scopus from inception to April 20th, 2022. Randomized controlled trials that assess the efficacy of using sildenafil in comparison to a placebo or any other vasodilator drug were eligible for inclusion. The inverse variance method was used to pool study effect estimates using the random effect model. Effect sizes are provided in the form of mean difference (MD) with 95% confidence intervals (CI). RESULTS Our study included 14 studies with (n = 849 children) with a mean age of 7.9 months old. Sildenafil showed a statistically significant decrease over placebo in mean and systolic pulmonary artery pressure (PAP) with MD -7.42 (95%CI [-13.13, -1.71], P = 0.01) and -8.02 (95%CI [-11.16, -4.88], P < 0.0001), respectively. Sildenafil revealed a decrease in mean aortic pressure and pulmonary artery/aortic pressure ratio over placebo with MD -0.34 (95%CI [-2.42, 1.73], P = 0.75) and MD -0.10 (95%CI [-0.11, -0.09], P < 0.00001), respectively. Regarding post corrective operations parameters, sildenafil had a statistically significant lower mechanical ventilation time, intensive care unit stay, and hospital stay over placebo with MD -19.43 (95%CI [-31.04, -7.81], s = 0.001), MD -34.85 (95%CI [-50.84, -18.87], P < 0.00001), and MD -41.87 (95%CI [-79.41, -4.33], P = 0.03), respectively. Nevertheless, no difference in mortality rates between sildenafil and placebo with OR 0.25 (95%CI 0.05, 1.30], P = 0.10) or tadalafil with OR 1 (95%CI 0.06, 17.12], P = 1). CONCLUSION Sildenafil is a well-tolerated treatment in congenital heart diseases induced pulmonary hypertension, as it has proven its efficacy not only in lowering both PAP mean and systolic but also in reducing the ventilation time, intensive care unit and hospital stay with no difference observed regarding mortality rates.
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Affiliation(s)
- Ahmed K. Awad
- Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | | | | | | | - Omar Ahmed
- Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
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Safety and effect of sildenafil on treating paediatric pulmonary arterial hypertension: a meta-analysis on the randomised controlled trials. Cardiol Young 2020; 30:1882-1889. [PMID: 33077013 DOI: 10.1017/s104795112000311x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Efficacy of sildenafil in treating paediatric pulmonary arterial hypertension is controversial. This systematic review aimed to explore the safety and effect of sildenafil on treating paediatric pulmonary arterial hypertension (PAH) through meta-analysis. METHODS AND RESULTS In this study, the electronic databases, including the Cochran Library database, EMBASE, and MEDLINE were systemically retrieved to identify the related randomised controlled trials (RCTs). Two reviewers had independently completed study selection, data collection, and assessment of the bias risk. Amongst 938 articles researched according to our retrieval strategy, 15 papers that involved 673 cases had been screened. Relative to control group, the sildenafil group had markedly reduced mortality (RR = 0.25, 95% CI: 0.12-0.51; p < 0.0001), but difference within the mortality was not statistically significant between high- and low-dose sildenafil groups (p = 0.152). Nonetheless, difference of the mean pulmonary arterial pressure between sildenafil as well as control group was of no statistical significance. Differences in the length of hospital stay and the incidences of pulmonary hypertensive crisis between children with PAH and controls were of no statistical significance. However, the summary estimate favoured that sildenafil reduced the duration of mechanical ventilation time, as well as the length of ICU stay and inotropic support. CONCLUSIONS Sildenafil therapy reduces the mortality of PAH patients, but its effects on the haemodynamic outcomes and other clinical outcomes are still unclear.
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Korun O. Should sildenafil be started 2 weeks before the operation in ventricular septal defect patients with high pulmonary vascular resistance? J Card Surg 2020; 36:421. [PMID: 33135281 DOI: 10.1111/jocs.15167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 10/03/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Oktay Korun
- Department of Pediatric Cardiac Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, İstanbul, Turkey
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Patel R, Upadhyay V, Bansal V. Should sildenafil be started 2 weeks before the operation in ventricular septal defect patients with high pulmonary vascular resistance? J Card Surg 2020; 36:422-423. [PMID: 33135291 DOI: 10.1111/jocs.15166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 10/16/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Ruchit Patel
- Department of Cardiovascular and Thoracic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vinay Upadhyay
- Department of Cardiovascular and Thoracic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vidur Bansal
- Department of Cardiovascular and Thoracic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Carr ZJ, Klick J, McDowell BJ, Charchaflieh JG, Karamchandani K. An Update on Systemic Sclerosis and its Perioperative Management. CURRENT ANESTHESIOLOGY REPORTS 2020; 10:512-521. [PMID: 32904358 PMCID: PMC7455511 DOI: 10.1007/s40140-020-00411-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Purpose of Review Systemic sclerosis or scleroderma (SSc) is a systemic, immune-mediated disease characterized by abnormal cutaneous and organ-based fibrosis that results in progressive end-organ dysfunction and decreased survival. SSc results in significant challenges for the practicing anesthesiologist due to its rarity, multi-system involvement, and limited evidence-based guidance for optimal perioperative care. In this update, we briefly discuss the recent evidence on the pathophysiology and current management of SSc, review the anesthesia-related literature, and extrapolate these observations into an optimal perioperative strategy for the care of SSc patients. Recent Findings Evidence shows that patients with SSc demonstrate an increased risk for perioperative myocardial infarction, high rates of interstitial lung disease, pulmonary arterial hypertension, neurological disease, gastric dysmotility disorders, and challenging airway management, all findings that may result in suboptimal perioperative outcomes. Summary Advances in SSc medical management have resulted in improved survival, likely increasing the number of patients who will be exposed to perioperative care. Optimal perioperative management and risk stratification should expand beyond the well-described airway challenges and consider numerous systemic manifestations of systemic sclerosis such as pulmonary arterial hypertension, interstitial lung disease, and cardiac sequelae.
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Affiliation(s)
- Zyad J. Carr
- Department of Anesthesiology, Yale New Haven Hospital, New Haven, CT 06510 USA
- Yale University School of Medicine, New Haven, CT 06510 USA
| | - John Klick
- Department of Anesthesiology, University of Vermont Medical Center, Burlington, VT 05405 USA
- Larner College of Medicine at The University of Vermont, Burlington, VT 05405 USA
| | - Brittany J. McDowell
- Department of Anesthesiology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA 17033 USA
- Penn State School of Medicine, Hershey, PA 17033 USA
| | - Jean G. Charchaflieh
- Department of Anesthesiology, Yale New Haven Hospital, New Haven, CT 06510 USA
- Yale University School of Medicine, New Haven, CT 06510 USA
| | - Kunal Karamchandani
- Department of Anesthesiology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA 17033 USA
- Penn State School of Medicine, Hershey, PA 17033 USA
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Kloner RA, Goldstein I, Kirby MG, Parker JD, Sadovsky R. Cardiovascular Safety of Phosphodiesterase Type 5 Inhibitors After Nearly 2 Decades on the Market. Sex Med Rev 2018; 6:583-594. [DOI: 10.1016/j.sxmr.2018.03.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 03/16/2018] [Accepted: 03/29/2018] [Indexed: 12/23/2022]
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Hornik CP, Onufrak NJ, Smith PB, Cohen-Wolkowiez M, Laughon MM, Clark RH, Gonzalez D. Association between oral sildenafil dosing, predicted exposure, and systemic hypotension in hospitalised infants. Cardiol Young 2018; 28:85-92. [PMID: 28784200 PMCID: PMC5720916 DOI: 10.1017/s1047951117001639] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND The relationship between sildenafil dosing, exposure, and systemic hypotension in infants is incompletely understood. OBJECTIVES The aim of this study was to characterise the relationship between predicted sildenafil exposure and hypotension in hospitalised infants. METHODS We extracted information on sildenafil dosing and clinical characteristics from electronic health records of 348 neonatal ICUs from 1997 to 2013, and we predicted drug exposure using a population pharmacokinetic model. RESULTS We identified 232 infants receiving sildenafil at a median dose of 3.2 mg/kg/day (2.0, 6.0). The median steady-state area under the concentration-time curve over 24 hours (AUC24,SS) and maximum concentration of sildenafil (Cmax,SS,SIL) were 712 ng×hour/ml (401, 1561) and 129 ng/ml (69, 293), respectively. Systemic hypotension occurred in 9% of the cohort. In multivariable analysis, neither dosing nor exposure were associated with systemic hypotension: odds ratio=0.96 (95% confidence interval: 0.81, 1.14) for sildenafil dose; 0.87 (0.59, 1.28) for AUC24,SS; 1.19 (0.78, 1.82) for Cmax,SS,SIL. CONCLUSIONS We found no association between sildenafil dosing or exposure with systemic hypotension. Continued assessment of sildenafil's safety profile in infants is warranted.
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Affiliation(s)
- Christoph P. Hornik
- Department of Pediatrics, Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Nikolas J. Onufrak
- Eshelman School of Pharmacy, Division of Pharmacotherapy and Experimental Therapeutics, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - P. Brian Smith
- Department of Pediatrics, Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Michael Cohen-Wolkowiez
- Department of Pediatrics, Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Matthew M. Laughon
- Department of Pediatrics, Division of Neonatology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Reese H. Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL, USA
| | - Daniel Gonzalez
- Eshelman School of Pharmacy, Division of Pharmacotherapy and Experimental Therapeutics, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Bhasin S, Gogia P, Nair R, Sahoo TK. Perioperative sildenafil therapy for children with ventricular septal defects and associated pulmonary hypertension undergoing corrective surgery: A randomised clinical trial. Indian J Anaesth 2017; 61:798-802. [PMID: 29242651 PMCID: PMC5664884 DOI: 10.4103/ija.ija_210_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background and Aims Sildenafil is known to reduce pulmonary artery pressure but its role in the perioperative period has not been well studied. We aimed to evaluate the efficacy of sildenafil in controlling post-operative pulmonary hypertension in children with pulmonary hypertension undergoing surgeries for correction of ventricular septal defect. Methods The patients were divided randomly into two groups of thirty each. Group 1 (placebo) received pre-operative placebo and post-operative sildenafil (0.5mg/kg every 6 hrs) while Group 2 (sildenafil) received pre- and post-operative sildenafil (0.5mg/kg every 6 hrs). Results In the Group 1, systolic pulmonary artery pressure reduced from 81.63 (±12.1) mmHg preoperatively to 79.26 (±11.29) mmHg pre-cardiopulmonary bypass (CPB) and 56.76 (±11) mmHg (with 10 minutes post-CPB), whereas in Group 2, it reduced from 83.3 (±12.1) before surgery to 68.9 (±11.3) mmHg pre-CPB and after CPB, to 42.2 (±7.6) mmHg (P = 0.001). The mean pulmonary artery pressure decreased from 60.63 (±10.5) mmHg to 42.13 (±8.3) mmHg in the Group 1 whereas it reduced from 54.36 (±10) mmHg to 31.36 (±6.5) mmHg in Group 2 (P = 0.001). The reductions in pulmonary artery/aortic ratio and Intensive Care Unit stay were statistically significant No adverse effects were recorded. Conclusion The use of perioperative sildenafil has a statistically significant reduction in the mean pulmonary artery pressure without any adverse effects.
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Affiliation(s)
- Sidharth Bhasin
- Department of Anesthesiology, Army Hospital Research and Referral, New Delhi, India
| | - Pooja Gogia
- Department of Radiotherapy, Pt. B.D.Sharma PGIMS, Rohtak, Haryana, India
| | - Rajeev Nair
- Department of Anesthesiology, Army Hospital Research and Referral, New Delhi, India
| | - Tapan Kumar Sahoo
- Department of Anesthesiology, Army Hospital Research and Referral, New Delhi, India
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Kraemer U, Cochius-den Otter S, Snoek KG, Tibboel D. Pharmacodynamic considerations in the treatment of pulmonary hypertension in infants: challenges and future perspectives. Expert Opin Drug Metab Toxicol 2015; 12:1-19. [DOI: 10.1517/17425255.2016.1116520] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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12
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Abman SH, Hansmann G, Archer SL, Ivy DD, Adatia I, Chung WK, Hanna BD, Rosenzweig EB, Raj JU, Cornfield D, Stenmark KR, Steinhorn R, Thébaud B, Fineman JR, Kuehne T, Feinstein JA, Friedberg MK, Earing M, Barst RJ, Keller RL, Kinsella JP, Mullen M, Deterding R, Kulik T, Mallory G, Humpl T, Wessel DL. Pediatric Pulmonary Hypertension: Guidelines From the American Heart Association and American Thoracic Society. Circulation 2015; 132:2037-99. [PMID: 26534956 DOI: 10.1161/cir.0000000000000329] [Citation(s) in RCA: 686] [Impact Index Per Article: 76.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pulmonary hypertension is associated with diverse cardiac, pulmonary, and systemic diseases in neonates, infants, and older children and contributes to significant morbidity and mortality. However, current approaches to caring for pediatric patients with pulmonary hypertension have been limited by the lack of consensus guidelines from experts in the field. In a joint effort from the American Heart Association and American Thoracic Society, a panel of experienced clinicians and clinician-scientists was assembled to review the current literature and to make recommendations on the diagnosis, evaluation, and treatment of pediatric pulmonary hypertension. This publication presents the results of extensive literature reviews, discussions, and formal scoring of recommendations for the care of children with pulmonary hypertension.
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MESH Headings
- Cardiovascular Agents/therapeutic use
- Child
- Child, Preschool
- Combined Modality Therapy
- Diagnostic Imaging/methods
- Disease Management
- Extracorporeal Membrane Oxygenation
- Genetic Counseling
- Heart Defects, Congenital/complications
- Heart Defects, Congenital/therapy
- Hernias, Diaphragmatic, Congenital/complications
- Hernias, Diaphragmatic, Congenital/therapy
- Humans
- Hypertension, Pulmonary/diagnosis
- Hypertension, Pulmonary/etiology
- Hypertension, Pulmonary/genetics
- Hypertension, Pulmonary/therapy
- Infant
- Infant, Newborn
- Lung/embryology
- Lung Transplantation
- Nitric Oxide/administration & dosage
- Nitric Oxide/therapeutic use
- Oxygen Inhalation Therapy
- Persistent Fetal Circulation Syndrome/diagnosis
- Persistent Fetal Circulation Syndrome/therapy
- Postoperative Complications/therapy
- Respiration, Artificial/adverse effects
- Respiration, Artificial/methods
- Ventilator-Induced Lung Injury/prevention & control
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Magee AG, Makhecha S, Bentley S. Risk-benefit considerations when prescribing phosphodiesterase-5 inhibitors in children. Expert Opin Drug Saf 2015; 14:633-42. [PMID: 25746065 DOI: 10.1517/14740338.2015.1022527] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Sildenafil (Revatio®) and tadalafil (Adcirca®) are specific inhibitors of the phosphodiesterase-5 enzyme and produce pulmonary vasodilation by inhibiting the breakdown of cyclic guanosine monophosphate (cGMP) in the walls of pulmonary arterioles. AREAS COVERED We focus on the efficacy and safety of sildenafil and tadalafil in the treatment of pulmonary hypertension (PH) in children through a PubMed literature search. EXPERT OPINION Although used since 1999 in the treatment of PH in children, it is only in the past few years that robust evidence for the use of sildenafil has emerged principally in the pivotal STARTS-1 study. The open-label extension of this study, STARTS-2, has revealed safety concerns substantiated by FDA post marketing surveillance leading to recommendations to use lower doses. More recently, tadalafil has been introduced allowing once daily dosing with apparently similar efficacy to sildenafil in children. Recently there have been suggestions that sildenafil and tadalafil may have a place in treating muscular dystrophy.
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Affiliation(s)
- Alan G Magee
- University of Southampton and Royal Brompton and Harefield NHS Foundation Trusts , Southampton and London , UK
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14
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Brunner N, de Jesus Perez VA, Richter A, Haddad F, Denault A, Rojas V, Yuan K, Orcholski M, Liao X. Perioperative pharmacological management of pulmonary hypertensive crisis during congenital heart surgery. Pulm Circ 2014; 4:10-24. [PMID: 25006417 DOI: 10.1086/674885] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Accepted: 09/12/2013] [Indexed: 01/12/2023] Open
Abstract
Pulmonary hypertensive crisis is an important cause of morbidity and mortality in patients with pulmonary arterial hypertension secondary to congenital heart disease (PAH-CHD) who require cardiac surgery. At present, prevention and management of perioperative pulmonary hypertensive crisis is aimed at optimizing cardiopulmonary interactions by targeting prostacyclin, endothelin, and nitric oxide signaling pathways within the pulmonary circulation with various pharmacological agents. This review is aimed at familiarizing the practitioner with the current pharmacological treatment for dealing with perioperative pulmonary hypertensive crisis in PAH-CHD patients. Given the life-threatening complications associated with pulmonary hypertensive crisis, proper perioperative planning can help anticipate cardiopulmonary complications and optimize surgical outcomes in this patient population.
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Affiliation(s)
- Nathan Brunner
- Division of Pulmonary and Critical Care Medicine, Stanford School of Medicine, Stanford, California, USA
| | - Vinicio A de Jesus Perez
- Division of Pulmonary and Critical Care Medicine, Stanford School of Medicine, Stanford, California, USA
| | - Alice Richter
- Division of Pulmonary and Critical Care Medicine, Stanford School of Medicine, Stanford, California, USA
| | - François Haddad
- Division of Cardiology, Stanford School of Medicine, Stanford, California, USA
| | - André Denault
- Division of Anesthesiology, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Vanessa Rojas
- Division of Pulmonary and Critical Care Medicine, Stanford School of Medicine, Stanford, California, USA
| | - Ke Yuan
- Division of Pulmonary and Critical Care Medicine, Stanford School of Medicine, Stanford, California, USA
| | - Mark Orcholski
- Division of Pulmonary and Critical Care Medicine, Stanford School of Medicine, Stanford, California, USA
| | - Xiaobo Liao
- Division of Pulmonary and Critical Care Medicine, Stanford School of Medicine, Stanford, California, USA ; Division of Cardiothoracic Surgery, Second Xiangya Hospital of Central South University, Changsha, Hunan, China
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15
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Abstract
OBJECTIVE In view of the recent U.S. Food and Drug Administration's warning against the use of sildenafil in pediatric patients, we aimed to provide an updated overview of the dosing and safety of sildenafil in infants and to explore the relevance of the present safety concerns to the infant population. DATA SOURCE The National Library of Medicine PubMed and Cochrane Database of Systematic Reviews were searched using the following terms: Sildenafil AND (infant OR infants OR newborn OR newborns OR child OR children OR childhood OR pediatric OR pediatrics OR paediatric OR paediatrics). STUDY SELECTION Studies presenting original clinical data regarding the dosing, use, or safety of sildenafil in infants with pulmonary hypertension would be included. DATA EXTRACTION Of the 49 included studies, case reports and case series were the most common type of publications (n = 25). The identified trials included 625 children, with more than 140 infants. Persistent pulmonary hypertension of the newborn and pulmonary hypertension associated with other conditions were the most common underlying diagnoses. CONCLUSION There is currently no evidence of serious adverse event in infants exposed to sildenafil. Present safety concerns regarding the use of sildenafil in pediatric patients should be further explored before being applied to infant population. Sildenafil remains a valuable option for the treatment of pulmonary hypertension in young infants. Prospective studies should be designed in such a way that they include a safety assessment to evaluate potential adverse outcomes of sildenafil therapy in this population.
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Affiliation(s)
- Samira Samiee-Zafarghandy
- Division of Pediatric Clinical Pharmacology, Children’s National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - P. Brian Smith
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
| | - Johannes N. van den Anker
- Division of Pediatric Clinical Pharmacology, Children’s National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC
- Department of Pediatrics, Children’s National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC
- Department of Pharmacology and Physiology, Children’s National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC
- Intensive Care, Erasmus Medical Center-Sophia Children’s Hospital, Rotterdam, The Netherlands
- Department of Paediatric Pharmacology, University Children’s Hospital Basel, Switzerland
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16
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El Midany AAH, Mostafa EA, Azab S, Hassan GA. Perioperative sildenafil therapy for pulmonary hypertension in infants undergoing congenital cardiac defect closure. Interact Cardiovasc Thorac Surg 2013; 17:963-8. [PMID: 23985411 DOI: 10.1093/icvts/ivt353] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Pulmonary hypertension in paediatric patients with ventricular septal defect remains one of the most important determinants of perioperative morbidity and mortality. Sildenafil is an oral, well-tolerated pulmonary vasodilator with few drug interactions. We studied the effect of oral sildenafil, when given before and after surgical closure compared with starting it postoperatively, on the pulmonary artery pressure and patients' outcome. METHODS We enrolled 101 infants with large ventricular septal defects who had moderate-to-severe pulmonary hypertension scheduled for surgical closure. They were randomly assigned to the sildenafil group (n = 51, mean age 10 months and mean weight 6.5 kg), in which oral sildenafil was started 2 weeks before surgery to be continued postoperatively, and to the control group (n = 50, mean age 11 months and mean weight 7.3 kg), in which sildenafil was started only postoperatively. It was started at 0.5 mg/kg and increased gradually to a maximum dose of 2 mg/kg in both groups. RESULTS Overall hospital mortality was 4.9%. Mean pulmonary artery pressure decreased significantly at all time points of recording in both groups (P < 0.0001). In the sildenafil group, it decreased preoperatively after sildenafil administration from 75.4 to 59.4 mmHg and postoperatively from 50.4 mmHg immediate post-cardiopulmonary bypass to reach 44.2 mmHg before discharge. In the control group, it decreased from 74.6 mmHg to 51 mmHg immediate post-cardiopulmonary bypass to reach 42.7 mmHg before discharge. No adverse effects have been recorded. Although there was no difference in the duration of mechanical ventilation and hospital stay between the two groups, intensive care unit stay was significantly shorter in the sildenafil group. Dobutamine doses were significantly higher in the sildenafil group; however, milrinone and epinephrine have been used more significantly in the control group. CONCLUSIONS The low cost, the oral availability and the good tolerability of sildenafil make it a suitable and simple alternative therapy for secondary pulmonary hypertension including persistent postoperative pulmonary hypertension associated with ventricular septal defect in resource limited places. However, starting sildenafil early before surgery does not add a great benefit in terms of improving postoperative pulmonary hypertension or patients' outcome.
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Affiliation(s)
- Ashraf A H El Midany
- Department of Cardiovascular & Thoracic Surgery, Ain Shams University, Cairo, Egypt
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17
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The Safety of Preoperative Vardenafil in Patients Undergoing Coronary Artery Bypass Graft Surgery. J Cardiovasc Pharmacol 2013; 62:106-9. [DOI: 10.1097/fjc.0b013e318291be81] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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