Pulmonary hypertension: its assessment and treatment

Beraprost sodium for chronic diabetic foot ulcer: a randomized controlled trial in thammasat university hospital

BACKGROUND

Chronic diabetic foot ulcer has a high rate of healing failure. Beraprost sodium, oral form of prostaglandin I2 analogue, maybe used for increasing wound healing.

OBJECTIVE

To compare the healing rate of chronic diabetic foot ulcer between Beraprost sodium and control groups.

DESIGN

A single blind randomized trial.

MATERIALS AND METHODS

Fifty non-healed chronic diabetic foot ulcer patients were randomized to be the study and control groups. Beraprost sodium was prescribed in the study group according to protocol.

RESULTS

At 6th week follow up, median wound healing rate in the study group was significantly higher than in the control group with the rate of 88.1% and 33.3%, respectively. Complete wound healing in the study group was also significantly higher than in the control group (48%:8%). In the study group, 9 patients (37.5%) could be administered with recommended dose. Side effects were headache in 14 patients (58.3%) and palpitation in one patient (4.2%). One patient was discontinued for severe headache.

CONCLUSIONS

The use of Beraprost sodium in chronic diabetic foot ulcer patients significantly increases the wound healing rate. Headache was the common side effect.

Prostanoids for Pulmonary Arterial Hypertension

Pulmonary arterial hypertension (PAH) is a severe condition that markedly reduces exercise capacity and survival in the affected patient population. PAH includes primary pulmonary hypertension (PPH) and pulmonary hypertension associated with collagen vascular diseases, congenital systemic-to-pulmonary shunts, portal hypertension and HIV infection. All these conditions share virtually identical obstructive pathologic changes of the pulmonary microcirculation and probably similar pathobiologic processes. The pathophysiology is characterized by a progressive increase in pulmonary vascular resistance, leading to right ventricular failure and death. Prostacyclin is an endogenous substance that is produced by vascular endothelial cells and induces vasodilatation, inhibition of platelet activity, and antiproliferative effects. A dysregulation of prostacyclin metabolic pathways has been shown in patients with PAH and this represents the rationale for the exogenous therapeutic administration of this substance. The clinical use of prostacyclin in patients with PAH has been made possible by the synthesis of stable analogs that possess different pharmacokinetic properties but share similar pharmacodynamic effects. Experience in humans has been initially collected with epoprostenol, which is a synthetic salt of prostacyclin. Epoprostenol has a short half-life in the circulation and requires continuous administration by the intravenous route by means of infusion pumps and permanent tunnelized catheters. In addition, epoprostenol is unstable at room temperature, and the complex delivery system required is associated with several adverse effects and potentially serious complications. For these reasons, alternatives to intravenous epoprostenol have been sought and this has led to the development of analogs that can be administered subcutaneously (treprostinil), orally (beraprost sodium) or by inhalation (iloprost). Three unblinded clinical trials and several uncontrolled trials have shown that treatment with epoprostenol improved symptoms and exercise capacity in New York Heart Association (NYHA) class III and IV PAH patients and also survival in patients with PPH. Subcutaneous treprostinil improved symptoms, exercise, hemodynamics and clinical events in the largest clinical trial ever performed in PAH, but local infusion site reactions limited efficacy in a proportion of patients. Oral beraprost sodium improved exercise capacity only in patients with PPH and is the only prostacyclin analog that has also been tested in NYHA class II patients. Inhaled iloprost has improved symptoms, exercise capacity and clinical events in patients with PAH and inoperable chronic thromboembolic pulmonary hypertension. The favorable effects of prostanoids observed in all studies coupled with different profiles of adverse events and tolerability for each prostacyclin analog allow the unique opportunity to select the most appropriate compound for the individual patient with PAH.