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Brewer J, Wilson M, Coons JC, Schmit A, Whittenhall ME, Kimber A, Broderick M, Lee D, Patzlaff N, Miller C, Ataya A, LaRoy V, King CS, Ravichandran AK, Kingrey JF, Sahay S. Practical management of oral treprostinil in patients with pulmonary arterial hypertension: Lessons from ADAPT, EXPEDITE, and expert consensus. Respir Med 2024; 231:107734. [PMID: 38986791 DOI: 10.1016/j.rmed.2024.107734] [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: 03/07/2024] [Revised: 06/18/2024] [Accepted: 07/04/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Oral treprostinil is a prostacyclin analogue approved to treat pulmonary arterial hypertension (PAH) by delaying disease progression and improving exercise capacity. Higher doses of oral treprostinil correlate with increased treatment benefit. Titrations may be challenging due to common side effects of prostacyclin-class therapies. STUDY DESIGN AND METHODS The multicenter, prospective, real-world, observational ADAPT Registry study followed adult patients with PAH for up to 78 weeks after initiating oral treprostinil (NCT03045029). Dosing, titration, and transitions of oral treprostinil were at the discretion of the prescriber. Patient-reported incidence and treatment of common side effects were collected to understand side effect management and tolerability. Insights from literature and expert recommendations were added to provide a consolidated resource for oral treprostinil use. RESULTS In total, 139 participants in ADAPT completed ≥1 weekly survey; (median age 60.0 years, 76 % female). Median treatment duration of oral treprostinil was 13.1 months. During early therapy (Months 1-5), 62 % (78/126) of patients reported headache and diarrhea, and 40 % (50/126) reported nausea. At Month 6, many patients who reported side effects during early therapy reported an improvement (61 % headache, 44 % diarrhea, 70 % nausea). Common side effect treatments, including acetaminophen, loperamide, and ondansetron, were effective. Approximately one-quarter of patients reporting the most common side effects were untreated at Month 6. CONCLUSION Patient selection for, and initiation and titration of, oral treprostinil should be individualized and may include parenteral treprostinil induction-transition for faster titration. Assertive side effect management may help patients reach higher and more efficacious doses of oral treprostinil.
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Affiliation(s)
| | | | | | - Ann Schmit
- Ascension St. Vincent Hospital, Indianapolis, IN, USA
| | | | | | | | - Dasom Lee
- United Therapeutics Corp, RTP, NC, USA
| | | | | | - Ali Ataya
- University of Florida, Gainesville, FL, USA
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Burger CD, Tsang Y, Chivers M, Vekaria RV, Doad G, Atkins N, Panjabi S. Oral Prostacyclin Pathway Agents Used in PAH: A Targeted Literature Review. CLINICOECONOMICS AND OUTCOMES RESEARCH 2024; 16:447-459. [PMID: 38831921 PMCID: PMC11146608 DOI: 10.2147/ceor.s460912] [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] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 05/14/2024] [Indexed: 06/05/2024] Open
Abstract
Purpose Pulmonary arterial hypertension (PAH) is a rare and progressive pulmonary vascular disease that can result in right heart failure and death. Oral prostacyclins play an important role in the management of intermediate-low risk PAH. This targeted literature review (TLR) aimed to identify and compare evidence supporting use of oral prostacyclin pathway agents (PPAs: selexipag and oral treprostinil) in intermediate-low risk PAH. Methods A targeted literature review was conducted. Literature databases (MEDLINE, Embase, and Cochrane reviews) were searched for studies describing clinical practice and treatment outcomes for oral treprostinil and selexipag globally, published in English (2012 to 2022). Electronic searches were supplemented by manual-searches of targeted conferences (2020 to 2022), and reference lists of identified publications were reviewed. One reviewer assessed studies for eligibility. Results In total, 95 publications met inclusion criteria: 47 full-text articles (selexipag n = 22; oral treprostinil n = 16; selexipag and oral treprostinil n = 9) and 48 conference materials. Selexipag and oral treprostinil target the prostacyclin pathway differently; their label-supporting trials had different primary endpoints (disease progression and hospitalization vs exercise capacity and disease progression), differing baseline therapy (0, 1 or 2 vs 0 or 1 baseline treatments), titration duration and dosing (personalized dose capped at 1600 ug twice daily (BID) vs increasing doses over time with no maximum dose), respectively. While both oral PPAs have demonstrated reduced risk of disease progression, only selexipag showed reduction in hospitalization rates. Oral PPAs have been shown to reduce healthcare costs in real-world clinical practice. This difference is reflected in labeled indications. Conclusion Given differences in trial- and real-world outcomes, number of prior therapies, and dosing, personalizing the choice of oral PPA is critical to maximizing the benefit for individual patients.
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Affiliation(s)
- Charles D Burger
- Division of Pulmonary Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Yuen Tsang
- Janssen Scientific Affiars, Titusville, NJ, USA
| | | | | | - Gurinderpal Doad
- Janssen Scientific Affiars, Titusville, NJ, USA
- Actelion Pharmaceuticals US, Inc, A Johnson and Johnson Co., Titusville, NJ, USA
| | | | - Sumeet Panjabi
- Janssen Scientific Affiars, Titusville, NJ, USA
- Actelion Pharmaceuticals US, Inc, A Johnson and Johnson Co., Titusville, NJ, USA
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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.
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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
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Coons JC, Empey PE. Pharmacogenomics in the Management of Pulmonary Arterial Hypertension: Current Perspectives. Pharmgenomics Pers Med 2023; 16:729-737. [PMID: 37457231 PMCID: PMC10349598 DOI: 10.2147/pgpm.s361222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 06/19/2023] [Indexed: 07/18/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare disease with heterogeneous causes that can lead to right ventricular (RV) failure and death if left untreated. There are currently 10 medications representative of five unique pharmacologic classes that are approved for treatment. These have led to significant improvements in overall clinical outcome. However, substantial variability in dosing requirements and treatment response is evident, leading to suboptimal outcome for many patients. Furthermore, dosing is empiric and iterative and can lead to delays in meeting treatment goals and burdensome adverse effects. Pharmacogenomic (PGx) associations have been reported with certain PAH medications, such as treprostinil and bosentan, and can explain some of the variability in response. Relevant genes associated with treprostinil include CYP2C8, CYP2C9, CAMK2D, and PFAS. CYP2C8 and CYP2C9 are the genes encoding the major metabolizing liver enzymes for treprostinil, and reduced function variants (*2, *3) with CYP2C9 were associated with lower treatment persistence. Additionally, a higher CYP2C9 activity score was associated with a significantly less risk of treatment discontinuation. Other genes of interest that have been explored with treprostinil include CAMK2D, which is associated with right ventricular dysfunction and significantly higher dose requirements. Similarly, PFAS is associated with lower concentrations of cyclic adenosine monophosphate and significantly higher dose requirements. Genes of interest with the endothelin receptor antagonist (ERA) class include GNG2 and CYP2C9. A genetic variant in GNG2 (rs11157866) was linked to a significantly increased rate of clinical improvement with ERAs. The *2 variant with CYP2C9 (encoding for the major metabolizing enzyme for bosentan) was significantly associated with a higher risk for elevations in hepatic aminotransferases and liver injury. In summary, this article reviews the relevant pharmacogenes that have been associated to date with dosing and outcome among patients who received PAH medications.
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Affiliation(s)
- James C Coons
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
- Department of Pharmacy, UPMC Presbyterian-Shadyside Hospital, Pittsburgh, PA, USA
| | - Philip E Empey
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
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Kingrey JF, Miller CE, Franco V, Smith JS, Zolty R, Oudiz RJ, Elwing JM, Huston JH, Melendres‐Groves L, Ravichandran A, Balasubramanian V, Wu B, Hwang S, Seaman S, Broderick M, Rahaghi FF. Implementing the EXPEDITE parenteral induction protocol: Rapid parenteral treprostinil titration and transition to oral treprostinil. Pulm Circ 2023; 13:e12255. [PMID: 37497167 PMCID: PMC10368085 DOI: 10.1002/pul2.12255] [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: 02/22/2023] [Revised: 05/30/2023] [Accepted: 06/13/2023] [Indexed: 07/28/2023] Open
Abstract
Treprostinil is a prostacyclin analogue that targets multiple cellular receptors to treat pulmonary arterial hypertension (PAH). In certain scenarios, patients may require aggressive treprostinil titration. Several studies have demonstrated that higher doses of treprostinil lead to greater clinical benefit. Data supports successful transitions from parenteral to oral treprostinil; however, administration routes, transition duration, and transition setting vary in the real-world. The EXPEDITE clinical trial (NCT03497689) prospectively studied whether rapid parenteral treprostinil induction can be used to achieve high doses of oral treprostinil (total daily dose: ≥12 mg) in prostacyclin naïve PAH patients. Parenteral prostacyclin induction may be more appropriate for patients who need to reach therapeutic dosing more urgently than longer titration durations reported with conventional de novo oral treprostinil initiation. This summary provides strategies utilized in EXPEDITE. Parenteral treprostinil was initiated at 2 ng/kg/min intravenously or subcutaneously; clinicians determined the frequency and dose increment of up-titration. Two distinct transition schedules from parenteral to oral treprostinil were employed: rapid cross-titration in an inpatient setting (median: 2 days) or gradual cross-titration in an outpatient setting (median: 5 days). Patient status was closely monitored after transition; oral treprostinil dose was titrated to clinical effect and tolerability. Factors considered when individualizing dosing strategies included parenteral and oral treprostinil target doses, nursing support, patient education, medication counseling and adverse events management. EXPEDITE demonstrated the time to a therapeutic dose of oral treprostinil is significantly shorter when utilizing a short-term parenteral induction strategy and may be suitable for patients requiring aggressive titration of oral treprostinil.
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Affiliation(s)
| | | | - Veronica Franco
- The Ohio State University Wexner Medical CenterColumbusOhioUSA
| | - Jimmy S. Smith
- The Ohio State University Wexner Medical CenterColumbusOhioUSA
| | - Ronald Zolty
- University of Nebraska Medical CenterOmahaNebraskaUSA
| | - Ronald J. Oudiz
- Lundquist Institute at Harbor‐UCLA Medical CenterTorranceCaliforniaUSA
| | - Jean M. Elwing
- University of Cincinnati College of MedicineCincinnatiOhioUSA
| | | | | | | | | | - Benjamin Wu
- United Therapeutics CorporationResearch Triangle ParkNorth CarolinaUSA
| | - Stephanie Hwang
- United Therapeutics CorporationResearch Triangle ParkNorth CarolinaUSA
| | - Scott Seaman
- United Therapeutics CorporationResearch Triangle ParkNorth CarolinaUSA
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Spikes LA, Bajwa AA, Burger CD, Desai SV, Eggert MS, El‐Kersh KA, Fisher MR, Johri S, Joly JM, Mehta J, Palevsky HI, Ramani GV, Restrepo‐Jaramillo R, Sahay S, Shah TG, Deng C, Miceli M, Smith P, Shapiro SM. BREEZE: Open-label clinical study to evaluate the safety and tolerability of treprostinil inhalation powder as Tyvaso DPI™ in patients with pulmonary arterial hypertension. Pulm Circ 2022; 12:e12063. [PMID: 35514770 PMCID: PMC9063953 DOI: 10.1002/pul2.12063] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 02/01/2022] [Accepted: 03/15/2022] [Indexed: 12/04/2022] Open
Abstract
Inhaled treprostinil is an approved therapy for pulmonary arterial hypertension (PAH) and pulmonary hypertension associated with interstitial lung disease in the United States. Studies have confirmed the robust benefits and safety of nebulized inhaled treprostinil, but it requires a time investment for nebulizer preparation, maintenance, and treatment. A small, portable treprostinil dry powder inhaler has been developed for the treatment of PAH. The primary objective of this study was to evaluate the safety and tolerability of treprostinil inhalation powder (TreT) in patients currently treated with treprostinil inhalation solution. Fifty-one patients on a stable dose of treprostinil inhalation solution enrolled and transitioned to TreT at a corresponding dose. Six-minute walk distance (6MWD), device preference and satisfaction (Preference Questionnaire for Inhaled Treprostinil Devices [PQ-ITD]), PAH Symptoms and Impact (PAH-SYMPACT®) questionnaire, and systemic exposure and pharmacokinetics for up to 5 h were assessed at baseline for treprostinil inhalation solution and at Week 3 for TreT. Adverse events (AEs) were consistent with studies of inhaled treprostinil in patients with PAH, and there were no study drug-related serious AEs. Statistically significant improvements occurred in 6MWD, PQ-ITD, and PAH-SYMPACT. Forty-nine patients completed the 3-week treatment phase and all elected to participate in an optional extension phase. These results demonstrate that, in patients with PAH, transition from treprostinil inhalation solution to TreT is safe, well-tolerated, and accompanied by statistically significant improvements in key clinical assessments and patient-reported outcomes with comparable systemic exposure between the two formulations at evaluated doses (trial registration: clinicaltrials.gov identifier: NCT03950739).
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Affiliation(s)
- Leslie A. Spikes
- Pulmonary and Critical Care MedicineUniversity of Kansas Medical CenterKansas CityKansasUSA
| | - Abubakr A. Bajwa
- Pulmonary MedicineAscension St. Vincent's Hospital SouthsideJacksonvilleFloridaUSA
| | | | - Sapna V. Desai
- Heart Failure and Transplantation CardiologyOchsner Medical CenterNew OrleansLouisianaUSA
| | - Michael S. Eggert
- Pulmonary and Critical Care MedicineSentara Heart HospitalNorfolkVirginiaUSA
| | - Karim A. El‐Kersh
- Pulmonary and Critical Care MedicineUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Micah R. Fisher
- Pulmonary and Critical Care MedicineEmory University School of MedicineAtlantaGeorgiaUSA
| | - Shilpa Johri
- Pulmonary and Critical Care MedicineHenrico Doctors' Hospital and Bon Secours St. Francis Medical CenterRichmondVirginiaUSA
| | - Joanna M. Joly
- Cardiology, Heart Failure and Transplantation CardiologyUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Jinesh Mehta
- Pulmonary and Critical Care MedicineThe Cleveland ClinicWestonFloridaUSA
| | | | - Gautam V. Ramani
- CardiologyUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | | | - Sandeep Sahay
- Pulmonary Hypertension and Pulmonary Critical CareHouston Methodist HospitalHoustonTexasUSA
| | - Trushil G. Shah
- Pulmonary and Critical Care MedicineUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Chunqin Deng
- Clinical Product DevelopmentUnited Therapeutics CorporationResearch Triangle ParkNorth CarolinaUSA
| | - Melissa Miceli
- Global Medical AffairsUnited Therapeutics CorporationNorth CarolinaResearch Triangle ParkUSA
| | - Peter Smith
- Clinical Product DevelopmentUnited Therapeutics CorporationResearch Triangle ParkNorth CarolinaUSA
| | - Shelley M. Shapiro
- Pulmonology, Greater Los Angeles VA Healthcare SystemCardiology Section, and David Geffen UCLA School of MedicineLos AngelesCaliforniaUSA
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Balasubramanian VP, Safdar Z, Sketch MR, Broderick M, Nelsen AC, Lee D, Melendres‐Groves L. Real‐world dosing characteristics and utilization of parenteral treprostinil in the outpatient setting. Pulm Circ 2022; 12:e12016. [PMID: 35506102 PMCID: PMC9052964 DOI: 10.1002/pul2.12016] [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: 03/08/2021] [Revised: 10/25/2021] [Accepted: 11/22/2021] [Indexed: 11/12/2022] Open
Abstract
Real‐world dosing and titration of parenteral (subcutaneous, SC; intravenous, IV) prostacyclin, a mainstay of pulmonary arterial hypertension (PAH) treatment, is not always consistent with prescribing information or randomized trials and has yet to be adequately characterized. The current study describes real‐world outpatient dosing and titration patterns over time, in PAH patients initiated on SC or IV treprostinil. A longitudinal, cross‐sectional analysis of medication shipment records from US specialty pharmacy services between 2009 and 2018 was conducted to determine dosing and titration patterns of SC or IV treprostinil in the outpatient setting beginning with the patient's first shipment. The sample for analysis included shipment records for 2647 patients (IV = 1040, SC = 1607). Although more patients were started on SC treprostinil than IV, median initial outpatient IV treprostinil dose (11 ng/kg/min at month on therapy one [MOT1]) was consistently and statistically significantly higher than initial outpatient SC dose (7.5 ng/kg/min at MOT1; p < 0.01). However, the SC treprostinil dose acceleration rate (DAR) was more aggressive from MOT1 to MOT6, MOT12, and MOT24, leading to a higher dose achieved at later timepoints. All between‐group DAR differences were statistically significant (p < 0.001). This study provides evidence that real‐world prescribing patterns of parenteral treprostinil in the outpatient setting differs from dosing described in pivotal trials, with important differences between SC and IV administration. Although initial outpatient IV treprostinil dosing was higher, SC titration was accelerated more aggressively and a higher dose was achieved by MOT3 suggesting that factors specific to SC administration (e.g., site pain) may not limit dosing and titration as previously thought.
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Affiliation(s)
- Vijay P. Balasubramanian
- Division of Pulmonary and Critical Care Medicine University of California, San Francisco Fresno California USA
| | - Zeenat Safdar
- Division of Pulmonary Critical Care Medicine and Sleep Houston Methodist Lung Center Houston Texas USA
- Weill Cornell College of Medicine Houston Texas USA
| | - Margaret R. Sketch
- United Therapeutics Corporation Research Triangle Park North Carolina USA
| | - Meredith Broderick
- United Therapeutics Corporation Research Triangle Park North Carolina USA
| | - Andrew C. Nelsen
- United Therapeutics Corporation Research Triangle Park North Carolina USA
| | - Dasom Lee
- United Therapeutics Corporation Research Triangle Park North Carolina USA
- Department of Statistics North Carolina State University Raleigh North Carolina USA
| | - Lana Melendres‐Groves
- Division of Pulmonary, Critical Care and Sleep Medicine University of New Mexico Albuquerque New Mexico USA
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Shapiro S, Mandras S, Restrepo-Jaramillo R, Shen E, Broderick M, Rao Y, Lee D, Nelsen AC. Survival and drug persistence in patients receiving inhaled treprostinil at doses greater than 54 µg (nine breaths) four times daily. Pulm Circ 2021; 11:20458940211052228. [PMID: 34733493 PMCID: PMC8558813 DOI: 10.1177/20458940211052228] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 09/22/2021] [Indexed: 12/05/2022] Open
Abstract
Treprostinil is a prostacyclin approved for the treatment of pulmonary arterial hypertension. Commercial data sets indicate that approximately 20-25% of patients are prescribed a higher dose than the maximum recommended dosage of nine breaths per treatment session (bps) (54 μg), four times a day (QID) and numerous studies have demonstrated the safety of doses >9 bps QID. This phase 4, retrospective analysis of specialty pharmacy records assessed the effects of inhaled treprostinil at doses >9 bps QID. Patients receiving inhaled treprostinil between September 2009 and June 2018 were included, and a random sampling of 5000 patients was selected for further analysis. Subjects were grouped based on the highest dose reached for ≥2 months within a rolling six-month window and were followed for up to three years. Of the total of 5000 patients analyzed, 28.5% received >9 bps QID. Survival rates were significantly higher in the >9 bps QID dosing group for years one, two, and three (P < 0.001). The time to transition to parenteral therapy was significantly longer for those at doses >9 bps (17.5 months) compared to doses ≤9 bps (9.5 moths; P < 0.0001). Drug persistence was also significantly higher for those taking >9 bps at years 1, 2, and 3 (P < 0.0001). Patients receiving inhaled treprostinil at doses >9 bps QID had a higher rate of survival and drug persistence over a three-year period, suggesting that higher doses may provide clinically relevant benefits while remaining tolerable.
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Affiliation(s)
- Shelley Shapiro
- Division of Pulmonary Critical Care – VAGLAHS, Cardiology Section – UCLA David Geffen School of Medicine
| | | | | | - Eric Shen
- United Therapeutics Corporation, Research Triangle Park, NC, USA
| | | | - Youlan Rao
- United Therapeutics Corporation, Research Triangle Park, NC, USA
| | - Dasom Lee
- United Therapeutics Corporation, Research Triangle Park, NC, USA
| | - Andrew C. Nelsen
- United Therapeutics Corporation, Research Triangle Park, NC, USA
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Coons JC, Crisamore K, Adams S, Modany A, Simon MA, Zhao W, Shaik IH, Venkataramanan R, Empey PE. A pilot study of oral treprostinil pharmacogenomics and treatment persistence in patients with pulmonary arterial hypertension. Ther Adv Respir Dis 2021; 15:17534666211013688. [PMID: 33929912 PMCID: PMC8111525 DOI: 10.1177/17534666211013688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 04/01/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND AIMS Treprostinil is a prostacyclin analog used to treat pulmonary arterial hypertension. Dosing is empiric and based on tolerability. Adverse effects are common and can affect treatment persistence. Pharmacogenomic variants that may affect treprostinil metabolism and transport have not been well-characterized. We aimed to investigate the pharmacogenomic sources of variability in treatment persistence and dosing. METHODS Patients were prospectively recruited from an IRB approved biobank registry at a single pulmonary hypertension center. A cohort of patients who received oral treprostinil were screened for participation. Pharmacogenomic analysis was for variants in CYP2C8, CYP2C9, and ABCC4. A retrospective review was conducted for demographics, clinical status, dosing, and response. Fisher's exact test was used for categorical data and Kruskal-Wallis test or Wilcoxon rank sum were used for continuous data. RESULTS A total of 15 patients received oral treprostinil and were consented. Their median age was 53 years, 73% were female, and 93% were White. The median total daily dose was 22.5 mg (13.5, 41) at last clinical observation. 40% of patients discontinued treatment with a majority due to adverse effects. Approximately 27% of patients had a loss-of-function variant in CYP2C8 (*1/*3 or *1/*4), whereas 47% of patients had a loss-of-function variant in CYP2C9 (*1/*2, *1/*3, or *2/*2). Minor allele frequencies for ABCC4 (rs1751034 and rs3742106) were 0.17 and 0.43, respectively. Survival analysis showed that increased CYP2C9 activity score was associated with decreased risk for treatment discontinuation [hazard ratio (HR): 0.13; 95% confidence interval (CI): 0.02, 0.91; p = 0.04]. Genetic variants were not significantly associated with dosing. CONCLUSION Genetic variants responsible for the metabolism and transport of oral treprostinil were common. Increased CYP2C9 activity score was associated with decreased risk for treatment discontinuation. However, dosing was not associated with genetic variants in metabolizing enzymes for treprostinil. Our findings suggest significant variability in treatment persistence to oral treprostinil, with pharmacogenomics being a potentially important contributor.The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- James C. Coons
- University of Pittsburgh School of Pharmacy, Clinical Pharmacist, Cardiology, UPMC Presbyterian Hospital, Salk Hall, Room 727, 3501 Terrace Street, Pittsburgh, PA 15261, USA
| | - Karryn Crisamore
- Department of Pharmaceutical Sciences, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | | | | | - Marc A. Simon
- Bioengineering, and Clinical Translational Science, Department of Medicine/Division of Cardiology, Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA
- Heart and Vascular Institute, Heart Failure Research, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Wenchen Zhao
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Imam H. Shaik
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Raman Venkataramanan
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Philip E. Empey
- Pharmacogenomics Center of Excellence, Institute for Personalized Medicine, Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences and the Clinical and Translational Science Institute, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
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