1
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Zhu HR, Kuang HY, Li Q, Ji XJ. Effects of oral targeted treatments in pulmonary arterial hypertension: A systematic review and meta-analysis. Front Cardiovasc Med 2022; 9:915470. [PMID: 35983180 PMCID: PMC9378982 DOI: 10.3389/fcvm.2022.915470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/08/2022] [Indexed: 11/26/2022] Open
Abstract
Background Although pulmonary arterial hypertension (PAH) is a fatal disease, specific drugs have been used to treat PAH. These drugs predominantly target these three pathobiological pathways: Endothelin receptor antagonist (ERA), nitric oxide (NO), and prostanoids pathways. In this review, we aimed to analyze the efficacy and safety of oral targeted treatments for PAH. Methods The national library of medicine (MEDLINE), excerpta medica database (EMBASE), and Cochrane Central Register of Controlled Trials databases were searched. Randomized controlled trials that compared the oral targeted drugs with placebos were selected. We calculated odds ratios (ORs) with 95% confidence intervals (CIs) for variables with dichotomous outcomes, and standardized mean differences with continuous outcomes variables. Additionally, the mean of the differences for the 6-min walk distance (6MWD) was analyzed. Results In total, 23 studies involving 7,121 patients were included in this study. These studies show that orally PAH-specific drugs could decrease the risk of clinical worsening events, with an OR of 0.55 (p < 0.001). Furthermore, these drugs could improve exercise capacity, showing a 21.74-m increase in 6MWD (95% CI: 17.53–25.95 m) and cause a greater amelioration of functional class (OR = 0.60, 95% CI: 0.47–0.76). Additionally, subgroup analysis indicated that compared with placebo, ERAs, and drugs in the NO pathway were most effective and safe, which are associated with an improvement in exercise capacity, 6MWD, and worsening events-free survival rate. Conclusion Nitric oxide exhibited the most prominent clinical effect on exercise tolerance. However, in the subgroup analysis, oral targeted drugs of different pathways show applicability to different populations, which highlights the need for precise treatment in the clinical setting. Systematic Review Registration [https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=297946], identifier [CRD 42022297946].
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Affiliation(s)
- Hui-ru Zhu
- National Clinical Research Center for Child Health and Disorders, Department of Ultrasound, Children’s Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Hong-yu Kuang
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qiang Li
- Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Department of Cardiology, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao-juan Ji
- Department of Ultrasound, Chongqing General Hospital, Chongqing, China
- *Correspondence: Xiao-juan Ji,
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2
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Kamp JC, Fuge J, Karsten JF, Rümke S, Hoeper MM, Park DH, Kühn C, Olsson KM. Periprocedural safety and outcome after pump implantation for intravenous treprostinil administration in patients with pulmonary arterial hypertension. BMC Pulm Med 2021; 21:164. [PMID: 33992098 PMCID: PMC8126130 DOI: 10.1186/s12890-021-01541-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 05/11/2021] [Indexed: 02/08/2023] Open
Abstract
Methods In this retrospective observational study, we analyzed all patients with pulmonary arterial hypertension undergoing LenusPro® pump implantation between November 2013 and October 2019 at our center. Periprocedural safety was assessed by describing all complications that occurred within 28 days after surgery; complications that occurred later were described to assess long-term safety. Clinical outcomes were measured by comparison of clinical parameters and echocardiographic measurements of right ventricular function from baseline to 6-months-follow-up. Results Fifty-four patients underwent LenusPro® pump implantation for intravenous treprostinil treatment during the investigation period. Periprocedural complications occurred in 5 patients; the only anesthesia-related complication (right heart failure with recovery after prolonged intensive care and death in the further course) occurred in the only patient who underwent general anesthesia. All other patients underwent local anesthesia with or without short-acting (analgo-) sedation. Eighteen long-term complications occurred in 15 patients, most notably pump pocket or catheter related problems. Transplant-free survival rates at 1, 2, and 3 years were 77 %, 56 %, and 48 %, respectively. Conclusions Subcutaneous pump implantation under local anesthesia and conscious analgosedation while avoiding intubation and mechanical ventilation is feasible in patients with advanced PAH. Controlled studies are needed to determine the safest anesthetic approach for this procedure. Background/Objectives Intravenous treprostinil treatment via a fully implantable pump is a treatment option for patients with advanced pulmonary arterial hypertension. However, there is no consensus on the preferred anesthetic approach for the implantation procedure. Primary objective was to assess periprocedural safety with particular attention to feasibility of local anesthesia and conscious analgosedation instead of general anesthesia. Long-term safety and clinical outcomes were secondary endpoints.
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Affiliation(s)
- Jan C Kamp
- Department of Respiratory Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Jan Fuge
- Department of Respiratory Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Jan F Karsten
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Stefan Rümke
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Da-Hee Park
- Department of Respiratory Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Christian Kühn
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Karen M Olsson
- Department of Respiratory Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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3
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Prostacyclin Analogues Inhibit Platelet Reactivity, Extracellular Vesicle Release and Thrombus Formation in Patients with Pulmonary Arterial Hypertension. J Clin Med 2021; 10:jcm10051024. [PMID: 33801460 PMCID: PMC7958838 DOI: 10.3390/jcm10051024] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/12/2021] [Accepted: 02/19/2021] [Indexed: 12/13/2022] Open
Abstract
(1) Background: Prostacyclin analogues (epoprostenol, treprostinil, and iloprost) induce vasodilation in pulmonary arterial hypertension (PAH) but also inhibit platelet function. (2) Objectives: We assessed platelet function in PAH patients treated with prostacyclin analogues and not receiving prostacyclin analogues. (3) Methods: Venous blood was collected from 42 patients treated with prostacyclin analogues (49.5 ± 15.9 years, 81% female) and 38 patients not receiving prostacyclin analogues (55.5 ± 15.6 years, 74% female). Platelet reactivity was analyzed by impedance aggregometry using arachidonic acid (AA; 0.5 mM), adenosine diphosphate (ADP; 6.5 µM), and thrombin receptor-activating peptide (TRAP; 32 µM) as agonists. In a subset of patients, concentrations of extracellular vesicles (EVs) from all platelets (CD61+), activated platelets (CD61+/CD62P+), leukocytes (CD45+), and endothelial cells (CD146+) were analyzed by flow cytometry. Platelet-rich thrombus formation was measured using a whole blood perfusion system. (4) Results: Compared to controls, PAH patients treated with prostacyclin analogues had lower platelet reactivity in response to AA and ADP (p = 0.01 for both), lower concentrations of platelet and leukocyte EVs (p ≤ 0.04), delayed thrombus formation (p ≤ 0.003), and decreased thrombus size (p = 0.008). Epoprostenol did not affect platelet reactivity but decreased the concentrations of platelet and leukocyte EVs (p ≤ 0.04). Treprostinil decreased platelet reactivity in response to AA and ADP (p ≤ 0.02) but had no effect on the concentrations of EVs. All prostacyclin analogues delayed thrombus formation and decreased thrombus size (p ≤ 0.04). (5) Conclusions: PAH patients treated with prostacyclin analogues had impaired platelet reactivity, EV release, and thrombus formation, compared to patients not receiving prostacyclin analogues.
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4
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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.
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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
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5
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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.
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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
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6
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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.
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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
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7
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Steringer-Mascherbauer R, Lummersdorfer M, Függer R, Sigmund E, Huber C, Engleder D, Fröschl U, Aichinger J. Long-term experience with implantable infusion pumps for intravenous treprostinil in pulmonary arterial hypertension-procedural safety and system-related complications. Pulm Circ 2020; 10:2045894020970830. [PMID: 33299542 PMCID: PMC7711148 DOI: 10.1177/2045894020970830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 10/11/2020] [Indexed: 12/21/2022] Open
Abstract
Implantable pumps for intravenous treprostinil provide a promising option to overcome
drawbacks of parenteral prostanoid administration with external pumps in pulmonary
hypertension. We retrospectively analyzed 85 patients undergoing implantation in a single
center since 2010. In our cohort, serious complications were rare, and flow rate increase
over time warrants careful monitoring.
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Affiliation(s)
| | - Maria Lummersdorfer
- Institute for Anesthesiology and Intensive Care, Ordensklinikum Linz GmbH Elisabethinen, Linz, Austria
| | - Reinhold Függer
- Department of Surgery, Ordensklinikum Linz GmbH Elisabethinen, Linz, Austria
| | - Elisabeth Sigmund
- Department of Cardiology, Ordensklinikum Linz GmbH Elisabethinen, Linz, Austria
| | - Charlotte Huber
- Department of Cardiology, Ordensklinikum Linz GmbH Elisabethinen, Linz, Austria
| | - Dagmar Engleder
- Institute for Anesthesiology and Intensive Care, Ordensklinikum Linz GmbH Elisabethinen, Linz, Austria
| | - Uwe Fröschl
- Department of Surgery, Ordensklinikum Linz GmbH Elisabethinen, Linz, Austria
| | - Josef Aichinger
- Department of Cardiology, Ordensklinikum Linz GmbH Elisabethinen, Linz, Austria
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8
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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.
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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
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9
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Inampudi C, Tedford RJ, Hemnes AR, Hansmann G, Bogaard HJ, Koestenberger M, Lang IM, Brittain EL. Treatment of right ventricular dysfunction and heart failure in pulmonary arterial hypertension. Cardiovasc Diagn Ther 2020; 10:1659-1674. [PMID: 33224779 PMCID: PMC7666956 DOI: 10.21037/cdt-20-348] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 05/13/2020] [Indexed: 01/09/2023]
Abstract
Right heart dysfunction and failure is the principal determinant of adverse outcomes in patients with pulmonary arterial hypertension (PAH). In addition to right ventricular (RV) dysfunction, systemic congestion, increased afterload and impaired myocardial contractility play an important role in the pathophysiology of RV failure. The behavior of the RV in response to the hemodynamic overload is primarily modulated by the ventricular interaction and its coupling to the pulmonary circulation. The presentation can be acute with hemodynamic instability and shock or chronic producing symptoms of systemic venous congestion and low cardiac output. The prognostic factors associated with poor outcomes in hospitalized patients include systemic hypotension, hyponatremia, severe tricuspid insufficiency, inotropic support use and the presence of pericardial effusion. Effective therapeutic management strategies involve identification and effective treatment of the triggering factors, improving cardiopulmonary hemodynamics by optimization of volume to improve diastolic ventricular interactions, improving contractility by use of inotropes, and reducing afterload by use of drugs targeting pulmonary circulation. The medical therapies approved for PAH act primarily on the pulmonary vasculature with secondary effects on the right ventricle. Mechanical circulatory support as a bridge to transplantation has also gained traction in medically refractory cases. The current review was undertaken to summarize recent insights into the evaluation and treatment of RV dysfunction and failure attributable to PAH.
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Affiliation(s)
- Chakradhari Inampudi
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ryan J. Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Anna R. Hemnes
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Harm-Jan Bogaard
- Department of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Martin Koestenberger
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Graz, Austria
| | - Irene Marthe Lang
- Division of Cardiology, Department of Medicine, Medical University of Vienna, Vienna
| | - Evan L. Brittain
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Translational and Clinical Cardiovascular Research Center, Nashville, TN, USA
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10
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Álvarez-Fuente M, Garrido-Lestache E, Rivero N, Centella T, Lamas MJ, Pérez-Caballero C, Vázquez JL, Del Cerro MJ. Implantable LENUS pro pump for treprostinil infusion in three pediatric patients. Pediatr Pulmonol 2020; 55:1254-1258. [PMID: 32149476 DOI: 10.1002/ppul.24707] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 02/19/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Prostanoid treatment in patients with severe pulmonary arterial hypertension (PAH) has been proven safe and effective. Subcutaneous administration of treprostinil has side effects, which limits their use and acceptance. An implantable pump for continuous intravenous treprostinil infusion has been recently approved. We describe our experience with the implantable pump in three pediatric patients. DESCRIPTION OF CASES The LENUS pro pump was implanted in three adolescents with severe PAH, who were treated with tadalafil, ambrisentan, and subcutaneous treprostinil. The indication of the Lenus pro pump implantation was the local side effects of subcutaneous treprostinil (pain, inflammation, and local infection) that were not well tolerated and that severely decreased their quality of life. The pump was surgically implanted under general anesthesia.One patient, in functional class IV, suffered postoperative hemodynamic instability and small pneumothorax, requiring an increase in treprostinil dose up to 85 ng/kg/min and a decrease 9 days after the pump implantation. The second patient who was discharged 4 days after surgery with treprostinil at 60 ng/kg/min reported improvement in his quality of life, but the dose requirement increased up to 92 ng/kg/min. After a 21-month follow-up, this patient received a lung transplant. The third patient presented a hematoma at the pump site with no other complications and had a follow-up of 9 months with an improvement in her quality of life. COMMENTS Implantable pumps for continuous parenteral prostanoid infusion in pediatric patients are an alternative to external pumps, especially when familiar psychological or psychomotor issues hinder the use of external pumps.
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Affiliation(s)
| | | | - Natalia Rivero
- Department of Pediatric Cardiology, Ramon y Cajal Hospital, Madrid, Spain
| | - Tomasa Centella
- Department of Pediatric Cardiac Surgery, Ramon y Cajal Hospital, Madrid, Spain
| | - Maria J Lamas
- Department of Pediatric Cardiac Surgery, Ramon y Cajal Hospital, Madrid, Spain
| | | | - Jose L Vázquez
- Pediatric Intensive Care Unit, Ramon y Cajal Hospital, Madrid, Spain
| | - Maria J Del Cerro
- Department of Pediatric Cardiology, Ramon y Cajal Hospital, Madrid, Spain
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11
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Richter MJ, Harutyunova S, Bollmann T, Classen S, Fuge J, Gall H, Gerhardt F, Ghofrani HA, Gunkel H, Grünig E, Halank M, Heine A, Klose H, Lange TJ, Neurohr C, Nickolaus K, Opitz CF, Rosenkranz S, Seyfarth HJ, Tello K, Ewert R, Olsson KM. Flow rate variance of a fully implantable pump for the delivery of intravenous treprostinil in pulmonary arterial hypertension. Pulm Circ 2020; 10:2045894020910136. [PMID: 32206306 PMCID: PMC7074510 DOI: 10.1177/2045894020910136] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 02/07/2020] [Indexed: 01/31/2023] Open
Abstract
Implantable infusion pumps might improve the convenience and safety of intravenous treprostinil for pulmonary arterial hypertension. The LENUS Pro® pump (approved in Europe) has a fixed flow rate. Based on 126 pumps and 2853 refills, we retrospectively analyzed the actual flow rate from 09/2010 to 09/2018. A relevant flow rate variance is evident after three years; therefore, flow rate monitoring and dose adjustment are mandatory.
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Affiliation(s)
- Manuel J Richter
- Department of Pneumology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany.,Department of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany.,German Center for Lung Research (DZL), Giessen, Germany
| | - Satenik Harutyunova
- Center for Pulmonary Hypertension, Thorax Clinic at the University Hospital Heidelberg, Heidelberg, Germany
| | - Tom Bollmann
- Department of Internal Medicine, Ernst-Moritz-Arndt University, Greifswald, Germany
| | - Simon Classen
- Department of Vascular Surgery, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany
| | - Jan Fuge
- German Center for Lung Research (DZL), Giessen, Germany.,Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Henning Gall
- Department of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany.,German Center for Lung Research (DZL), Giessen, Germany
| | - Felix Gerhardt
- Department III of Internal Medicine and Cologne Cardiovascular Research Center (CCRC), Cologne University Heart Center, Cologne, Germany
| | - Hossein A Ghofrani
- Department of Pneumology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany.,Department of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany.,German Center for Lung Research (DZL), Giessen, Germany.,Department of Medicine, Imperial College London, London, UK
| | | | - Ekkehard Grünig
- Center for Pulmonary Hypertension, Thorax Clinic at the University Hospital Heidelberg, Heidelberg, Germany
| | - Michael Halank
- Department of Internal Medicine I, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Alexander Heine
- Department of Internal Medicine, Ernst-Moritz-Arndt University, Greifswald, Germany
| | - Hans Klose
- Department of Pneumology, University of Hamburg, Hamburg, Germany
| | - Tobias J Lange
- Department of Internal Medicine II, Division of Pneumology, University Medical Center Regensburg, Regensburg, Germany
| | - Claus Neurohr
- Department for Pneumology and Respiratory Medicine, Robert-Bosch-Hospital, Gerlingen, Germany
| | - Kai Nickolaus
- Department of Pneumology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany
| | | | - Stephan Rosenkranz
- Department III of Internal Medicine and Cologne Cardiovascular Research Center (CCRC), Cologne University Heart Center, Cologne, Germany
| | | | - Khodr Tello
- Department of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany.,German Center for Lung Research (DZL), Giessen, Germany
| | - Ralf Ewert
- Department of Internal Medicine, Ernst-Moritz-Arndt University, Greifswald, Germany
| | - Karen M Olsson
- German Center for Lung Research (DZL), Giessen, Germany.,Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
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12
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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:E481. [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.
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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.
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13
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Davies EW, Llewellyn S, Beaudet A, Kosmas CE, Gin-Sing W, Doll HA. Elicitation of health state utilities associated with the mode of administration of drugs acting on the prostacyclin pathway in pulmonary arterial hypertension. Patient Prefer Adherence 2018; 12:1079-1088. [PMID: 29950821 PMCID: PMC6016589 DOI: 10.2147/ppa.s160662] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [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
INTRODUCTION Pulmonary arterial hypertension (PAH) is a rare, incurable disease associated with decreased life expectancy and a marked impact on quality of life (QoL). There are three classes of drugs available for treatment: endothelin receptor antagonists (ERA), drugs acting on nitric oxide pathway (riociguat and phosphodiesterase type 5 inhibitors [PDE5i]), and drugs acting on prostacyclin pathway. The latter have widely different modes of administration - continuous intravenous infusion, continuous subcutaneous infusion, inhaled, and oral - each associated with variable treatment burden, and implications for health economic assessment. This study aimed to establish utility values associated with different modes of administration of drugs acting on the prostacyclin pathway for use in economic evaluations of PAH treatments. METHODS A UK general public sample completed the EQ-5D-5L and valued four health states in time trade-off interviews. The health states drafted from literature and interviews with PAH experts (n=3) contained identical descriptions of PAH and ERA/PDE5i treatment, but differed in description of administration including oral (tablets), inhaled (nebulizer), continuous subcutaneous infusion, and continuous intravenous infusion. RESULTS A total of 150 participants (63% female; mean age 37 years) completed interviews. Utilities are presented as values between 0 and 1, with 0 representing the state of being dead and 1 representing being in full health. The mean (SD) utility for oral health state was 0.85 (0.16), while all other health states were significantly lower at 0.74 (0.27) for inhaled (p=0.001), 0.59 (0.31) for subcutaneous (p<0.001) and 0.54 (0.32) for intravenous (p<0.001), indicating that there are disutilities (negative differences) associated with non-oral health states. Disutilities were -0.11 for inhaled, -0.26 for subcutaneous, and -0.31 for intravenous administration. CONCLUSION The results demonstrate quantifiable QoL differences between modes of administration of drugs acting on the prostacyclin pathway. QoL burden should be considered for economic evaluation of drugs for PAH treatment.
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Affiliation(s)
- Evan W Davies
- Actelion Pharmaceuticals Ltd., Allschwil, Switzerland
- Correspondence: Evan W Davies, Actelion Pharmaceuticals Ltd., Gewerbestrasse 16, Allschwil 4123, Switzerland, Tel +41 61 565 5669, Email
| | | | | | | | - Wendy Gin-Sing
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
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