Long-term epoprostenol therapy in pulmonary artery hypertension

Rapid initiation of intravenous epoprostenol infusion is the favored option in patients with advanced pulmonary arterial hypertension

Background

Intravenous infusion (IVI) of epoprostenol is an effective treatment for patients with advanced pulmonary arterial hypertension (PAH). However, there is no widely accepted standard method for initiating the IVI therapy. This study evaluated the hemodynamic improvements achieved with IVI epoprostenol to determine the optimal protocol for treatment initiation.

Methods and Results

We retrospectively analyzed 42 consecutive PAH patients who underwent IVI epoprostenol in Keio University Hospital from 2001 to 2013. The study group comprised 30 women with a mean age of 34.3 ± 1.9 years. The etiology of PAH was idiopathic or heritable PAH (I/HPAH) in 38 cases, PAH associated with connective tissue disease in 3, and Eissenmenger’s syndrome in the remaining case. We divided the patients into rapid- and slow-initiation therapy groups according to the cumulative epoprostenol dose administered during the first 180 days, and compared the hemodynamic changes between the groups. The median cumulative doses were 6142 ± 165 μg/kg and 3998 ± 132 μg/kg epoprostenol, respectively. While there were no significant differences in mean pulmonary artery pressure (mPAP), pulmonary vascular resistance (PVR), or cardiac index (CI) between the groups before the IVI epoprostenol therapy, the rapid-initiation therapy group achieved significant improvements in these hemodynamic data compared with the slow-initiation therapy group (P < 0.005) at the follow-up right-heart catheterization (RHC).

Conclusion

Rapid initiation of IVI epoprostenol therapy achieved the optimal hemodynamic improvements in patients with severe PAH.

Marked hemodynamic improvements by high-dose epoprostenol therapy in patients with idiopathic pulmonary arterial hypertension

BACKGROUND

The appropriate dose range of epoprostenol is thought to be 25-40 ng · kg(-1) · min(-1) based on the results of previous studies showing that epoprostenol therapy reduced mean pulmonary artery pressure (mPAP) by 12-22% and pulmonary vascular resistance (PVR) by 32-53% compared with baseline values in patients with idiopathic pulmonary arterial hypertension (IPAH). However, the efficacy of treatment of IPAH patients with epoprostenol >40 ng · kg(-1) · min(-1) has not been determined and this was the aim of the present study.

METHODS AND RESULTS

The study group comprised 16 consecutive patients, none of whom died; 2 dropped out because they could not be titrated up as needed to the highest effective epoprostenol dose. Hemodynamics were evaluated in 14 IPAH patients who received high-dose epoprostenol monotherapy. The mean epoprostenol dosage was 107 ± 40 ng · kg(-1) · min(-1) (range, 54-190 ng · kg(-1) · min(-1)) and the mean duration of high-dose epoprostenol therapy was 1,355 ± 627 days (range, 582-2,410 days). Significant decreases from baseline values were seen in mPAP (from 66 ± 16 to 47 ± 12 mmHg, P<0.001) and PVR (from 21.6 ± 8.3 to 6.9 ± 2.9 Wood units, P<0.001). Compared with the baseline state, high-dose epoprostenol therapy reduced mPAP by 30% and PVR by 68%.

CONCLUSIONS

The present study suggests high-dose epoprostenol therapy is a new treatment strategy for IPAH.

Meta-analysis of randomized controlled trials on treatment of pulmonary arterial hypertension

BACKGROUND

The aim of the present meta-analysis was to evaluate the efficacy and safety of treating pulmonary arterial hypertension (PAH) with inhaled iloprost, oral bosentan and sildenafil.

METHODS AND RESULTS

The randomized controlled trials on the 3 drugs and placebo were retrieved from the databases MEDLINE, EMBASE, BIOSIS Previews and CNKI up to August 2009. In total 11 studies and 1,391 patients were selected. Compared with placebo, iloprost, bosentan and sildenafil reduced clinical worsening significantly (odds ratio [OR] =0.33, 95% confidence interval [CI] =0.22-0.49, P<0.00001), improved New York Heart Association/World Health Organization functional class (OR =2.81, 95%CI =1.95-4.03, P<0.00001), increased the 6-min walk test by 33.19 m, reduced systolic pulmonary arterial pressure, mean pulmonary arterial pressure and pulmonary vascular resistance, increased the cardiac index by 0.40 L x min(-1) x m(-2) and increased the cardiac output by 0.53 L/min. The incidence of serious adverse events was similar in the medication groups and the placebo group (OR =1.09, 95%CI =0.69-1.71, P=0.72). In terms of the clinical worsening and functional class amelioration, insignificant differences were found among iloprost, bosentan and sildenafil, but iloprost had the highest incidence of serious adverse events among the 3 drugs.

CONCLUSIONS

Inhaled iloprost and oral bosentan and sildenafil are effective and safe in treating PAH.