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Pizzuto MF, Laughon MM, Jackson WM. Current and emerging pharmacotherapies for the treatment of pulmonary arterial hypertension in infants. Expert Opin Pharmacother 2023; 24:1875-1886. [PMID: 37707346 PMCID: PMC10843401 DOI: 10.1080/14656566.2023.2257598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 09/07/2023] [Indexed: 09/15/2023]
Abstract
INTRODUCTION Pulmonary hypertension (PH) is a complex condition that encompasses an array of underlying disease processes and affects a diverse population of infants, including those with congenital heart disease, congenital diaphragmatic hernia, persistent PH of the newborn, and those with lung disease such as bronchopulmonary dysplasia. While there are treatments available to adults with PH, limited data exists for infants, especially for the newer medications. Therapies that target the three main pathophysiologic pathways of pulmonary hypertension appear to benefit infants, but which are best for each individual disease process is unclear. AREAS COVERED A review of the therapies to treat pulmonary hypertension is covered in this article including the prostacyclin pathway, endothelin pathway, and the nitric oxide pathway. Other adjunctive treatments are also discussed. Findings are based on a PubMed literature search of research papers spanning 1990-2023 and a search of ongoing trials registered with clinicaltrials.gov. EXPERT OPINION Overall therapies seem to improve outcomes with most infants with PH. However, given the diverse population of infants with PH, it is imperative to understand the basis for the PH in individual patients and understand which therapies can be applicable. Further research into tailored therapy for the specific populations is warranted.
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Affiliation(s)
- Matthew F. Pizzuto
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Matthew M. Laughon
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Wesley M. Jackson
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
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2
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Muralidharan P, Acosta MF, Gomez AI, Grijalva C, Tang H, Yuan JXJ, Mansour HM. Design and Comprehensive Characterization of Tetramethylpyrazine (TMP) for Targeted Lung Delivery as Inhalation Aerosols in Pulmonary Hypertension (PH): In Vitro Human Lung Cell Culture and In Vivo Efficacy. Antioxidants (Basel) 2021; 10:antiox10030427. [PMID: 33799587 PMCID: PMC7998162 DOI: 10.3390/antiox10030427] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/03/2021] [Accepted: 03/05/2021] [Indexed: 02/07/2023] Open
Abstract
This is the first study reporting on the design and development innovative inhaled formulations of the novel natural product antioxidant therapeutic, tetramethylpyrazine (TMP), also known as ligustrazine. TMP is obtained from Chinese herbs belonging to the class of Ligusticum. It is known to have antioxidant properties. It can act as a Nrf2/ARE activator and a Rho/ROCK inhibitor. The present study reports for the first time on the comprehensive characterization of raw TMP (non-spray dried) and spray dried TMP in a systematic manner using thermal analysis, electron microscopy, optical microscopy, and Raman spectroscopy. The in vitro aerosol dispersion performance of spray dried TMP was tested using three different FDA-approved unit-dose capsule-based human dry powder inhaler devices. In vitro human cellular studies were conducted on pulmonary cells from different regions of the human lung to examine the biocompatibility and non-cytotoxicity of TMP. Furthermore, the efficacy of inhaled TMP as both liquid and dry powder inhalation aerosols was tested in vivo using the monocrotaline (MCT)-induced PH rat model.
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Affiliation(s)
- Priya Muralidharan
- College of Pharmacy, The University of Arizona, Tucson, AZ 85721, USA; (P.M.); (M.F.A.); (A.I.G.); (C.G.)
| | - Maria F. Acosta
- College of Pharmacy, The University of Arizona, Tucson, AZ 85721, USA; (P.M.); (M.F.A.); (A.I.G.); (C.G.)
| | - Alexan I. Gomez
- College of Pharmacy, The University of Arizona, Tucson, AZ 85721, USA; (P.M.); (M.F.A.); (A.I.G.); (C.G.)
- Department of Biomedical Engineering, The Arizona State University, Phoenix, AZ 85287, USA
- Department of Medicine, Division of Translational & Regenerative Medicine, College of Medicine, The University of Arizona, Tucson, AZ 85721, USA; (H.T.); (J.X.-J.Y.)
| | - Carissa Grijalva
- College of Pharmacy, The University of Arizona, Tucson, AZ 85721, USA; (P.M.); (M.F.A.); (A.I.G.); (C.G.)
| | - Haiyang Tang
- Department of Medicine, Division of Translational & Regenerative Medicine, College of Medicine, The University of Arizona, Tucson, AZ 85721, USA; (H.T.); (J.X.-J.Y.)
| | - Jason X.-J. Yuan
- Department of Medicine, Division of Translational & Regenerative Medicine, College of Medicine, The University of Arizona, Tucson, AZ 85721, USA; (H.T.); (J.X.-J.Y.)
- Department of Medicine, University of California, San Diego, La Jolla, CA 92093, USA
| | - Heidi M. Mansour
- College of Pharmacy, The University of Arizona, Tucson, AZ 85721, USA; (P.M.); (M.F.A.); (A.I.G.); (C.G.)
- Department of Medicine, Division of Translational & Regenerative Medicine, College of Medicine, The University of Arizona, Tucson, AZ 85721, USA; (H.T.); (J.X.-J.Y.)
- The BIO5 Research Institute, The University of Arizona, Tucson, AZ 85721, USA
- Institute of the Environment, The University of Arizona, Tucson, AZ 85721, USA
- Correspondence: ; Tel.: +1-520-626-2768
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3
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Abstract
Pulmonary arterial hypertension (PAH) is a rare disease in infants and children that is associated with significant morbidity and mortality. The disease is characterized by progressive pulmonary vascular functional and structural changes resulting in increased pulmonary vascular resistance and eventual right heart failure and death. In many pediatric patients, PAH is idiopathic or associated with congenital heart disease and rarely is associated with other conditions such as connective tissue or thromboembolic disease. PAH associated with developmental lung diseases such as bronchopulmonary dysplasia or congenital diaphragmatic hernia is increasingly more recognized in infants and children. Although treatment of the underlying disease and reversal of advanced structural changes have not yet been achieved with current therapy, quality of life and survival have improved significantly. Targeted pulmonary vasodilator therapies, including endothelin receptor antagonists, prostacyclin analogs, and phosphodiesterase type 5 inhibitors have resulted in hemodynamic and functional improvement in children. The management of pediatric PAH remains challenging as treatment decisions depend largely on results from evidence-based adult studies and the clinical experience of pediatric experts. This article reviews the current drug therapies and their use in the management of PAH in children.
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Affiliation(s)
- Catherine M Avitabile
- Division of Cardiology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Erika E Vorhies
- Division of Pediatric Cardiology, Department of Pediatrics, University of Calgary Cumming School of Medicine, Alberta Children's Hospital, Calgary, Canada
| | - David Dunbar Ivy
- B100, Division of Pediatric Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, 13123 East 16th Avenue, Aurora, CO, 80045, USA.
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Rashid J, Nozik-Grayck E, McMurtry IF, Stenmark KR, Ahsan F. Inhaled combination of sildenafil and rosiglitazone improves pulmonary hemodynamics, cardiac function, and arterial remodeling. Am J Physiol Lung Cell Mol Physiol 2019; 316:L119-L130. [PMID: 30307312 PMCID: PMC6383494 DOI: 10.1152/ajplung.00381.2018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 10/01/2018] [Accepted: 10/01/2018] [Indexed: 01/15/2023] Open
Abstract
Currently, dual- or triple-drug combinations comprising different vasodilators are the mainstay for the treatment of pulmonary arterial hypertension (PAH). However, the patient outcome continues to be disappointing because the existing combination therapy cannot restrain progression of the disease. Previously, we have shown that when given as a monotherapy, long-acting inhaled formulations of sildenafil (a phosphodiesterase-5 inhibitor) and rosiglitazone (a peroxisome proliferator receptor-γ agonist) ameliorate PAH in rats. Thus, with a goal to develop a new combination therapy, we prepared and characterized poly(lactic-co-glycolic acid) (PLGA)-based long-acting inhalable particles of sildenafil and rosiglitazone. We then assessed the efficacy of the combinations of sildenafil and rosiglitazone, given in plain forms or as PLGA particles, in reducing mean pulmonary arterial pressure (mPAP) and improving pulmonary arterial remodeling and right ventricular hypertrophy (RVH) in Sugen 5416 plus hypoxia-induced PAH rats. After intratracheal administration of the formulations, we catheterized the rats and measured mPAP, cardiac output, total pulmonary resistance, and RVH. We also conducted morphometric studies using lung tissue samples and assessed the degree of muscularization, the arterial medial wall thickening, and the extent of collagen deposition. Compared with the plain drugs, given via the pulmonary or oral route as a single or dual combination, PLGA particles of the drugs, although given at a longer dosing interval compared with the plain drugs, caused more pronounced reduction in mPAP without affecting mean systemic pressure, improved cardiac function, slowed down right heart remodeling, and reduced arterial muscularization. Overall, PLGA particles of sildenafil and rosiglitazone, given as an inhaled combination, could be a viable alternative to currently available vasodilator-based combination therapy for PAH.
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Affiliation(s)
- Jahidur Rashid
- Department of Pharmaceutical Sciences, School of Pharmacy, Texas Tech University Health Sciences Center , Amarillo, Texas
| | - Eva Nozik-Grayck
- Department of Pediatrics, University of Colorado Anschutz Medical Campus , Aurora, Colorado
| | - Ivan F McMurtry
- Department of Pharmacology, Center for Lung Biology, University of South Alabama , Mobile, Alabama
| | - Kurt R Stenmark
- Department of Pediatrics, University of Colorado Anschutz Medical Campus , Aurora, Colorado
| | - Fakhrul Ahsan
- Department of Pharmaceutical Sciences, School of Pharmacy, Texas Tech University Health Sciences Center , Amarillo, Texas
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Rosenzweig EB, Abman SH, Adatia I, Beghetti M, Bonnet D, Haworth S, Ivy DD, Berger RMF. Paediatric pulmonary arterial hypertension: updates on definition, classification, diagnostics and management. Eur Respir J 2019; 53:1801916. [PMID: 30545978 PMCID: PMC6351335 DOI: 10.1183/13993003.01916-2018] [Citation(s) in RCA: 326] [Impact Index Per Article: 65.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 10/09/2018] [Indexed: 12/16/2022]
Abstract
Paediatric pulmonary arterial hypertension (PAH) shares common features of adult disease, but is associated with several additional disorders and challenges that require unique approaches. This article discusses recent advances, ongoing challenges and distinct approaches for the care of children with PAH, as presented by the Paediatric Task Force of the 6th World Symposium on Pulmonary Hypertension. We provide updates of the current definition, epidemiology, classification, diagnostics and treatment of paediatric PAH, and identify critical knowledge gaps. Several features of paediatric PAH including the prominence of neonatal PAH, especially in pre-term infants with developmental lung diseases, and novel genetic causes of paediatric PAH are highlighted. The use of cardiac catheterisation as a diagnostic modality and haemodynamic definitions of PAH, including acute vasoreactivity, are addressed. Updates are provided on issues related to utility of the previous classification system to reflect paediatric-specific aetiologies and approaches to medical and interventional management of PAH, including the Potts shunt. Although a lack of clinical trial data for the use of PAH-targeted therapy persists, emerging data are improving the identification of appropriate targets for goal-oriented therapy in children. Such data will likely improve future clinical trial design to enhance outcomes in paediatric PAH.
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Affiliation(s)
- Erika B Rosenzweig
- Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Steven H Abman
- University of Colorado, Children's Hospital Colorado, Denver, CO, USA
| | - Ian Adatia
- Glenwood Children's Heart Clinic, Edmonton, AB, Canada
| | - Maurice Beghetti
- Pediatric Cardiology Unit and Centre Universitaire de Cardiologie et Chirurgie Cardiaque Pédiatrique, University Hospitals of Geneva and Lausanne, Lausanne, Switzerland
| | - Damien Bonnet
- Hôpital Necker Enfants Malades, AP-HP, Université Paris Descartes, Paris, France
| | | | - D Dunbar Ivy
- University of Colorado, Children's Hospital Colorado, Denver, CO, USA
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Pediatric Cardiology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Li Q, Dimopoulos K, Zhang C, Zhu Y, Liu Q, Gu H. Acute Effect of Inhaled Iloprost in Children with Pulmonary Arterial Hypertension Associated with Simple Congenital Heart Defects. Pediatr Cardiol 2018; 39:757-762. [PMID: 29426959 DOI: 10.1007/s00246-018-1818-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 01/17/2018] [Indexed: 11/29/2022]
Abstract
Inhaled prostacyclin analogue iloprost is currently utilized in adult patients with pulmonary arterial hypertension (PAH), but little information is available on its use in the pediatric population. This study evaluated the safety and acute haemodynamic effects of inhaled iloprost in children with PAH associated with congenital heart disease (CHD). Children with PAH-CHD who underwent cardiac catheterization and iloprost administration in our catheter laboratory between June 2007 and October 2015 were included. Iloprost was administered by atomization inhalation and changes in hemodynamic parameters were recorded. In total, 100 children with PAH-CHD were enrolled. Median age was 13 [1.5-18.0] years and 34% were male. A ventricular septal defect was present in 84%, a patent duct in 12%, a complete atrioventricular septal defect in 2%, and an isolated atrial septal defect in 2%. Pulmonary vascular resistance indexed (PVRI) was above 8 WU m2 in 96% and was above a third systemic (Rp/Rs > 0.33) in 97%. Iloprost was well tolerated in all patients. Following iloprost inhalation, mean pulmonary arterial pressure decreased from 78.4 ± 9.2 to 72.8 ± 10.8 mmHg (p < 0.01) and pulmonary-to-systemic blood flow ratio (Qp/Qs) increased from 1.12 ± 0.48 to 1.37 ± 0.63 (p < 0.01), with no change in cardiac index (Qs). PVRI decreased from 21.0 ± 9.0 to 16.9 ± 8.0 WU m2 (p < 0.01) following inhalation but 92% patients still had a PVRI > 8 WU m2 and 93% an Rp/Rs > 0.33. Acute inhalation of iloprost in children with PAH associated with CHD resulted in a significant improvement in hemodynamic parameters. Despite this, few patients achieve strict criteria of operability, underscoring the importance of early screening and timely repair of CHD.
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Affiliation(s)
- Qiangqiang Li
- Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, 4th Floor, Cardiac Surgery Building, No. 2 Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Konstantinos Dimopoulos
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital and Imperial College, London, UK
| | - Chen Zhang
- Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, 4th Floor, Cardiac Surgery Building, No. 2 Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Yan Zhu
- Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, 4th Floor, Cardiac Surgery Building, No. 2 Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Qian Liu
- Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, 4th Floor, Cardiac Surgery Building, No. 2 Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Hong Gu
- Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, 4th Floor, Cardiac Surgery Building, No. 2 Anzhen Road, Chaoyang District, Beijing, 100029, China.
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7
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Davis MD, Donn SM, Ward RM. Administration of Inhaled Pulmonary Vasodilators to the Mechanically Ventilated Neonatal Patient. Paediatr Drugs 2017; 19:183-192. [PMID: 28374138 DOI: 10.1007/s40272-017-0221-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Pulmonary hypertension is a life-threatening condition that affects people of all ages that can occur as an idiopathic disorder at birth or as part of a variety of cardiovascular and infectious disorders. It is commonly treated with inhaled pulmonary vasodilators such as nitric oxide and less frequently using formulations and analogs of prostacyclin. To minimize systemic effects and preserve pulmonary vasodilation, vasodilators are often administered directly into the airway. Nitric oxide is the only USA Food and Drug Administration-approved inhaled pulmonary vasodilator that can be used during mechanical ventilation. Over the past two decades, interest has grown in the use of aerosolized prostacyclin and prostacyclin analogs for the treatment of pulmonary hypertension during mechanical ventilation. Clinicians who administer inhaled prostacyclin may not have a clear understanding of its risks because of the lack of data from large clinical trials examining safety and efficacy; moreover, its safe use remains poorly documented. The off-label use of drugs is legitimate, but prescribers must recognize the potential complications and liability in doing so. This manuscript aims to address potential problems related to the aerosol administration of pulmonary vasodilators in the mechanically ventilated neonatal patient.
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Affiliation(s)
- Michael D Davis
- Physiology and Biophysics, Virginia Commonwealth University School of Medicine, 1217 East Marshall Street, Hermes A. Kontos Medical Sciences Building Room 215, Richmond, VA, 23298, USA.
| | - Steven M Donn
- Division of Neonatal-Perinatal Medicine, C.S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
| | - Robert M Ward
- Professor Emeritus, Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
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DiBlasi RM, Crotwell DN, Shen S, Zheng J, Fink JB, Yung D. Iloprost drug delivery during infant conventional and high-frequency oscillatory ventilation. Pulm Circ 2016; 6:63-9. [PMID: 27162615 PMCID: PMC4860545 DOI: 10.1086/685080] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Iloprost is a selective pulmonary vasodilator approved for inhalation by the Food and Drug Administration. Iloprost has been increasingly used in the management of critically ill neonates with hypoxic lung disease. This in vitro study was designed to test the hypothesis that aerosol drug delivery could be effectively administered to infants with both conventional ventilation and high-frequency oscillatory ventilation (HFOV). A neonatal test lung model configured with newborn lung mechanics was ventilated with a conventional ventilator and an HFOV with standard settings. A vibrating-mesh nebulizer was placed (1) proximal to the patient airway in the inspiratory limb between the humidifier probe and patient wye (conventional) as well as between the vent circuit and the endotracheal tube (ETT) for HFOV and (2) between the ventilator and humidifier (distal). Iloprost was nebulized in three separate runs using three new nebulizers in each of the circuit locations. A collecting filter was placed at the distal end of the ETT for each trial. Iloprost was quantified using high-performance liquid chromatography. The percentage of nominal dose delivered was greater with the nebulizer placed proximal to the airway for conventional ventilation (10.74% ± 2%) and HFOV (29% ± 2%) than with it placed in the distal position (2.96% ± 0.2% vs. 0.96% ± 0.8%, respectively; P < 0.05). Drug delivery in proximal position was nearly threefold greater during HFOV than during conventional ventilation. In conclusion, iloprost drug delivery was best achieved when the nebulizer was placed proximal to the patient airway during neonatal mechanical ventilation. Drug delivery appears to be more efficient during HFOV than during conventional ventilation.
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Affiliation(s)
- Robert M DiBlasi
- Respiratory Therapy Department, Seattle Children's Hospital, Seattle, Washington, USA; Seattle Children's Hospital Research Institute, Seattle, Washington, USA
| | - Dave N Crotwell
- Respiratory Therapy Department, Seattle Children's Hospital, Seattle, Washington, USA
| | - Shuijie Shen
- Seattle Children's Hospital Research Institute, Seattle, Washington, USA
| | - Jiang Zheng
- Seattle Children's Hospital Research Institute, Seattle, Washington, USA
| | | | - Delphine Yung
- Department of Cardiology, Seattle Children's Hospital, Seattle, Washington, USA
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Abstract
Pulmonary arterial hypertension (PAH) is a rare disease in infants and children that is associated with significant morbidity and mortality. The disease is characterized by progressive pulmonary vascular functional and structural changes resulting in increased pulmonary vascular resistance and eventual right heart failure and death. In the majority of pediatric patients, PAH is idiopathic or associated with congenital heart disease and rarely is associated with other conditions such as connective tissue or thromboembolic disease. Although treatment of the underlying disease and reversal of advanced structural changes has not yet been achieved with current therapy, quality of life and survival have been improved significantly. Targeted pulmonary vasodilator therapies, including endothelin receptor antagonists, prostacyclin analogs, and phosphodiesterase type 5 inhibitors, have demonstrated hemodynamic and functional improvement in children. The management of pediatric PAH remains challenging, as treatment decisions continue to depend largely on results from evidence-based adult studies and the clinical experience of pediatric experts. This article reviews the current drug therapies and their use in the management of PAH in children.
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Affiliation(s)
- Erika E Vorhies
- Division of Pediatric Cardiology, Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
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10
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Takatsuki S, Ivy DD. Current challenges in pediatric pulmonary hypertension. Semin Respir Crit Care Med 2013; 34:627-44. [PMID: 24037630 DOI: 10.1055/s-0033-1356461] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Pulmonary arterial hypertension (PAH) in the pediatric population is associated with a variety of underlying diseases and causes, significantly morbidity and mortality. In the majority of patients, PAH in children is idiopathic or associated with congenital heart disease (CHD), with pulmonary hypertension (PH) associated with connective tissue disease, a rare cause in children. Classification of pediatric PH has generally followed the WHO classification, but recognition of the importance of fetal origins of PH and developmental abnormalities have led to the formation of a new pediatric-specific classification. Incidence data from the Netherlands has revealed an annual incidence and point prevalence of 0.7 and 4.4 for idiopathic PAH and 2.2 and 15.6 for associated pulmonary arterial hypertension-CHD cases per million children. Although the treatment with new selective pulmonary vasodilators offers hemodynamic and functional improvement in pediatric populations, the treatments in children largely depend on results from evidence-based adult studies and experience of clinicians treating children. A recent randomized clinical trial of sildenafil and its long-term extension has led to disparate recommendations in the United States and Europe.
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Affiliation(s)
- Shinichi Takatsuki
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado
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Sung KW, Jeon YB, Kim NY, Park KY, Park CH, Choi CH, Choi DY. The Effects of Perioperative Inhaled Iloprost on Pulmonary Hypertension with Congenital Heart Disease. Cardiology 2013; 126:224-9. [DOI: 10.1159/000354248] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 07/01/2013] [Indexed: 11/19/2022]
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Abstract
Pulmonary arterial hypertension is a serious disease with significant morbidity and mortality. Although it can occur idiopathically, it is more commonly associated with other cardiac or lung diseases. While most of the available therapies have been tested in adult populations and most therapies in children remain off-label, new reports and randomized trials are emerging that inform the treatment of pediatric populations. This review discusses currently available therapies for pediatric pulmonary hypertension, their biological rationales, and evidence for their clinical effectiveness.
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Affiliation(s)
- Robin H Steinhorn
- Department of Pediatrics, The Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University, 225 East Chicago Avenue, Chicago, IL 60611, USA.
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Brown AT, Gillespie JV, Miquel-Verges F, Holmes K, Ravekes W, Spevak P, Brady K, Easley RB, Golden WC, McNamara L, Veltri MA, Lehmann CU, McMillan KN, Schwartz JM, Romer LH. Inhaled epoprostenol therapy for pulmonary hypertension: Improves oxygenation index more consistently in neonates than in older children. Pulm Circ 2012; 2:61-6. [PMID: 22558521 PMCID: PMC3342750 DOI: 10.4103/2045-8932.94835] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
The purpose of this study was to determine the efficacy of inhaled epoprostenol for treatment of acute pulmonary hypertension (PH) in pediatric patients and to formulate a plan for a prospective, randomized study of pulmonary vasodilator therapy in this population. Inhaled epoprostenol is an effective treatment for pediatric PH. A retrospective chart review was conducted of all pediatric patients who received inhaled epoprostenol at a tertiary care hospital between October 2005 and August 2007. The study population was restricted to all patients under 18 years of age who received inhaled epoprostenol for greater than 1 hour and had available data for oxygenation index (OI) calculation. Arterial blood gas values and ventilator settings were collected immediately prior to epoprostenol initiation, and during epoprostenol therapy (as close to 12 hours after initiation as possible). Echocardiograms were reviewed during two time frames: Within 48 hours prior to therapy initiation and within 96 hours after initiation. Of the 20 patients in the study population, 13 were neonates, and the mean OI for these patients improved during epoprostenol administration (mean OI before and during therapy was 25.6±16.3 and 14.5±13.6, respectively, P=0.02). Mean OI for the seven patients greater than 30 days of age was not significantly different during treatment (mean OI before and during therapy was 29.6±15.0 and 25.6±17.8, P=0.56). Improvement in echocardiographic findings (evidence of decreased right-sided pressures or improved right ventricular function) was demonstrated in 20% of all patients. Inhaled epoprostenol is an effective therapy for the treatment of selected pediatric patients with acute PH. Neonates may benefit more consistently from this therapy than older infants and children. A randomized controlled trial is needed to discern the optimal role for inhaled prostanoids in the treatment of acute PH in childhood.
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Affiliation(s)
- Anna T Brown
- Department of Anesthesiology and Critical Care Medicine, Baltimore, Maryland, USA
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Abstract
PURPOSE OF REVIEW Pulmonary arterial hypertension (PAH) is an important cause of morbidity and mortality in children. Approved medications for the treatment of adult PAH have been used to treat children, but evidence-based treatment algorithms for children are lacking. RECENT FINDINGS Pediatric PAH registries have begun to define the incidence and prevalence of idiopathic PAH and PAH associated with congenital heart disease. A pediatric-specific classification of pulmonary hypertensive vascular disease has been proposed. Furthermore, the first randomized placebo-controlled trial of type-5 phosphodiesterase therapy in treatment-naïve children with PAH has been completed and reported. This trial highlights the importance of the difficulties of performing clinical trials in children with targeted PAH therapy as well as the importance of long-term follow-up of adverse events. SUMMARY Classification, clinical trials, and therapy for children with PAH must take into account the unique aspects of PAH in children.
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Affiliation(s)
- Dunbar Ivy
- The Children's Hospital Heart Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA.
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Tissot C, Ivy DD, Beghetti M. Medical therapy for pediatric pulmonary arterial hypertension. J Pediatr 2010; 157:528-32. [PMID: 20656296 PMCID: PMC3127257 DOI: 10.1016/j.jpeds.2010.06.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2009] [Revised: 05/11/2010] [Accepted: 06/08/2010] [Indexed: 01/09/2023]
Affiliation(s)
- Cecile Tissot
- Pediatric Cardiology Unit, The Children's University Hospital of Geneva, Geneva, Switzerland
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Ivy D, Saji BT. A New Era in Medical Management of Severe Pediatric Pulmonary Arterial Hypertension. NIHON SHONI JUNKANKI GAKKAI ZASSHI = PEDIATRIC CARDIOLOGY AND CARDIAC SURGERY 2010; 26:206-218. [PMID: 23264720 PMCID: PMC3527842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Pulmonary arterial hypertension (PAH) is a life-threatening disease whose prognosis has changed dramatically over the past decade since the introduction of new therapeutic agents as well as the off-label application of adult pulmonary hypertension specific therapies to children. Nevertheless, PAH still has no cure and the aim of treatment is to prolong survival by improving quality of life, symptoms, exercise capacity and hemodynamics. The selection of appropriate therapies for PH is complex and must be carefully chosen according to the etiology and pulmonary vasoreactivity. As insight advances into mechanisms responsible for the development of PAH, the introduction of novel therapeutic agents will hopefully further improve the outcome of this incurable disease.
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Affiliation(s)
- Dunbar Ivy
- Department of Pediatrics, University of Colorado Denver School of Medicine, Denver, Colorado, USA
| | - Ben T Saji
- Department of Pediatrics, Toho University, Medical Center, Tokyo, Japan
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