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Burger CD, Wu B, Classi P, Morland K. Inhaled treprostinil vs iloprost: Comparison of adherence, persistence, and health care resource utilization in patients with pulmonary arterial hypertension. J Manag Care Spec Pharm 2023; 29:101-108. [PMID: 36580122 PMCID: PMC10387966 DOI: 10.18553/jmcp.2023.29.1.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND: Pulmonary arterial hypertension (PAH) is associated with a substantial clinical and economic burden. Inhaled prostacyclins are a well-established part of pharmacotherapy for PAH. There are differences between inhaled therapies in the burden imposed by administration frequency. Simpler and less time-consuming inhaled PAH therapies may improve both adherence and persistence and potentially affect outcomes. OBJECTIVE: To compare real-world health care resource use, costs, and treatment adherence and persistence in patients with PAH who initiated inhaled treprostinil or iloprost. METHODS: Adult patients with 1 inpatient or 2 outpatient medical claims separated by at least 30 days with a diagnosis of PAH were identified using International Classification of Diseases, Ninth Revision or Tenth Revision, Clinical Modification codes with a pharmacy claim for inhaled treprostinil or iloprost. Patients were required to be continuously enrolled in the health plan for 6 months prior to and 12 months after the index date. A proportion of days covered of 0.8 or more was considered adherent; persistence was no gap in therapy for at least 60 days. All-cause health care resource utilization and all-cause costs were assessed. RESULTS: 405 and 62 patients were included in the inhaled treprostinil and iloprost cohorts, respectively. Adherence (50.9% and 22.6%; P < 0.0001) and persistence (6 months, 65.2% vs 35.5%; 12 months, 46.7% vs 16.1%; log-rank P < 0.001) were significantly better with inhaled treprostinil. Post-index allcause inpatient admissions (39.3% vs 54.8%; P = 0.02) and post-index emergency department (ED) utilization (36.3% vs 50.0%; P = 0.04) were lower with inhaled treprostinil. Among patients who were persistent with therapy through 12 months, there was no significant difference between groups in mean (SD) all-cause total costs ($266,462 [137,324] vs $262,826 [112,452] for inhaled treprostinil vs iloprost, respectively; P = 0.98). CONCLUSIONS: The results suggest that inhaled treprostinil is less burdensome, is associated with greater adherence and persistence, and may reduce all-cause hospitalizations and ED visits. DISCLOSURES: This study was funded by the United Therapeutics Corporation to obtain data for this analysis and compose the manuscript. Dr Burger has served as clinical investigator in multicenter interventional trials sponsored by United Therapeutics but did not receive any direct compensation. Drs Wu and Morland and Mr Classi are employees of United Therapeutics Corporation and own stock/shares in the company.
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Affiliation(s)
| | - Benjamin Wu
- United Therapeutics Corporation, Research Triangle Park, NC
| | - Peter Classi
- United Therapeutics Corporation, Research Triangle Park, NC
| | - Kellie Morland
- United Therapeutics Corporation, Research Triangle Park, NC
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DuBrock HM, Burger CD, Bartolome SD, Feldman JP, Ivy DD, Rosenzweig EB, Sager JS, Presberg KW, Mathai SC, Lammi MR, Klinger JR, Eggert M, De Marco T, Elwing JM, Badesch D, Bull TM, Cadaret LM, Ramani G, Thenappan T, Ford H, Al‐Naamani N, Simon MA, Mazimba S, Runo JR, Chakinala M, Horn EM, Ryan JJ, Frantz RP, Krowka MJ. Erratum: Health disparities and treatment approaches in portopulmonary hypertension and idiopathic pulmonary arterial hypertension: An analysis of the Pulmonary Hypertension Association Registry. Pulm Circ 2022; 12:e12172. [PMID: 36540874 PMCID: PMC9755810 DOI: 10.1002/pul2.12172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 12/05/2022] [Indexed: 12/23/2022] Open
Abstract
[This corrects the article DOI: 10.1177/20458940211020913.].
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Affiliation(s)
- Hilary M. DuBrock
- Division of Pulmonary and Critical Care Medicine, Department of Internal MedicineMayo ClinicRochesterMinnesotaUSA
| | - Charles D. Burger
- Division of Pulmonary and Critical Care Medicine, Department of Internal MedicineMayo ClinicJacksonvilleFloridaUSA
| | - Sonja D. Bartolome
- Division of Pulmonary and Critical Care Medicine, Department of Internal MedicineUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Jeremy P. Feldman
- Division of Pulmonary and Critical Care Medicine, Department of Internal MedicineArizona Pulmonary Specialists Ltd.PhoenixArizonaUSA
| | - David D. Ivy
- Division of Cardiology, Department of PediatricsChildren's HospitalAuroraColoradoUSA
| | - Erika B. Rosenzweig
- Division of Cardiology, Department of PediatricsColumbia University Medical CenterNew YorkNew YorkUSA
| | - Jeffrey S. Sager
- Division of Pulmonary and Critical Care Medicine, Department of Internal MedicineCottage Pulmonary Hypertension CenterSanta BarbaraCaliforniaUSA
| | - Kenneth W. Presberg
- Division of Pulmonary and Critical Care Medicine, Department of Internal MedicineMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Stephen C. Mathai
- Division of Pulmonary and Critical Care Medicine, Department of Internal MedicineJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Matthew R. Lammi
- Division of Pulmonary and Critical Care Medicine, Department of Internal MedicineComprehensive Pulmonary Hypertension Center, Louisiana State University Health Sciences CenterNew OrleansLouisianaUSA
| | - James R. Klinger
- Division of Pulmonary and Critical Care Medicine, Department of Internal MedicineBrown UniversityProvidenceRhode IslandUSA
| | - Michael Eggert
- Division of Pulmonary and Critical Care Medicine, Department of Internal MedicineSentara Cardiovascular Research InstituteNorfolkVirginiaUSA
| | - Teresa De Marco
- Division of Cardiology, Department of Internal MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Jean M. Elwing
- Division of Pulmonary and Critical Care Medicine, Department of Internal MedicineUniversity of CincinnatiCincinnatiOhioUSA
| | - David Badesch
- Division of Pulmonary and Critical Care Medicine, Department of Internal MedicineUniversity of ColoradoDenverColoradoUSA
| | - Todd M. Bull
- Division of Pulmonary and Critical Care Medicine, Department of Internal MedicineUniversity of ColoradoDenverColoradoUSA
| | - Linda M. Cadaret
- Division of Cardiology, Department of Internal Medicine, Roy J. and Lucille A. Carver College of MedicineUniversity of IowaIowa CityIowaUSA
| | - Gautam Ramani
- Division of Cardiology, Department of Internal MedicineUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Thenappan Thenappan
- Division of Cardiology, Department of Internal MedicineUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - H. James Ford
- Division of Pulmonary and Critical Care Medicine, Department of Internal MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Nadine Al‐Naamani
- Division of Pulmonary and Critical Care Medicine, Department of Internal MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Marc A. Simon
- Division of Cardiology, Department of Internal MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Sula Mazimba
- Division of Cardiology, Department of Internal MedicineUniversity of Virginia Health SystemCharlottesvilleVirginiaUSA
| | - James R. Runo
- Division of Pulmonary and Critical Care, Department of Internal MedicineUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Murali Chakinala
- Division of Pulmonary and Critical Care Medicine, Department of Internal MedicineWashington University at Barnes‐JewishSt. LouisMissouriUSA
| | - Evelyn M. Horn
- Division of Cardiology, Department of Internal MedicineWeill‐Cornell Medical SchoolNew YorkNew YorkUSA
| | - John J. Ryan
- Division of Cardiology, Department of Internal MedicineUniversity of UtahSalt Lake CityUtahUSA
| | - Robert P. Frantz
- Department of Cardiovascular DiseasesMayo ClinicMinnesotaRochesterUSA
| | - Michael J. Krowka
- Division of Pulmonary and Critical Care Medicine, Department of Internal MedicineMayo ClinicRochesterMinnesotaUSA
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Cajigas HR, Burger CD, Cartin-Ceba R, DuBrock H, Swanson K, Vargas HE, Keaveny AP, Watt KD, Krowka M. Portopulmonary Hypertension in Nontransplanted Patients: Results of the Largest US Single-Institution Registry. Mayo Clin Proc 2022; 97:2236-2247. [PMID: 36336515 DOI: 10.1016/j.mayocp.2022.08.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 08/19/2022] [Accepted: 08/30/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To explore clinical characteristics, risk profiles, and outcomes of patients with portopulmonary hypertension (PoPH) who have contraindications to liver transplant (LT). METHODS From the largest US single-institution registry of patients with PoPH, we analyzed 160 patients who did not receive LT between 1988 to 2019. Pulmonary arterial hypertension (PAH)-pertinent characteristics, hemodynamic features, treatments, and risk stratification were compared at baseline, first follow-up visit, and censor/death time. RESULTS Median survival for the entire cohort was 27.5 months from the diagnosis of PoPH. Overall survival was 89%, 77%, 51%, and 38% at 6 months, 1 year, 3 years, and 5 years, respectively. Survival was significantly affected by the severity of liver disease (P<.001). Most patients received PAH-specific therapies (136 [85%]), predominantly monotherapy (123 [77%)]. With treatment, significant improvements were noted in World Health Organization functional class (P=.04), 6-minute walk distance (P<.001), right ventricular function (P<.001), pulmonary vascular resistance (P<.001), and Registry to Evaluate Early and Long-term Pulmonary Arterial Hypertension Disease Management (REVEAL) Lite 2 score (P=.02) univariately. Per European Society of Cardiology risk stratification, no patient met full criteria for low risk at baseline or at follow-up. In a multivariate Cox risk model, 6-minute walk distance, right atrial pressure, pulmonary capillary wedge pressure, bilirubin level, and Model for End-Stage Liver Disease-sodium score of 15 or higher were associated with increased risk of death. CONCLUSION Patients with PoPH who did not undergo LT had a poor prognosis. This persisted despite use of PAH-specific therapies and significant improvements in hemodynamics, echocardiography parameters of right ventricle function, 6-minute walk distance, and World Health Organization functional class.
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Affiliation(s)
- Hector R Cajigas
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Mayo Clinic, Rochester, MN.
| | - Charles D Burger
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Mayo Clinic, Jacksonville, FL
| | - Rodrigo Cartin-Ceba
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Mayo Clinic, Scottsdale, AZ
| | - Hilary DuBrock
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Karen Swanson
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Mayo Clinic, Scottsdale, AZ
| | - Hugo E Vargas
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Scottsdale, AZ
| | - Andrew P Keaveny
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Jacksonville, FL
| | - Kymberly D Watt
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Michael Krowka
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Mayo Clinic, Rochester, MN
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Helgeson SA, Burger CD, Moss JE, Zeiger TK, Taylor BJ. Remote 6-minute-Walk Testing in Patients with Pulmonary Hypertension: Further Validation Needed? Am J Respir Crit Care Med 2022; 206:650-651. [PMID: 35608525 PMCID: PMC9716909 DOI: 10.1164/rccm.202204-0762le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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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 T, 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] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [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)
| | | | | | | | | | | | | | - Shilpa Johri
- Henrico Doctors' Hospital and Bon Secours St. Francis Medical CenterRichmondVAUSA
| | | | | | | | | | | | | | - Trushil Shah
- University of Texas Southwestern Medical CenterDallasTXUSA
| | - Chunqin Deng
- United Therapeutics Corporation, Research Triangle ParkNCUSA
| | - Melissa Miceli
- United Therapeutics Corporation, Research Triangle ParkNCUSA
| | - Peter Smith
- United Therapeutics Corporation, Research Triangle ParkNCUSA
| | - Shelley M. Shapiro
- Greater Los Angeles VA Healthcare System, Cardiology Section, and David Geffen UCLA School of MedicineLos AngelesCAUSA
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Rahaghi FF, Balasubramanian VP, Bourge RC, Burger CD, Chakinala MM, Eggert MS, Elwing JM, Feldman J, King C, Klinger JR, Mathai SC, Wesley McConnell J, Palevsky HI, Restrepo‐Jaramillo R, Safdar Z, Sager JS, Sood N, Sulica R, James White R, Hill NS. Delphi Consensus Recommendation for Optimization of Pulmonary Hypertension Therapy Focusing On Switching from a Phosphodiesterase 5 Inhibitor to Riociguat. Pulm Circ 2022; 12:e12055. [PMID: 35514769 PMCID: PMC9063960 DOI: 10.1002/pul2.12055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/03/2022] [Accepted: 03/01/2022] [Indexed: 11/06/2022] Open
Abstract
Dual combination therapy with a phosphodiesterase‐5 inhibitor (PDE5i) and endothelin receptor antagonist is recommended for most patients with intermediate‐risk pulmonary arterial hypertension (PAH). The RESPITE and REPLACE studies suggest that switching from a PDE5i to a soluble guanylate cyclase (sGC) activator may provide clinical improvement in this situation. The optimal approach to escalation or transition of therapy in this or other scenarios is not well defined. We developed an expert consensus statement on the transition to sGC and other treatment escalations and transitions in PAH using a modified Delphi process. The Delphi process used a panel of 20 physicians with expertise in PAH. Panelists answered three questionnaires on the management of treatment escalations and transitions in PAH. The initial questionnaire included open‐ended questions. Later questionnaires consolidated the responses into statements that panelists rated on a Likert scale from −5 (strongly disagree) to +5 (strongly agree) to determine consensus. The Delphi process produced several consensus recommendations. Escalation should be considered for patients who are at high risk or not achieving treatment goals, by adding an agent from a new class, switching from oral to parenteral prostacyclins, or increasing the dose. Switching to a new class or within a class should be considered if tolerability or other considerations unrelated to efficacy are affecting adherence. Switching from a PDE5i to an SGC activator may benefit patients with intermediate risk who are not improving on their present therapy. These consensus‐based recommendations may be helpful to clinicians and beneficial for patients when evidence‐based guidance is unavailable.
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Affiliation(s)
- Franck F. Rahaghi
- Advanced Lung Disease Clinic, Cleveland Clinic Florida Weston FL USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Zeenat Safdar
- Center for Advanced Lung Diseases, Houston Methodist Hospital, Weill Cornell Medicine Houston TX USA
| | | | - Namita Sood
- University of California‐ Davis Sacramento CA
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Temesgen Z, Burger CD, Baker J, Polk C, Libertin CR, Kelley CF, Marconi VC, Orenstein R, Catterson VM, Aronstein WS, Durrant C, Chappell D, Ahmed O, Chappell G, Badley AD. Lenzilumab in hospitalised patients with COVID-19 pneumonia (LIVE-AIR): a phase 3, randomised, placebo-controlled trial. The Lancet Respiratory Medicine 2022; 10:237-246. [PMID: 34863332 PMCID: PMC8635458 DOI: 10.1016/s2213-2600(21)00494-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/26/2021] [Accepted: 10/28/2021] [Indexed: 12/15/2022]
Abstract
Background The pathophysiology of COVID-19 includes immune-mediated hyperinflammation, which could potentially lead to respiratory failure and death. Granulocyte-macrophage colony-stimulating factor (GM-CSF) is among cytokines that contribute to the inflammatory processes. Lenzilumab, a GM-CSF neutralising monoclonal antibody, was investigated in the LIVE-AIR trial to assess its efficacy and safety in treating COVID-19 beyond available treatments. Methods In LIVE-AIR, a phase 3, randomised, double-blind, placebo-controlled trial, hospitalised adult patients with COVID-19 pneumonia not requiring invasive mechanical ventilation were recruited from 29 sites in the USA and Brazil and were randomly assigned (1:1) to receive three intravenous doses of lenzilumab (600 mg per dose) or placebo delivered 8 h apart. All patients received standard supportive care, including the use of remdesivir and corticosteroids. Patients were stratified at randomisation by age and disease severity. The primary endpoint was survival without invasive mechanical ventilation to day 28 in the modified intention-to-treat population (mITT), comprising all randomised participants who received at least one dose of study drug under the documented supervision of the principal investigator or sub-investigator. Adverse events were assessed in all patients who received at least one dose of study drug. This trial is registered with ClinicalTrials.gov, NCT04351152, and is completed. Findings Patients were enrolled from May 5, 2020, until Jan 27, 2021. 528 patients were screened, of whom 520 were randomly assigned and included in the intention-to-treat population. 479 of these patients (n=236, lenzilumab; n=243, placebo) were included in the mITT analysis for the primary outcome. Baseline demographics were similar between groups. 311 (65%) participants were males, mean age was 61 (SD 14) years at baseline, and median C-reactive protein concentration was 79 (IQR 41–137) mg/L. Steroids were administered to 449 (94%) patients and remdesivir to 347 (72%) patients; 331 (69%) patients received both treatments. Survival without invasive mechanical ventilation to day 28 was achieved in 198 (84%; 95% CI 79–89) participants in the lenzilumab group and in 190 (78%; 72–83) patients in the placebo group, and the likelihood of survival was greater with lenzilumab than placebo (hazard ratio 1·54; 95% CI 1·02–2·32; p=0·040). 68 (27%) of 255 patients in the lenzilumab group and 84 (33%) of 257 patients in the placebo group experienced at least one adverse event that was at least grade 3 in severity based on CTCAE criteria. The most common treatment-emergent adverse events of grade 3 or higher were related to respiratory disorders (26%) and cardiac disorders (6%) and none led to death. Interpretation Lenzilumab significantly improved survival without invasive mechanical ventilation in hospitalised patients with COVID-19, with a safety profile similar to that of placebo. The added value of lenzilumab beyond other immunomodulators used to treat COVID-19 alongside steroids remains unknown. Funding Humanigen.
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Affiliation(s)
- Zelalem Temesgen
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN, USA.
| | - Charles D Burger
- Mayo Clinic, Division of Pulmonary, Allergy and Sleep Medicine, Jacksonville, FL, USA
| | - Jason Baker
- Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | | | | | - Colleen F Kelley
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA; Grady Memorial Hospital, Atlanta, GA, USA
| | - Vincent C Marconi
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA; Rollins School of Public Health and Emory Vaccine Center, Atlanta, GA, USA
| | - Robert Orenstein
- Mayo Clinic Arizona, Division of Infectious Diseases, Phoenix, AZ, USA
| | | | | | | | | | | | | | - Andrew D Badley
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN, USA; Department of Molecular Medicine, Mayo Clinic, Rochester, MN, USA
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8
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Pati S, Thompson GE, Mull CJ, Allen DH, Fazio JR, Felix HM, Paulson M, Chaudhry R, Matcha GV, Maniaci MJ, Burger CD, Quest DJ. Improving Patient Selection and Prioritization for Hospital at Home Through Predictive Modeling. AMIA Annu Symp Proc 2022; 2022:856-865. [PMID: 37128392 PMCID: PMC10148353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Hospital at home is designed to offer patients hospital level care in the comfort of their own home. The process by which clinicians select eligible patients that are clinically and socially appropriate for this model of care requires labor-intensive manual chart reviews. We addressed this problem by providing a predictive model, web application, and data pipeline that produces an eligibility score based on a set of clinical and social factors that influence patients' success in the program. Providers used this predictive model to prioritize the order in which they perform chart reviews and patient screenings. Training performance area under the curve (AUC) was 0.77. Testing 'in production' had an AUC of 0.75. Admission criteria in training rapidly changed over the course of the study due to the novelty of the clinical model. The current algorithm successfully identified many inconsistencies in enrollment and has streamlined the process of patient identification.
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Affiliation(s)
- Satyabrata Pati
- Center for Digital Health - Mayo Clinic, Rochester, Minnesota
| | - Gina E Thompson
- Center for Digital Health - Mayo Clinic, Rochester, Minnesota
| | | | - Daniel H Allen
- Center for Digital Health - Mayo Clinic, Rochester, Minnesota
| | - Jacey R Fazio
- Center for Digital Health - Mayo Clinic, Rochester, Minnesota
| | - Heidi M Felix
- Division of Hospital Internal Medicine - Mayo Clinic, Jacksonville, Florida
| | - Margaret Paulson
- Division of Hospital Internal Medicine - Mayo Clinic, Eau Claire, Wisconsin
| | - Rajeev Chaudhry
- Division of Community Internal Medicine - Mayo Clinic, Rochester, Minnesota
| | - Gautam V Matcha
- Division of Hospital Internal Medicine - Mayo Clinic, Jacksonville, Florida
| | - Michael J Maniaci
- Division of Hospital Internal Medicine - Mayo Clinic, Jacksonville, Florida
| | - Charles D Burger
- Division of Pulmonary, Allergy, and Sleep Medicine - Mayo Clinic, Jacksonville, Florida
| | - Daniel J Quest
- Center for Digital Health - Mayo Clinic, Rochester, Minnesota
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9
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Burger CD. In reply-Exercise-Based Cardiopulmonary Rehabilitation: A Suitable Addition to Pharmacological Therapy for Pulmonary Hypertension. Mayo Clin Proc 2022; 97:191-192. [PMID: 34996556 DOI: 10.1016/j.mayocp.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 11/04/2021] [Indexed: 11/21/2022]
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10
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Nyman MA, Jose T, Croghan IT, Parkulo MA, Burger CD, Schroeder DR, Hurt RT, O'Horo JC. Utilization of an Electronic Health Record Integrated Risk Score to Predict Hospitalization Among COVID-19 Patients. J Prim Care Community Health 2022; 13:21501319211069748. [PMID: 35068257 PMCID: PMC8796071 DOI: 10.1177/21501319211069748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Objective: To evaluate the performance of an Electronic Health Record (EHR) integrated risk score for COVID-19 positive outpatients to predict 30-day risk of hospitalization. Patients and Methods: A retrospective observational study of 67 470 patients with COVID-19 confirmed by polymerase chain reaction (PCR) test between March 12, 2020 and February 8, 2021. Risk scores were calculated based on data in the chart at the time of the incident infection. Results: The Mayo Clinic COVID-19 risk score consisted of 13 components included age, sex, chronic lung disease, congenital heart disease, congestive heart failure, coronary artery disease, diabetes mellitus, end stage liver disease, end stage renal disease, hypertension, immune compromised, nursing home resident, and pregnant. Univariate analysis showed all components, except pregnancy, have significant (P < .001) association with admission. The Mayo Clinic COVID-19 risk score showed a Receiver Operating Characteristic Area Under Curve (AUC) of 0.837 for the prediction of admission for this large cohort of COVID-19 positive patients. Conclusion: The Mayo Clinic COVID-19 risk score is a simple score that is easily integrated into the EHR with excellent predictive performance for severe COVID-19. It can be leveraged to stratify risk for severe COVID-19 at initial contact, when considering therapeutics or in the allocation of vaccine supply.
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Affiliation(s)
| | - Thulasee Jose
- Mayo Clinic, Rochester, MN, USA.,Baptist Hospitals of Southeast Texas, Beaumont, TX, USA
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Burger CD, DuBrock HM, Cartin-Ceba R, Moss JE, Shapiro BP, Frantz RP. Topic-Based, Recent Literature Review on Pulmonary Hypertension. Mayo Clin Proc 2021; 96:3109-3121. [PMID: 34479734 DOI: 10.1016/j.mayocp.2021.05.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/25/2021] [Accepted: 05/28/2021] [Indexed: 01/22/2023]
Abstract
Pulmonary hypertension is a complex condition but a relatively common manifestation of severe cardiopulmonary disease. By contrast, pulmonary arterial hypertension is uncommon and is more prevalent in young women. To better categorize patients and to guide clinical decision-making, 5 diagnostic groups and associated subgroups characterize the spectrum of disease. A multidisciplinary approach to evaluation and treatment is recommended by published guidelines and often entails referral to a designated pulmonary hypertension center. Several key publications during the last couple of years merit review. The PubMed database was searched for English-language studies and guidelines relating to pulmonary hypertension. The following terms were searched, alone and in combination: pulmonary hypertension, pulmonary arterial hypertension, portopulmonary hypertension, and chronic thromboembolic pulmonary hypertension. The focus was on those publications with new information on evaluation and management of pulmonary hypertension between January 1, 2019, and January 31, 2021. Of the subgroups, 2 were of particular interest for this review: portopulmonary hypertension and chronic thromboembolic pulmonary hypertension. Last, available data on the impact of the coronavirus disease 2019 pandemic and newer treatment agents in early trials were selectively reviewed. The review is therefore intended to serve as a practical, focused review of important topics germane to those clinicians caring for patients with pulmonary hypertension.
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Affiliation(s)
- Charles D Burger
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic, Jacksonville, FL.
| | - Hilary M DuBrock
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Rodrigo Cartin-Ceba
- Division of Pulmonary Medicine, Mayo Clinic, Scottsdale, AZ; Department of Critical Care Medicine, Mayo Clinic, Scottsdale, AZ
| | - John E Moss
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic, Jacksonville, FL; Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | - Brian P Shapiro
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL
| | - Robert P Frantz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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12
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Abstract
Little is known about the effect of wearing a facemask on the physiological and perceptual responses to exercise in patients with pulmonary arterial hypertension (PAH). We performed a single-center retrospective study to evaluate whether facemask wearing impacted distanced covered, rating of perceived exertion (RPE), and arterial oxygen saturation (SpO2) during a 6-minute walk test (6MWT) in PAH patients. Forty-five patients being treated for group 1 PAH and who performed a 6MWT before and after implementation of a facemask mandate were included in the analysis. Each included patient performed a 6MWT without (test 1) and with (test 2) a facemask between October 1, 2019, and October 31, 2020. At both time points, all patients also underwent a submaximal cardiopulmonary exercise test, echocardiogram, and blood laboratory tests, with a Registry to Evaluate Early and Long-Term PAH Disease Management Lite 2.0 score calculated. The two 6MWTs were performed 81±51 days apart, and all patients were clinically stable at both testing timepoints. Six-minute walk test distance was not different between test 1 and test 2 (405±108 m vs 400±103 m, P=.81). Similarly, both end-test RPE and lowest SpO2 during the 6MWT were not different in test 1 and test 2 (RPE: 2.5±1.7 vs 2.5±2.1, P=.91; SpO2 nadir: 92.8±3.4% vs 93.3±3.3%, P=.55). Our findings show that wearing a facemask has no discernable impact on the arterial oxygen saturation and perceptual responses to exercise or exercise capacity in patients with moderate-to-severe PAH. This study reinforces the evidence that wearing a facemask is safe in PAH patients, even during exercise.
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Affiliation(s)
- Scott A. Helgeson
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL
- Correspondence: Address to Scott A. Helgeson, MD, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL.
| | - Charles D. Burger
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | - John E. Moss
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | - Tonya K. Zeiger
- Division of Pulmonary Medicine, Mayo Clinic, Jacksonville, FL
| | - Bryan J. Taylor
- Division of Cardiovascular Disease, Mayo Clinic, Jacksonville, FL
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13
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Helgeson SA, Waddle MR, Burnside RC, Debella YT, Lee AS, Burger CD, Li Z, Johnson PW, Patel NM. Association between Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers and Lung Cancer. South Med J 2021; 114:607-613. [PMID: 34480196 DOI: 10.14423/smj.0000000000001293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are the most commonly prescribed antihypertensives, with prior studies identifying a possible association between long-term use and increased rates of lung cancer. This study evaluated this potential association in a large population using propensity matching. METHODS This was a population-based cohort study in a large healthcare system in three regions of the United States. Pairwise propensity score matching was performed using demographics and comorbidities. All of the adult patients in the healthcare system from January 1, 2000 to April 30, 2018 with at least 1 year of follow-up were included. RESULTS In total, 3,253,811 patients with a median age of 59 (range 18-103) years were included. The ACEI group had a higher freedom from lung cancer versus controls at 15 years (98.47%, 95% confidence interval [CI] 98.41-98.54) versus 98.26%, (95% CI 98.20-98.33), whereas ARBs had similar rates versus controls at all time points. For patients diagnosed as having lung cancer, median all-cause survival was significantly higher in the ACEI (34.7 months, 95% CI 32.8-36.6) and ARB (30.9 months, 95% CI 28.1-33.8) groups than the control group (20.6 months, 95% CI 20.1-21.1). CONCLUSIONS This study showed lower rates of lung cancer with ACEI use and no difference in risk with ARBs. In addition, use of these medications was found to be associated with increased survival in those diagnosed as having lung cancer. This study supports the continued use of these medications without concern for increasing the risk of lung cancer.
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Affiliation(s)
- Scott A Helgeson
- From the Departments of Pulmonary Medicine, Radiation Oncology, and Statistics, Mayo Clinic, Jacksonville, Florida
| | - Mark R Waddle
- From the Departments of Pulmonary Medicine, Radiation Oncology, and Statistics, Mayo Clinic, Jacksonville, Florida
| | - Rebecca C Burnside
- From the Departments of Pulmonary Medicine, Radiation Oncology, and Statistics, Mayo Clinic, Jacksonville, Florida
| | - Yalew T Debella
- From the Departments of Pulmonary Medicine, Radiation Oncology, and Statistics, Mayo Clinic, Jacksonville, Florida
| | - Augustine S Lee
- From the Departments of Pulmonary Medicine, Radiation Oncology, and Statistics, Mayo Clinic, Jacksonville, Florida
| | - Charles D Burger
- From the Departments of Pulmonary Medicine, Radiation Oncology, and Statistics, Mayo Clinic, Jacksonville, Florida
| | - Zhuo Li
- From the Departments of Pulmonary Medicine, Radiation Oncology, and Statistics, Mayo Clinic, Jacksonville, Florida
| | - Patrick W Johnson
- From the Departments of Pulmonary Medicine, Radiation Oncology, and Statistics, Mayo Clinic, Jacksonville, Florida
| | - Neal M Patel
- From the Departments of Pulmonary Medicine, Radiation Oncology, and Statistics, Mayo Clinic, Jacksonville, Florida
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14
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DuBrock HM, Burger CD, Bartolome SD, Feldman JP, Ivy DD, Rosenzweig EB, Sager JS, Presberg KW, Mathai SC, Lammi MR, Klinger JR, Eggert M, De Marco T, Elwing JM, Badesch D, Bull TM, Cadaret LM, Ramani G, Thenappan T, Ford HJ, Al-Naamani N, Simon MA, Mazimba S, Runo JR, Chakinala M, Horn EM, Ryan JJ, Frantz RP, Krowka MJ. Health disparities and treatment approaches in portopulmonary hypertension and idiopathic pulmonary arterial hypertension: an analysis of the Pulmonary Hypertension Association Registry. Pulm Circ 2021; 11:20458940211020913. [PMID: 34158918 PMCID: PMC8186121 DOI: 10.1177/20458940211020913] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Compared to idiopathic pulmonary arterial hypertension (IPAH), patients with portopulmonary hypertension (POPH) have worse survival. Health disparities may contribute to these differences but have not been studied. We sought to compare socioeconomic factors in patients with POPH and IPAH and to determine whether socioeconomic status and/or POPH diagnosis were associated with treatment and health-care utilization. We performed a cross-sectional study of adults enrolled in the Pulmonary Hypertension Association Registry. Patients with IPAH (n = 344) and POPH (n = 57) were compared. Compared with IPAH, patients with POPH were less likely to be college graduates (19.6% vs. 34.9%, p = 0.02) and more likely to be unemployed (54.7% vs. 30.5%, p < 0.001) and have an annual household income below poverty level (45.7% vs. 19.0%, p < 0.001). Patients with POPH had similar functional class, quality of life, 6-min walk distance, and mean pulmonary arterial pressure with a higher cardiac index. Compared with IPAH, patients with POPH were less likely to receive combination therapy (46.4% vs. 62.2%, p = 0.03) and endothelin receptor antagonists (28.6% vs. 55.1%, p < 0.001) at enrollment with similar treatment at follow-up. Patients with POPH had more emergency department visits (1.7 ± 2.1 vs. 0.9 ± 1.2, p = 0.009) and hospitalizations in the six months preceding enrollment (1.5 ± 2.1 vs. 0.8 ± 1.1, p = 0.02). Both POPH diagnosis and lower education level were independently associated with a higher number of emergency department visits. Compared to IPAH, patients with POPH have lower socioeconomic status, are less likely to receive initial combination therapy and endothelin receptor antagonists but have similar treatment at follow-up, and have increased health-care utilization.
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Affiliation(s)
- Hilary M DuBrock
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Charles D Burger
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Sonja D Bartolome
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jeremy P Feldman
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Arizona Pulmonary Specialists, Ltd, Scottsdale, AZ, USA
| | - D Dunbar Ivy
- Division of Cardiology, Department of Pediatrics, Children's Hospital Colorado, Aurora, CO, USA
| | - Erika B Rosenzweig
- Division of Cardiology, Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Jeffrey S Sager
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Cottage Pulmonary Hypertension Center, Santa Barbara, CA, USA
| | - Kenneth W Presberg
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Matthew R Lammi
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Comprehensive Pulmonary Hypertension Center, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - James R Klinger
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Brown University, Providence, RI, USA
| | - Michael Eggert
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Sentara Cardiovascular Research Institute, Norfolk, VA, USA
| | - Teresa De Marco
- Division of Cardiology, Department of Internal Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Jean M Elwing
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - David Badesch
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Colorado, Denver, CO, USA
| | - Todd M Bull
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Colorado, Denver, CO, USA
| | - Linda M Cadaret
- Division of Cardiology, Department of Internal Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Gautam Ramani
- Division of Cardiology, Department of Internal Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Thenappan Thenappan
- Division of Cardiology, Department of Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - H James Ford
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Nadine Al-Naamani
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Marc A Simon
- Division of Cardiology, Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Division of Cardiology, Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Sula Mazimba
- Division of Cardiology, Department of Internal Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - James R Runo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Murali Chakinala
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Washington University at Barnes-Jewish, St. Louis, MO, USA
| | - Evelyn M Horn
- Division of Cardiology, Department of Internal Medicine, Weill Cornell Medical School, New York, NY, USA
| | - John J Ryan
- Division of Cardiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Robert P Frantz
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Michael J Krowka
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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15
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Temesgen Z, Burger CD, Baker J, Polk C, Libertin C, Kelley C, Marconi VC, Orenstein R, Durrant C, Chappell D, Ahmed O, Chappell G, Badley AD. LENZILUMAB EFFICACY AND SAFETY IN NEWLY HOSPITALIZED COVID-19 SUBJECTS: RESULTS FROM THE LIVE-AIR PHASE 3 RANDOMIZED DOUBLE-BLIND PLACEBO-CONTROLLED TRIAL. medRxiv 2021:2021.05.01.21256470. [PMID: 33972949 PMCID: PMC8109186 DOI: 10.1101/2021.05.01.21256470] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Severe COVID-19 pneumonia results from a hyperinflammatory immune response (cytokine storm, CS), characterized by GM-CSF mediated activation and trafficking of myeloid cells, leading to elevation of downstream inflammatory chemokines (MCP-1, IL-8, IP-10), cytokines (IL-6, IL-1), and other markers of systemic inflammation (CRP, D-dimer, ferritin). CS leads to fever, hypotension, coagulopathy, respiratory failure, ARDS, and death. Lenzilumab is a novel Humaneered® anti-human GM-CSF monoclonal antibody that directly binds GM-CSF and prevents signaling through its receptor. The LIVE-AIR Phase 3 randomized, double-blind, placebo-controlled trial investigated the efficacy and safety of lenzilumab to assess the potential for lenzilumab to improve the likelihood of ventilator-free survival (referred to herein as survival without ventilation, SWOV), beyond standard supportive care, in hospitalized subjects with severe COVID-19. METHODS Subjects with COVID-19 (n=520), ≥18 years, and ≤94% oxygen saturation on room air and/or requiring supplemental oxygen, but not invasive mechanical ventilation, were randomized to receive lenzilumab (600 mg, n=261) or placebo (n=259) via three intravenous infusions administered 8 hours apart. Subjects were followed through Day 28 following treatment. RESULTS Baseline demographics were comparable between the two treatment groups: male, 64.7%; mean age, 60.5 years; mean BMI, 32.5 kg/m2; mean CRP, 98.36 mg/L; CRP was <150 mg/L in 77.9% of subjects. The most common comorbidities were obesity (55.1%), diabetes (53.4%), chronic kidney disease (14.0%), and coronary artery disease (13.6%). Subjects received steroids (93.7%), remdesivir (72.4%), or both (69.1%). Lenzilumab improved the likelihood of SWOV by 54% in the mITT population (HR: 1.54; 95%CI: 1.02-2.31, p=0.041) and by 90% in the ITT population (HR: 1.90; 1.02-3.52, nominal p=0.043) compared to placebo. SWOV also relatively improved by 92% in subjects who received both corticosteroids and remdesivir (1.92; 1.20-3.07, nominal p=0.0067); by 2.96-fold in subjects with CRP<150 mg/L and age <85 years (2.96; 1.63-5.37, nominal p=0.0003); and by 88% in subjects hospitalized ≤2 days prior to randomization (1.88; 1.13-3.12, nominal p=0.015). Survival was improved by 2.17-fold in subjects with CRP<150 mg/L and age <85 years (2.17; 1.04-4.54, nominal p=0.040). CONCLUSION Lenzilumab significantly improved SWOV in hospitalized, hypoxic subjects with COVID-19 pneumonia over and above treatment with remdesivir and/or corticosteroids. Subjects with CRP<150 mg/L and age <85 years demonstrated an improvement in survival and had the greatest benefit from lenzilumab. NCT04351152.
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Affiliation(s)
| | - Charles D. Burger
- Mayo Clinic, Division of Pulmonary, Allergy and Sleep Medicine, Jacksonville, FL
| | - Jason Baker
- Hennepin Healthcare Research Institute, Minneapolis, MN
| | | | | | - Colleen Kelley
- Emory University School of Medicine, Division of Infectious Diseases; Special Immunology Service Grady Memorial Hospital, Atlanta, GA
| | - Vincent C. Marconi
- Emory University School of Medicine, Rollins School of Public Health, and Emory Vaccine Center, Division of Infectious Diseases, Atlanta, GA
| | | | | | | | | | | | - Andrew D. Badley
- Mayo Clinic, Division of Infectious Disease and Department of Molecular Medicine, Rochester, MN
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16
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O'Horo JC, Cerhan JR, Cahn EJ, Bauer PR, Temesgen Z, Ebbert J, Abril A, Abu Saleh OM, Assi M, Berbari EF, Bierle DM, Bosch W, Burger CD, Cano Cevallos EJ, Clements CM, Carmona Porquera EM, Castillo Almeida NE, Challener DW, Chesdachai S, Comba IY, Corsini Campioli CG, Crane SJ, Dababneh AS, Enzler MJ, Fadel HJ, Ganesh R, De Moraes AG, Go JR, Gordon JE, Gurram PR, Guru PK, Halverson EL, Harrison MF, Heaton HA, Hurt R, Kasten MJ, Lee AS, Levy ER, Libertin CR, Mallea JM, Marshall WF, Matcha G, Meehan AM, Franco PM, Morice WG, O'Brien JJ, Oeckler R, Ommen S, Oravec CP, Orenstein R, Ough NJ, Palraj R, Patel BM, Pureza VS, Pickering B, Phelan DM, Razonable RR, Rizza S, Sampathkumar P, Sanghavi DK, Sen A, Siegel JL, Singbartl K, Shah AS, Shweta F, Speicher LL, Suh G, Tabaja H, Tande A, Ting HH, Tontz RC, Vaillant JJ, Vergidis P, Warsame MY, Yetmar ZA, Zomok CCD, Williams AW, Badley AD. Outcomes of COVID-19 With the Mayo Clinic Model of Care and Research. Mayo Clin Proc 2021; 96:601-618. [PMID: 33673913 PMCID: PMC7831394 DOI: 10.1016/j.mayocp.2020.12.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 12/11/2020] [Accepted: 12/15/2020] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To report the Mayo Clinic experience with coronavirus disease 2019 (COVID-19) related to patient outcomes. METHODS We conducted a retrospective chart review of patients with COVID-19 diagnosed between March 1, 2020, and July 31, 2020, at any of the Mayo Clinic sites. We abstracted pertinent comorbid conditions such as age, sex, body mass index, Charlson Comorbidity Index variables, and treatments received. Factors associated with hospitalization and mortality were assessed in univariate and multivariate models. RESULTS A total of 7891 patients with confirmed COVID-19 infection with research authorization on file received care across the Mayo Clinic sites during the study period. Of these, 7217 patients were adults 18 years or older who were analyzed further. A total of 897 (11.4%) patients required hospitalization, and 354 (4.9%) received care in the intensive care unit (ICU). All hospitalized patients were reviewed by a COVID-19 Treatment Review Panel, and 77.5% (695 of 897) of inpatients received a COVID-19-directed therapy. Overall mortality was 1.2% (94 of 7891), with 7.1% (64 of 897) mortality in hospitalized patients and 11.3% (40 of 354) in patients requiring ICU care. CONCLUSION Mayo Clinic outcomes of patients with COVID-19 infection in the ICU, hospital, and community compare favorably with those reported nationally. This likely reflects the impact of interprofessional multidisciplinary team evaluation, effective leveraging of clinical trials and available treatments, deployment of remote monitoring tools, and maintenance of adequate operating capacity to not require surge adjustments. These best practices can help guide other health care systems with the continuing response to the COVID-19 pandemic.
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Key Words
- apache iv, acute physiology and chronic health evaluation iv
- ards, acute respiratory distress syndrome
- bmi, body mass index
- cci, charlson comorbidity index
- covid-19, coronavirus disease 2019
- eap, expanded access program
- ecmo, extracorporeal membrane oxygenation
- ehr, electronic health record
- icd-10, international classification of diseases, tenth revision
- icu, intensive care unit
- los, length of stay
- nih, national institutes of health
- or, odds ratio
- sars-cov-2, severe acute respiratory syndrome coronavirus 2
- sofa, sequential organ failure assessment
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Affiliation(s)
- John Charles O'Horo
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - James R Cerhan
- Division of Health Science Research, Mayo Clinic, Rochester, MN
| | - Elliot J Cahn
- Division of Health Science Research, Mayo Clinic, Rochester, MN
| | - Philippe R Bauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | | | - Jon Ebbert
- Division of Community Internal Medicine, Mayo Clinic, Rochester, MN
| | - Andy Abril
- Division of Rheumatology, Mayo Clinic, Jacksonville, FL
| | | | - Mariam Assi
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Elie F Berbari
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Dennis M Bierle
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Wendelyn Bosch
- Division of Infectious Diseases, Mayo Clinic, Jacksonville, FL
| | - Charles D Burger
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | | | | | - Eva M Carmona Porquera
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | | | | | | | - Isin Y Comba
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | | | - Sarah J Crane
- Division of Community Internal Medicine, Mayo Clinic, Rochester, MN
| | - Ala S Dababneh
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Mark J Enzler
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Hind J Fadel
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Ravindra Ganesh
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | | | - John R Go
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Joel E Gordon
- Department of Family Medicine, Mayo Clinic Health System, Mankato, MN
| | - Pooja R Gurram
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Pramod K Guru
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | | | | | | | - Ryan Hurt
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Mary J Kasten
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Augustine S Lee
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | - Emily R Levy
- Division of Pediatric Critical Care Medicine, Mayo Clinic, Rochester, MN; Division of Pediatric Infectious Diseases, Mayo Clinic, Rochester, MN
| | | | - Jorge M Mallea
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | | | - Gautam Matcha
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL
| | - Anne M Meehan
- Division of Hospital Medicine, Mayo Clinic, Rochester, MN
| | | | - William G Morice
- Department of Laboratory Medicine Pathology, Mayo Clinic, Rochester, MN
| | - Jennifer J O'Brien
- Department of Laboratory Medicine Pathology, Mayo Clinic, Jacksonville, FL
| | - Richard Oeckler
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN; Division of Infectious Diseases, Mayo Clinic, Scottsdale, AZ
| | - Steve Ommen
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | | | - Natalie J Ough
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Raj Palraj
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Bhavesh M Patel
- Department of Critical Care Medicine, Mayo Clinic, Scottsdale, AZ
| | - Vincent S Pureza
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN
| | - Brian Pickering
- Division of Intensive Care, Department of Anesthesia, Mayo Clinic, Rochester, MN
| | - David M Phelan
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | | | - Stacey Rizza
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | | | | | - Ayan Sen
- Department of Critical Care Medicine, Mayo Clinic, Scottsdale, AZ
| | | | - Kai Singbartl
- Department of Critical Care, Mayo Clinic, Rochester, MN
| | - Aditya S Shah
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Fnu Shweta
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Leigh L Speicher
- Division of General Internal Medicine, Mayo Clinic, Jacksonville, FL
| | - Gina Suh
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Hussam Tabaja
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Aaron Tande
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Henry H Ting
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL
| | - Russell C Tontz
- Division of Occupational Medicine, Mayo Clinic Health System, Mankato, MN
| | | | | | | | | | | | - Amy W Williams
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Andrew D Badley
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN; Department of Molecular Medicine, Mayo Clinic, Rochester, MN.
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17
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Jose T, Warner DO, O'Horo JC, Peters SG, Chaudhry R, Binnicker MJ, Burger CD. Digital Health Surveillance Strategies for Management of Coronavirus Disease 2019. Mayo Clin Proc Innov Qual Outcomes 2020; 5:109-117. [PMID: 33521582 PMCID: PMC7831529 DOI: 10.1016/j.mayocpiqo.2020.12.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective To describe the design, implementation, and utilization of electronic health record (EHR)-based digital health surveillance strategies used to manage the coronavirus disease 2019 (COVID-19) pandemic and to ensure delivery of high-quality clinical care, such as case identification, remote monitoring, telemedicine services, and recruitment to clinical trials at Mayo Clinic. Methods The design and implementation work described in this report was performed at Mayo Clinic, a large multistate integrated health care system with more than 1.5 million annual patient visits that uses the Epic EHR system. Rule-based live registries were designed in the EHR system to classify patients who currently test positive for COVID-19, patients who test positive but have recovered from COVID-19, patients who are thought to have COVID-19 but do not yet meet clinical diagnostic criteria, patients who test negative for COVID-19, and patients who exceed a risk score for serious complications from COVID-19. Results By use of registries, custom dashboards and operational reports were developed to provide a daily high-level summary for clinical practice use and up-to-date information to manage individual patients affected by COVID-19, including support of case identification, contact isolation, and other care management tasks. Conclusion We developed and implemented a systematic approach to the use of EHR patient registries to manage the COVID-19 pandemic that proved feasible and useful in a large multistate group clinical practice. The key to harnessing the potential of digital surveillance tools to promote patient-centered care during the COVID-19 pandemic was to use the registry data, reports, and dashboards as informatics tools to inform decision-making.
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Affiliation(s)
- Thulasee Jose
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - David O Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - John C O'Horo
- Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Steve G Peters
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | | | | | - Charles D Burger
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Internal Medicine, Mayo Clinic, Jacksonville, FL
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18
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Lee JD, Burger CD, Delossantos GB, Grinnan D, Ralph DD, Rayner SG, Ryan JJ, Safdar Z, Ventetuolo CE, Zamanian RT, Leary PJ. A Survey-based Estimate of COVID-19 Incidence and Outcomes among Patients with Pulmonary Arterial Hypertension or Chronic Thromboembolic Pulmonary Hypertension and Impact on the Process of Care. Ann Am Thorac Soc 2020; 17:1576-1582. [PMID: 32726561 PMCID: PMC7706604 DOI: 10.1513/annalsats.202005-521oc] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/29/2020] [Indexed: 12/20/2022] Open
Abstract
Rationale: Patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) typically undergo frequent clinical evaluation. The incidence and outcomes of coronavirus disease (COVID-19) and its impact on routine management for patients with pulmonary vascular disease is currently unknown.Objectives: To assess the cumulative incidence and outcomes of recognized COVID-19 for patients with PAH/CTEPH followed at accredited pulmonary hypertension centers, and to evaluate the pandemic's impact on clinic operations at these centers.Methods: A survey was e-mailed to program directors of centers accredited by the Pulmonary Hypertension Association. Descriptive analyses and linear regression were used to analyze results.Results: Seventy-seven center directors were successfully e-mailed a survey, and 58 responded (75%). The cumulative incidence of COVID-19 recognized in individuals with PAH/CTEPH was 2.9 cases per 1,000 patients, similar to the general U.S. population. In patients with PAH/CTEPH for whom COVID-19 was recognized, 30% were hospitalized and 12% died. These outcomes appear worse than the general population. A large impact on clinic operations was observed including fewer clinic visits and substantially increased use of telehealth. A majority of centers curtailed diagnostic testing and a minority limited new starts of medical therapy. Most centers did not use experimental therapies in patients with PAH/CTEPH diagnosed with COVID-19.Conclusions: The cumulative incidence of COVID-19 recognized in patients with PAH/CTEPH appears similar to the broader population, although outcomes may be worse. Although the total number of patients with PAH/CTEPH recognized to have COVID-19 was small, the impact of COVID-19 on broader clinic operations, testing, and treatment was substantial.
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Affiliation(s)
| | - Charles D. Burger
- Department of Pulmonary Medicine, Mayo Clinic Florida, Jacksonville, Florida
| | | | - Daniel Grinnan
- Department of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | | | | | - John J. Ryan
- Department of Medicine, University of Utah, Salt Lake City, Utah
| | - Zeenat Safdar
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Corey E. Ventetuolo
- Department of Medicine and Health Services, Policy and Practice, Brown University, Providence, Rhode Island; and
| | | | - Peter J. Leary
- Department of Medicine and
- Department of Epidemiology, University of Washington, Seattle, Washington
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19
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Temesgen Z, Assi M, Shweta FNU, Vergidis P, Rizza SA, Bauer PR, Pickering BW, Razonable RR, Libertin CR, Burger CD, Orenstein R, Vargas HE, Palraj R, Dababneh AS, Chappell G, Chappell D, Ahmed O, Sakemura R, Durrant C, Kenderian SS, Badley AD. GM-CSF Neutralization With Lenzilumab in Severe COVID-19 Pneumonia: A Case-Cohort Study. Mayo Clin Proc 2020; 95:2382-2394. [PMID: 33153629 PMCID: PMC7470718 DOI: 10.1016/j.mayocp.2020.08.038] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 08/28/2020] [Accepted: 08/31/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess the efficacy and safety of lenzilumab in patients with severe coronavirus disease 2019 (COVID-19) pneumonia. METHODS Hospitalized patients with COVID-19 pneumonia and risk factors for poor outcomes were treated with lenzilumab 600 mg intravenously for three doses through an emergency single-use investigational new drug application. Patient characteristics, clinical and laboratory outcomes, and adverse events were recorded. We also identified a cohort of patients matched to the lenzilumab patients for age, sex, and disease severity. Study dates were March 13, 2020, to June 18, 2020. All patients were followed through hospital discharge or death. RESULTS Twelve patients were treated with lenzilumab; 27 patients comprised the matched control cohort (untreated). Clinical improvement, defined as improvement of at least 2 points on the 8-point ordinal clinical endpoints scale, was observed in 11 of 12 (91.7%) patients treated with lenzilumab and 22 of 27 (81.5%) untreated patients. The time to clinical improvement was significantly shorter for the lenzilumab-treated group compared with the untreated cohort with a median of 5 days versus 11 days (P=.006). Similarly, the proportion of patients with acute respiratory distress syndrome (oxygen saturation/fraction of inspired oxygen<315 mm Hg) was significantly reduced over time when treated with lenzilumab compared with untreated (P<.001). Significant improvement in inflammatory markers (C-reactive protein and interleukin 6) and markers of disease severity (absolute lymphocyte count) were observed in patients who received lenzilumab, but not in untreated patients. Cytokine analysis showed a reduction in inflammatory myeloid cells 2 days after lenzilumab treatment. There were no treatment-emergent adverse events attributable to lenzilumab. CONCLUSION In high-risk COVID-19 patients with severe pneumonia, granulocyte-macrophage colony-stimulating factor neutralization with lenzilumab was safe and associated with faster improvement in clinical outcomes, including oxygenation, and greater reductions in inflammatory markers compared with a matched control cohort of patients hospitalized with severe COVID-19 pneumonia. A randomized, placebo-controlled clinical trial to validate these findings is ongoing (NCT04351152).
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Affiliation(s)
| | - Mariam Assi
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - F N U Shweta
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | | | - Stacey A Rizza
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Philippe R Bauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Brian W Pickering
- Department of Anesthesia and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | | | | | | | | | - Hugo E Vargas
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ
| | - Raj Palraj
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Ala S Dababneh
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | | | | | | | - Reona Sakemura
- T Cell Engineering, Mayo Clinic, Rochester, MN; Division of Hematology, Mayo Clinic, Rochester, MN
| | | | - Saad S Kenderian
- T Cell Engineering, Mayo Clinic, Rochester, MN; Division of Hematology, Mayo Clinic, Rochester, MN; Department of Immunology, Mayo Clinic, Rochester, MN; Department of Molecular Medicine, Mayo Clinic, Rochester, MN
| | - Andrew D Badley
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN; Department of Molecular Medicine, Mayo Clinic, Rochester, MN
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20
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Sher T, Burger CD, DeMartino ES, de Moraes AG, Sharp RR. Resuscitation and COVID-19: Recalibrating Patient and Family Expectations During a Pandemic. Mayo Clin Proc 2020; 95:1848-1851. [PMID: 32861329 PMCID: PMC7323655 DOI: 10.1016/j.mayocp.2020.06.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 06/19/2020] [Indexed: 01/08/2023]
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21
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Affiliation(s)
- Charles D Burger
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic, Jacksonville, FL.
| | | | | | - Jon O Ebbert
- Division of Community Internal Medicine, Mayo Clinic, Rochester, MN
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22
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Temesgen Z, Assi M, Vergidis P, Rizza SA, Bauer PR, Pickering BW, Razonable RR, Libertin CR, Burger CD, Orenstein R, Vargas HE, Varatharaj Palraj BR, Dababneh AS, Chappell G, Chappell D, Ahmed O, Sakemura R, Durrant C, Kenderian SS, Badley A. First Clinical Use of Lenzilumab to Neutralize GM-CSF in Patients with Severe COVID-19 Pneumonia. medRxiv 2020. [PMID: 32587983 DOI: 10.1101/2020.06.08.20125369] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND In COVID-19, high levels of granulocyte macrophage-colony stimulating factor (GM-CSF) and inflammatory myeloid cells correlate with disease severity, cytokine storm, and respiratory failure. With this rationale, we used lenzilumab, an anti-human GM-CSF monoclonal antibody, to treat patients with severe COVID-19 pneumonia. METHODS Hospitalized patients with COVID-19 pneumonia and risk factors for poor outcomes were treated with lenzilumab 600 mg intravenously for three doses through an emergency single-use IND application. Patient characteristics, clinical and laboratory outcomes, and adverse events were recorded. All patients receiving lenzilumab through May 1, 2020 were included in this report. RESULTS Twelve patients were treated with lenzilumab. Clinical improvement was observed in 11 out of 12 (92%), with a median time to discharge of 5 days. There was a significant improvement in oxygenation: The proportion of patients with SpO2/FiO2 < 315 at the end of observation was 8% vs. compared to 67% at baseline (p=0.00015). A significant improvement in mean CRP and IL-6 values on day 3 following lenzilumab administration was also observed (137.3 mg/L vs 51.2 mg/L, p = 0.040; 26.8 pg/mL vs 16.1 pg/mL, p = 0.035; respectively). Cytokine analysis showed a reduction in inflammatory myeloid cells two days after lenzilumab treatment. There were no treatment-emergent adverse events attributable to lenzilumab, and no mortality in this cohort of patients with severe COVID-19 pneumonia. CONCLUSIONS In high-risk COVID-19 patients with severe pneumonia, GM-CSF neutralization with lenzilumab was safe and associated with improved clinical outcomes, oxygen requirement, and cytokine storm.
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23
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Helgeson SA, Menon D, Helmi H, Vadlamudi C, Moss JE, Zeiger TK, Burger CD. Psychosocial and Financial Burden of Therapy in USA Patients with Pulmonary Arterial Hypertension. Diseases 2020; 8:diseases8020022. [PMID: 32545763 PMCID: PMC7349780 DOI: 10.3390/diseases8020022] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/08/2020] [Accepted: 06/10/2020] [Indexed: 11/16/2022] Open
Abstract
Abstract: Pulmonary arterial hypertension (PAH) is a devastating disease with significant morbidity and mortality. There are many psychosocial and financial implications of this disease; however, little is known how this affects the treatment of PAH patients. A questionnaire-based prospective cohort study was performed on 106 PAH patients from a Pulmonary Hypertension Center and the Pulmonary Hypertension Association national conference in 2018. The demographic, treatment, psychosocial, employment, financial impact on treatment data was obtained. The majority of patients had cardiopulmonary symptoms despite treatment. The symptoms affected their social and work lives, with about one in three applying for disability because of their PAH. The majority of PAH patients had insurance coverage, but still noted a significant financial burden of the disease, with nearly a half who needed financial assistance to pay for their PAH medications. Thirty (28.3%; 95% CI, 20.6-37.5%) patients mentioned they changed their medication regimen, with some skipping doses outright (28 [26.4%; 95% CI, 19-35.6%]) in order to save money. PAH continues to cause significant psychosocial and financial burden on patients despite advances in medications. This impact ranged from dissatisfaction with quality of life, to unemployment, to altering their medication regimen to save money.
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Affiliation(s)
- Scott A. Helgeson
- Department of Pulmonary Medicine, Mayo Clinic, Jacksonville, FL 32224, USA; (C.V.); (J.E.M.); (T.K.Z.); (C.D.B.)
- Correspondence:
| | - Divya Menon
- Department of Pulmonary and Critical Care Medicine, Tufts Medical Center, Boston, MA 02111, USA;
| | - Haytham Helmi
- Department of Emergency Medicine, University of Florida, Jacksonville, FL 32224, USA;
| | - Charitha Vadlamudi
- Department of Pulmonary Medicine, Mayo Clinic, Jacksonville, FL 32224, USA; (C.V.); (J.E.M.); (T.K.Z.); (C.D.B.)
| | - John E. Moss
- Department of Pulmonary Medicine, Mayo Clinic, Jacksonville, FL 32224, USA; (C.V.); (J.E.M.); (T.K.Z.); (C.D.B.)
| | - Tonya K. Zeiger
- Department of Pulmonary Medicine, Mayo Clinic, Jacksonville, FL 32224, USA; (C.V.); (J.E.M.); (T.K.Z.); (C.D.B.)
| | - Charles D. Burger
- Department of Pulmonary Medicine, Mayo Clinic, Jacksonville, FL 32224, USA; (C.V.); (J.E.M.); (T.K.Z.); (C.D.B.)
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24
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Preston IR, Burger CD, Bartolome S, Safdar Z, Krowka M, Sood N, Ford HJ, Battarjee WF, Chakinala MM, Gomberg-Maitland M, Hill NS. Ambrisentan in portopulmonary hypertension: A multicenter, open-label trial. J Heart Lung Transplant 2020; 39:464-472. [PMID: 32008947 DOI: 10.1016/j.healun.2019.12.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 12/04/2019] [Accepted: 12/29/2019] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Ambrisentan has shown effectiveness in the treatment of Group 1 pulmonary arterial hypertension (PAH). Although portopulmonary hypertension (PoPH) is a subset of Group 1 PAH, few clinical trials have been testing PAH therapies in patients with PoPH. The objective of this study is to evaluate the efficacy and safety of ambrisentan in PoPH. METHODS This study is a prospective, multicenter, open-label trial in which treatment-naive patients with PoPH with Child-Pugh class A/B were administered with ambrisentan for 24 weeks, followed by a long-term extension (24-28 weeks). The primary end-points were change in pulmonary vascular resistance (PVR) and 6-minutes walk distance (6MWD) at 24 weeks, whereas secondary end-points included safety, World Health Organization (WHO) functional class (FC) and echocardiographic assessments. RESULTS Of the 31 patients, 23 finished 24 weeks of ambrisentan therapy and 19 finished the extension. PVR decreased significantly (mean ± SD) (7.1 ± 5 vs 3.8 ± 1.8 Wood units, p < 0.001), whereas 6MWD remained unchanged (314 ± 94 vs 336 ± 108 m). Other hemodynamic parameters such as right atrial pressure (13 ± 8 vs 9 ± 4 mm Hg, p < 0.05), mean pulmonary arterial pressure (46 ± 13 vs. 38 ± 8 mm Hg, p < 0.01), cardiac index (2.6 ± 0.6 vs. 3.5 ± 0.7 liter/min/m2, p < 0.001) showed improvement, whereas pulmonary capillary wedge pressure remained unchanged. Of the 22 patients with WHO FC assessments at baseline and 24 weeks, WHO FC improved significantly (p = 0.005). Most frequent drug-related adverse events were edema (38.7%) and headache (22.5%). One episode of leg edema resulted into the permanent discontinuation of ambrisentan. CONCLUSIONS Ambrisentan monotherapy in PoPH improves hemodynamics and FC at 24 weeks; however, it did not show any improvement in 6MWD. These preliminary outcomes should be interpreted with caution (Clinicaltrials.Gov:NCT01224210).
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Affiliation(s)
- Ioana R Preston
- Pulmonary, Critical Care and Sleep Division, Tufts Medical Center, Boston, Massachusetts.
| | - Charles D Burger
- Department of Pulmonary Medicine, Mayo Clinic Florida, Jacksonville, Florida
| | - Sonja Bartolome
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Zeenat Safdar
- Pulmonary and Critical Care Division, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Namita Sood
- Pulmonary and Critical Care Division, Ohio State University Medical Center, Columbus, Ohio
| | - Hubert J Ford
- Division of Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Wejdan F Battarjee
- Pulmonary, Critical Care and Sleep Division, Tufts Medical Center, Boston, Massachusetts
| | - Murali M Chakinala
- Division of Pulmonary and Critical Care Medicine, Washington University Medical Center, St. Louis, Missouri
| | - Mardi Gomberg-Maitland
- Division of Cardiology, George Washington University Hospital, Washington, District of Columbia
| | - Nicholas S Hill
- Pulmonary, Critical Care and Sleep Division, Tufts Medical Center, Boston, Massachusetts
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25
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Benza RL, Gomberg-Maitland M, Elliott CG, Farber HW, Foreman AJ, Frost AE, McGoon MD, Pasta DJ, Selej M, Burger CD, Frantz RP. Predicting Survival in Patients With Pulmonary Arterial Hypertension: The REVEAL Risk Score Calculator 2.0 and Comparison With ESC/ERS-Based Risk Assessment Strategies. Chest 2019. [PMID: 30772387 DOI: 10.1016/j.chest.2019.02.004)] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Pulmonary arterial hypertension is a progressive, fatal disease. Published treatment guidelines recommend treatment escalation on the basis of regular patient assessment with the goal of achieving or maintaining low-risk status. Various strategies are available to determine risk status. This analysis describes an update of the Registry to Evaluate Early and Long-Term PAH Disease Management (REVEAL) risk calculator (REVEAL 2.0) and compares it with recently published European Society of Cardiology/Respiratory Society guideline-derived risk assessment strategies. METHODS A subpopulation from the US-based registry REVEAL that survived ≥ 1 year postenrollment (baseline for this cohort) was analyzed. For REVEAL 2.0, point values and cutpoints were reassessed, and new variables were evaluated. The Kaplan-Meier method was used to estimate survival at 12 months postbaseline; discrimination was quantified using the c-statistic. Mortality estimates and discrimination were compared between REVEAL 2.0 and Comparative, Prospective Registry of Newly Initiated Therapies for Pulmonary Hypertension (COMPERA) and French Pulmonary Hypertension Registry (FPHR) risk assessment strategies. For this comparison, a three-category REVEAL 2.0 score was computed in which patients were classified as low-, intermediate-, or high-risk. RESULTS REVEAL 2.0 demonstrated similar discrimination as the original calculator in this subpopulation (c-statistic = 0.76 vs 0.74), provided excellent separation of risk among the risk categories, and predicted clinical worsening as well as mortality in patients who were followed ≥ 1 year. The REVEAL 2.0 three-category score had greater discrimination (c-statistic = 0.73) than COMPERA (c-statistic = 0.62) or FPHR (c-statistic = 0.64). Compared with REVEAL 2.0, COMPERA and FPHR both underestimated and overestimated risk. CONCLUSIONS REVEAL 2.0 demonstrates greater risk discrimination than the COMPERA and FPHR risk assessment strategies in patients enrolled in REVEAL. After external validation, the REVEAL 2.0 calculator can assist clinicians and patients in making informed treatment decisions on the basis of individual risk profiles. TRIAL REGISTRY ClinicalTrials.gov; No. NCT00370214; URL: www.clinicaltrials.gov.
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Affiliation(s)
| | | | - C Greg Elliott
- Intermountain Medical Center and the University of Utah, Salt Lake City, UT
| | | | | | - Adaani E Frost
- Houston Methodist Hospital Lung Center, Weill-Cornell Medical College, Houston, TX
| | | | | | - Mona Selej
- Actelion Pharmaceuticals US Inc., South San Francisco, CA
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26
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Benza RL, Gomberg-Maitland M, Elliott CG, Farber HW, Foreman AJ, Frost AE, McGoon MD, Pasta DJ, Selej M, Burger CD, Frantz RP. Predicting Survival in Patients With Pulmonary Arterial Hypertension. Chest 2019; 156:323-337. [DOI: 10.1016/j.chest.2019.02.004] [Citation(s) in RCA: 266] [Impact Index Per Article: 53.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 01/16/2019] [Accepted: 02/01/2019] [Indexed: 12/21/2022] Open
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27
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Helgeson SA, Enderby CY, Moss JE, Gass JM, Zeiger TK, Burger CD. Twelve-Year Survival in a Patient With Systemic Sclerosis-Associated Pulmonary Arterial Hypertension on Nifedipine Monotherapy. Mayo Clin Proc Innov Qual Outcomes 2019; 3:376-379. [PMID: 31485576 PMCID: PMC6713838 DOI: 10.1016/j.mayocpiqo.2019.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 05/28/2019] [Accepted: 06/10/2019] [Indexed: 11/29/2022] Open
Abstract
Pulmonary arterial hypertension is a progressive vascular disease with a high mortality rate without proper therapy. Identification of the appropriate treatment for each patient is critical in regard to adverse effects, health care costs, ease of treatment, and the potential for prognostication. Treatment strategies typically begin with acute vasoreactivity testing, which is performed during a right heart catherization. If positive, a calcium channel blocker may work; however, another pulmonary arterial hypertension-specific medication is necessary when testing is negative. Acute vasoreactivity testing is currently recommended to be performed only in certain subgroups of pulmonary arterial hypertension, but not when related to connective tissue disease. In this report, we describe a patient who had systemic sclerosis-related pulmonary arterial hypertension with a positive acute vasoreactivity test result. The patient was placed on calcium channel blocker monotherapy that has been well tolerated for 12 years, resulting in improved symptoms and exercise capacity. The long-term response to calcium channel blocker therapy in systemic sclerosis-associated pulmonary arterial hypertension has not been previously described. In addition, pulmonary artery pressures have been well controlled. The absence of genetic smooth muscle variants prevalent in vasoresponsive idiopathic pulmonary arterial hypertension is also unique.
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Key Words
- AVT, acute vasoreactivity testing
- CCB, calcium channel blocker
- CREST, calcinosis cutis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia
- CTD, connective tissue disease
- PAH, pulmonary arterial hypertension
- PAOP, pulmonary arterial occlusion pressure
- PVR, pulmonary vascular resistance
- RHC, right heart catherization
- SSc, systemic sclerosis
- TTE, transthoracic echocardiogram
- mPAP, mean pulmonary arterial pressure
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Affiliation(s)
- Scott A Helgeson
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | | | - John E Moss
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | - Jennifer M Gass
- Department of Laboratory Genetics and Genomics, Greenwood Genetic Center, SC
| | - Tonya K Zeiger
- Department of Pulmonary Medicine, Mayo Clinic, Jacksonville, FL
| | - Charles D Burger
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL
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28
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Mira-Avendano I, Abril A, Burger CD, Dellaripa PF, Fischer A, Gotway MB, Lee AS, Lee JS, Matteson EL, Yi ES, Ryu JH. Interstitial Lung Disease and Other Pulmonary Manifestations in Connective Tissue Diseases. Mayo Clin Proc 2019; 94:309-325. [PMID: 30558827 DOI: 10.1016/j.mayocp.2018.09.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/24/2018] [Accepted: 09/17/2018] [Indexed: 12/22/2022]
Abstract
Lung involvement in connective tissue diseases is associated with substantial morbidity and mortality, most commonly in the form of interstitial lung disease, and can occur in any of these disorders. Patterns of interstitial lung disease in patients with connective tissue disease are similar to those seen in idiopathic interstitial pneumonias, such as idiopathic pulmonary fibrosis. It may be difficult to distinguish between the 2 ailments, particularly when interstitial lung disease presents before extrapulmonary manifestations of the underlying connective tissue disease. There are important clinical implications in achieving this distinction. Given the complexities inherent in the management of these patients, a multidisciplinary evaluation is needed to optimize the diagnostic process and management strategies. The aim of this article was to summarize an approach to diagnosis and management based on the opinion of experts on this topic.
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Affiliation(s)
- Isabel Mira-Avendano
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, FL.
| | - Andy Abril
- Division of Rheumatology, Mayo Clinic, Jacksonville, FL
| | - Charles D Burger
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, FL
| | - Paul F Dellaripa
- Division of Rheumatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Aryeh Fischer
- Department of Medicine, University of Colorado, Denver, Aurora, CO
| | - Michael B Gotway
- Division of Cardiothoracic Radiology, Mayo Clinic, Scottsdale, AZ
| | - Augustine S Lee
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, FL
| | - Joyce S Lee
- Department of Medicine, University of Colorado, Denver, Aurora, CO
| | - Eric L Matteson
- Center for Clinical and Translational Science, Mayo Clinic, Rochester, MN
| | - Eunhee S Yi
- Division of Anatomic Pathology, Mayo Clinic, Rochester, MN
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
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Abstract
Lymphangioleiomyomatosis (LAM) is a rare disease associated with cystic lung destruction and abdominal tumors, including lymphangioleiomyomas, which frequently occur in the retroperitoneal region. Sirolimus therapy is currently recommended for LAM patients with abnormal or declining lung function with an adjusted dose to maintain a serum trough level of 5–15 ng/mL. We describe a significant reduction of retroperitoneal lymphangioleiomyomas after treatment with low-dose sirolimus therapy (serum trough level <5 ng/mL) in a patient with sporadic LAM.
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Affiliation(s)
- Kamonpun Ussavarungsi
- Division of Pulmonary and Critical Care, Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - Archana T Laroia
- Division of Cardiovascular and Pulmonary Imaging, Department of Radiology, University of Iowa, Iowa City, IA, USA
| | - Charles D Burger
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
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30
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Krencz I, Sebestyen A, Papay J, Jeney A, Hujber Z, Burger CD, Keller CA, Khoor A. In situ analysis of mTORC1/2 and cellular metabolism-related proteins in human Lymphangioleiomyomatosis. Hum Pathol 2018; 79:199-207. [PMID: 29885404 DOI: 10.1016/j.humpath.2018.05.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 05/11/2018] [Accepted: 05/24/2018] [Indexed: 10/14/2022]
Abstract
Lymphangioleiomyomatosis (LAM) is a rare progressive cystic lung disease with features of a low-grade neoplasm. It is primarily caused by mutations in TSC1 or TSC2 genes. Sirolimus, an inhibitor of mTOR complex 1 (mTORC1), slows down disease progression in some, but not all patients. Hitherto, other potential therapeutic targets such as mTOR complex 2 (mTORC2) and various metabolic pathways have not been investigated in human LAM tissues. The aim of this study was to assess activities of mTORC1, mTORC2 and various metabolic pathways in human LAM tissues through analysis of protein expression. Immunohistochemical analysis of p-S6 (mTORC1 downstream protein), Rictor (mTORC2 scaffold protein) as well as GLUT1, GAPDH, ATPB, GLS, MCT1, ACSS2 and CPT1A (metabolic pathway markers) were performed on lung tissue from 11 patients with sporadic LAM. Immunoreactivity was assessed in LAM cells with bronchial smooth muscle cells as controls. Expression of p-S6, Rictor, GAPDH, GLS, MCT1, ACSS2 and CPT1A was significantly higher in LAM cells than in bronchial smooth muscle cells (P<.01). No significant differences were found between LAM cells and normal bronchial smooth muscle cells in GLUT1 and ATPB expression. The results are uniquely derived from human tissue and indicate that, in addition to mTORC1, mTORC2 may also play an important role in the pathobiology of LAM. Furthermore, glutaminolysis, acetate utilization and fatty acid β-oxidation appear to be the preferred bioenergetic pathways in LAM cells. mTORC2 and these preferred bioenergetic pathways appear worthy of further study as they may represent possible therapeutic targets in the treatment of LAM.
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Affiliation(s)
- Ildiko Krencz
- 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, H-1085 Budapest, Hungary
| | - Anna Sebestyen
- 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, H-1085 Budapest, Hungary
| | - Judit Papay
- 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, H-1085 Budapest, Hungary
| | - Andras Jeney
- 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, H-1085 Budapest, Hungary
| | - Zoltan Hujber
- 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, H-1085 Budapest, Hungary
| | - Charles D Burger
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
| | - Cesar A Keller
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic, Jacksonville, FL 32224, United States; Division of Transplant Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
| | - Andras Khoor
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Jacksonville, FL 32224, United States.
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Helgeson SA, Imam JS, Moss JE, Hodge DO, Burger CD. Comparison of Brain Natriuretic Peptide Levels to Simultaneously Obtained Right Heart Hemodynamics in Stable Outpatients with Pulmonary Arterial Hypertension. Diseases 2018; 6:diseases6020033. [PMID: 29723983 PMCID: PMC6023321 DOI: 10.3390/diseases6020033] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Revised: 04/21/2018] [Accepted: 04/27/2018] [Indexed: 11/16/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a progressive disease that requires validated biomarkers of disease severity. While PAH is defined hemodynamically by right heart catheterization (RHC), brain natriuretic peptide (BNP) is recommended by guidelines to assess disease status. Retrospectively collected data in 138 group 1 PAH patients were examined for the correlation of BNP levels to simultaneously obtained right heart catheterization (RHC). Patients were mostly Caucasian women, with functional class III symptoms, mean BNP of 406 ± 443 pg/mL, and an average right atrial pressure (RAP) of 9.9 ± 5.7 mm Hg and mean pulmonary artery pressure (mPAP) of 47.3 ± 14.7 mm Hg. Significant correlation was demonstrated between BNP and RAP (p = 0.021) and mPAP (p = 0.003). Additional correlation was seen with right heart size on echocardiography: right atrial (RAE; p = 0.04) and right ventricular enlargement (p = 0.03). An increased BNP level was an independent predictor of mortality (p < 0.0001), along with RAP (p = 0.039) and RAE (p = 0.018). Simultaneous collection of BNP at the time of RHC confirmed the correlation of BNP with right heart hemodynamics. The current results reinforce the use of BNP level as a continuous variable to assess disease severity in group 1 PAH.
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Affiliation(s)
- Scott A Helgeson
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL 32224, USA.
| | - J Saadi Imam
- Department of Pulmonary & Critical Care Medicine, The University of Texas Medical Branch, Galveston, TX 77555, USA.
| | - John E Moss
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL 32224, USA.
| | - David O Hodge
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL 32224, USA.
| | - Charles D Burger
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL 32224, USA.
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Batton KA, Austin CO, Bruno KA, Burger CD, Shapiro BP, Fairweather D. Sex differences in pulmonary arterial hypertension: role of infection and autoimmunity in the pathogenesis of disease. Biol Sex Differ 2018; 9:15. [PMID: 29669571 PMCID: PMC5907450 DOI: 10.1186/s13293-018-0176-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 04/09/2018] [Indexed: 01/14/2023] Open
Abstract
Registry data worldwide indicate an overall female predominance for pulmonary arterial hypertension (PAH) of 2–4 over men. Genetic predisposition accounts for only 1–5% of PAH cases, while autoimmune diseases and infections are closely linked to PAH. Idiopathic PAH may include patients with undiagnosed autoimmune diseases based on the relatively high presence of autoantibodies in this group. The two largest PAH registries to date report a sex ratio for autoimmune connective tissue disease-associated PAH of 9:1 female to male, highlighting the need for future studies to analyze subgroup data according to sex. Autoimmune diseases that have been associated with PAH include female-dominant systemic sclerosis, systemic lupus erythematosus, rheumatoid arthritis, Sjögren’s syndrome, and thyroiditis as well as male-dominant autoimmune diseases like myocarditis which has been linked to HIV-associated PAH. The sex-specific association of PAH to certain infections and autoimmune diseases suggests that sex hormones and inflammation may play an important role in driving the pathogenesis of disease. However, there is a paucity of data on sex differences in inflammation in PAH, and more research is needed to better understand the pathogenesis underlying PAH in men and women. This review uses data on sex differences in PAH and PAH-associated autoimmune diseases from registries to provide insight into the pathogenesis of disease.
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Affiliation(s)
- Kyle A Batton
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, USA
| | | | - Katelyn A Bruno
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Charles D Burger
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Brian P Shapiro
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - DeLisa Fairweather
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, USA.
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Burger CD, Ozbay AB, Lazarus HM, Riehle E, Montejano LB, Lenhart G, White RJ. Treatment Patterns and Associated Health Care Costs Before and After Treatment Initiation Among Pulmonary Arterial Hypertension Patients in the United States. J Manag Care Spec Pharm 2018; 24:834-842. [PMID: 29436260 PMCID: PMC10398102 DOI: 10.18553/jmcp.2018.17391] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Despite multiple treatment options, the prognosis of pulmonary arterial hypertension (PAH) remains poor. PAH patients experience a high economic burden due to comorbidities, hospitalizations, and medication costs. Although combination therapy has been shown to reduce hospitalizations, the relationship between treatment, health care utilization, and costs remains unclear. OBJECTIVE To provide a characterization of health care utilization and costs in real-world settings by comparing periods before and after initiating PAH-specific treatment. METHODS This retrospective study identified PAH patients in the Truven Health MarketScan Commercial and Medicare Supplemental Databases between 2010 and 2014 who initiated treatment with endothelin receptor antagonists (ERAs), phosphodiesterase-5 inhibitors (PDE-5Is), or soluble guanylate cyclase (sGC) stimulators. The index date was the date of the first PAH pharmacy claim. We included patients with ≥ 2 medical claims with diagnoses for PAH (ICD-9-CM: 416.0, 416.8) or PAH-related conditions and continuous enrollment in medical and pharmacy benefits for the 6 months before and after the index date. Treatment patterns were assessed at the drug class level (ERAs, PDE-5Is, sGC stimulators, and prostacyclins) from outpatient pharmacy claims during the 6-month post-index period. All-cause and PAH-related utilization and costs were measured. McNemar's and paired t-tests were used to compare patients' health care resource utilization and costs in the 6-month pre- and posttreatment periods. RESULTS A total of 3,908 patients met the selection criteria. The study sample was 63% female with a mean age of 63 ± 15 years. Only 5% of patients began initial combination therapy for PAH, defined as claims for ≥ 2 medication classes within the first 30 days of treatment. Treatment interruption (≥ 30-day gap in days supply) of any PAH-specific medication was observed in 38% of patients. Compared with the 6-month pre-index period, the proportion of patients in the 6-month post-index period with any inpatient admission decreased, 42% versus 30% (P < 0.001). In addition, PAH-related inpatient admissions decreased in the 6-month post-index period from 7% to 3% (P < 0.001). After treatment initiation, patients' nonpharmacy medical costs decreased from $48,200 (SD = $117,686) to $33,962 (SD = $90,294; P < 0.001), mainly attributable to reduced inpatient costs. However, total average medical costs including pharmacy costs remained comparable after treatment initiation (pre-index period = $51,455 vs. post-index period = $53,923; P = 0.213). CONCLUSIONS This study found that while patients' PAH-related pharmacy costs increased after treatment initiation, the increase was offset by reduced inpatient utilization; therefore, total health care costs remained constant. While the majority of patients in this study were treated with monotherapy, the recently completed AMBITION study indicated that initial combination therapy with ambrisentan plus tadalafil reduced PAH-related hospitalizations compared with initial monotherapy with either of these agents. Future cost analyses of patients treated with combination therapy will be required to determine the economic effect of initial combination therapy. DISCLOSURES This study was sponsored and funded by Gilead Sciences. Ozbay is an employee of Gilead Sciences. At the time that this project and manuscript were developed, Lazarus was an employee of Gilead Sciences and may own stock/stock options. Riehle, Montejano, and Lenhart are employees of Truven Health Analytics, an IBM company, which received funding from Gilead Sciences to conduct this study. Burger and White do research with, and are paid consultants for, Gilead Sciences; they do not own equity and received no personal compensation for the work here. Burger also reports consultancy and advisory board work for Actelion Pharmaceuticals and grants from Gilead Sciences, Actelion Pharmaceuticals, Bayer, and United Therapeutics.
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Affiliation(s)
| | | | | | - Ellen Riehle
- 4 Truven Health Analytics, an IBM company, Ann Arbor, Michigan
| | | | - Gregory Lenhart
- 4 Truven Health Analytics, an IBM company, Ann Arbor, Michigan
| | - R James White
- 2 University of Rochester Medical Center; Rochester, New York
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Díaz-Gómez JL, Ripoll JG, Mira-Avendano I, Moss JE, Divertie GD, Frank RD, Burger CD. Multidisciplinary Perioperative Management of Pulmonary Arterial Hypertension in Patients Undergoing Noncardiac Surgery. South Med J 2018; 111:64-73. [DOI: 10.14423/smj.0000000000000755] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Burger CD, Pruett JA, Lickert CA, Berger A, Murphy B, Drake W. Prostacyclin Use Among Patients with Pulmonary Arterial Hypertension in the United States: A Retrospective Analysis of a Large Health Care Claims Database. J Manag Care Spec Pharm 2017; 24:291-302. [PMID: 29406840 PMCID: PMC10397685 DOI: 10.18553/jmcp.2017.17228] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Prostacyclins play an important role in the management of pulmonary arterial hypertension (PAH). Intravenous prostacyclin was the first disease-specific treatment for patients with PAH. Subcutaneous and nonparenteral (oral or inhaled) formulations have subsequently become available. However, data are lacking on how these different prostacyclin formulations are being used in clinical practice. OBJECTIVES To (a) conduct retrospective analyses of a large U.S. health care claims database to describe the characteristics of patients with PAH initiating prostacyclin therapy, and (b) evaluate their treatment patterns, health care resource use, and associated costs. METHODS Truven Commercial and Medicare databases were used to define annual cohorts of adults with PAH between January 1, 2010, and October 31, 2015. These patients were identified based on claims with ICD-9-CM diagnoses indicative of PAH (codes 416.0 or 416.8) and claims for PAH-specific medications and PAH-related procedures. Patients with evidence of receiving a prostacyclin were identified, and prostacyclin use was categorized as parenteral versus nonparenteral. Health care costs were assessed alternatively employing an all-cause and PAH-related perspective. RESULTS Of 13,633 adults with identified PAH, 3,006 (22.0%) received a prostacyclin during at least 1 year of the study period, and annual prevalence of prostacyclin use ranged from 19.9% to 22.6%. Across calendar years, the median age of prostacyclin users ranged from 56 to 58 years, and 71.9%-75.8% were female. Among prostacyclin users, parenteral prostacyclin use declined from 63.2% in 2010 to 46.5% in 2015, while use of nonparenteral prostacyclins increased from 39.7% to 56.2% over the same period (both P < 0.001). Few patients (2.7%-4.1%) received both parenteral and nonparenteral formulations in a given calendar year. Among patients using prostacyclins, receipt of other PAH-specific medications increased from 62.1% in 2010 to 79.2% in 2015. Comparing the 6 months preceding the first prostacyclin prescription (any formulation) to the 6 months subsequent, mean overall health care costs rose from $61,243 to $119,283, and PAH-related health care costs increased from $58,815 to $116,661, driven mainly by PAH-specific medications, spending on which increased from $15,053 to $73,705 (all P < 0.001). CONCLUSIONS While overall use of prostacyclins was relatively constant from 2010 to 2015, our findings revealed a shift from parenteral to nonparenteral formulations, coupled with increased prescribing of PAH-related medications from other drug classes. Further research is needed to better understand how these changes in patterns of prostacyclin use affect levels of health care resource utilization and costs and patients' overall quality of life. DISCLOSURES This research was funded by Actelion Pharmaceuticals US, a Janssen pharmaceutical company of Johnson & Johnson. Burger has received grant funding from Actelion, Gilead Sciences, and United Therapeutics; personal fees from Actelion and Gilead Sciences; and nonfinancial support from Actelion. Pruett, Lickert, and Drake are employees of Actelion. Pruett and Lickert own shares in Actelion. Berger and Murphy are employees of Evidera, a consultancy that received payment from Actelion to conduct this research. Pruett, Lickert, Berger, and Drake contributed to study conception and participated with Burger in study design. Lickert and Murphy performed the data analyses. Burger, Pruett, Lickert, Murphy, and Drake interpreted the data. All authors participated in manuscript drafting and/or critical revision, approved the final manuscript, and agree to be accountable for all aspects of the work.
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Affiliation(s)
| | - Janis A Pruett
- 2 Actelion Pharmaceuticals US, South San Francisco, California
| | | | | | | | - William Drake
- 2 Actelion Pharmaceuticals US, South San Francisco, California
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Burger CD, Ghandour M, Padmanabhan Menon D, Helmi H, Benza RL. Early intervention in the management of pulmonary arterial hypertension: clinical and economic outcomes. Clinicoecon Outcomes Res 2017; 9:731-739. [PMID: 29200882 PMCID: PMC5703162 DOI: 10.2147/ceor.s119117] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) has a high morbidity rate and is fatal if left untreated. Increasing evidence supports early intervention, possibly with initial combination therapy. PAH-specific pharmaceuticals, however, are expensive and may have serious adverse effects, particularly when used in combination. The currently dynamic health care economy reinforces the need for a review of early intervention from both outcomes and economic perspectives. We aimed to review the clinical and economic impact of PAH therapy, particularly examining drug cost, hospitalization burden, and health care economics impact, and the effect of early intervention on clinical outcomes. We searched PubMed, Scopus, Ovid, and MEDLINE databases from 2005 to 2017 for studies comparing drug cost, clinical outcomes, and hospitalization burden associated with therapy for PAH. Emerging data indicate that early therapy is effective, but drug therapy is expensive, particularly with combination therapy. Efficacy studies also generally show benefit of combination therapy for patients in World Health Organization functional class II, with a consistent decrease in hospitalization. Pharmacoeconomic studies are limited but indicate that increased pharmacy costs are at least partially offset by decreased health care utilization, particularly inpatient care. Modeling also shows a cost benefit with combination therapy at 2 years. Nonetheless, more rigorously collected health care economic data should be incorporated into future drug efficacy trials to provide a clearer understanding of the impact and the associated cost benefit of early PAH therapy. Increasing evidence in support of early intervention and combination therapy for PAH is associated with rising medication costs that are largely offset by reduced hospitalization, on the basis of the currently available literature. Nonetheless, the studies performed to date have methodologic limitations that highlight the need for prospective studies using more robust economic modeling.
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Affiliation(s)
| | | | | | - Haytham Helmi
- Division of Transplant Medicine and Research Administration, Mayo Clinic, Jacksonville, FL, USA
| | - Raymond L Benza
- Advanced Heart Failure, Transplant, Mechanical Circulatory Support and Pulmonary Hypertension, Allegheny Health Network, Pittsburg, PA, USA
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Rahaghi FF, Alnuaimat HM, Awdish RLA, Balasubramanian VP, Bourge RC, Burger CD, Butler J, Cauthen CG, Chakinala MM, deBoisblanc BP, Eggert MS, Engel P, Feldman J, McConnell JW, Park M, Sager JS, Sood N, Palevsky HI. Recommendations for the clinical management of patients receiving macitentan for pulmonary arterial hypertension (PAH): A Delphi consensus document. Pulm Circ 2017; 7:702-711. [PMID: 28671484 PMCID: PMC5841904 DOI: 10.1177/2045893217721695] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
In patients treated with macitentan (Opsumit®, Actelion Pharmaceuticals Ltd., Basel, Switzerland) for pulmonary arterial hypertension (PAH), prevention and/or effective management of treatment-related adverse events may improve adherence. However, management of these adverse events can be challenging and the base of evidence and clinical experience for macitentan is limited. In the absence of evidence, consensus recommendations from physicians experienced in using macitentan to treat PAH may benefit patients and physicians who are using macitentan. Consensus recommendations were developed by a panel of physicians experienced with macitentan and PAH using a modified Delphi process. Over three iterations, panelists developed and refined a series of statements on the use of macitentan in PAH and rated their agreement with each statement on a Likert scale. The panel of 18 physicians participated and developed a total of 118 statements on special populations, add-on therapy, drug–drug interactions, warnings and precautions, hospitalization and functional class, and adverse event management. The resulting consensus recommendations are intended to provide practical guidance on real-world issues in using macitentan to treat patients with PAH.
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Affiliation(s)
| | | | | | | | - Robert C Bourge
- 5 The University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | | | | | | | | | - Peter Engel
- 12 Ohio Heart & Vascular Center; The Christ Hospital, Cincinnati OH, USA
| | | | | | - Myung Park
- 15 Houston Methodist Hospital, Houston, TX, USA
| | - Jeffrey S Sager
- 16 Cottage Pulmonary Hypertension Center, Santa Barbara, CA, USA
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Bajwa AA, Shujaat A, Patel M, Thomas C, Rahaghi F, Burger CD. The safety and tolerability of inhaled treprostinil in patients with pulmonary hypertension and chronic obstructive pulmonary disease. Pulm Circ 2017; 7:82-88. [PMID: 28680567 PMCID: PMC5448530 DOI: 10.1086/689291] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 08/29/2016] [Indexed: 12/31/2022] Open
Abstract
The primary aim was to explore the safety and tolerability of inhaled treprostinil when used in patients with pulmonary hypertension (PH) with concomitant chronic obstructive pulmonary disease (COPD). Patients with a diagnosis of pre-capillary PH (defined as pulmonary artery mean pressure of ≥ 25 mmHg and pulmonary artery wedge pressure or left ventricular end diastolic pressure of ≤ 15 mmHg) who were being initiated on inhaled treprostinil and had concomitant COPD (defined as FEV1/FVC ratio ≤ 70% with FEV1 ≥ 40% predicted) were considered for inclusion in this pilot study. Assessments included adverse events, physical exam, World Health Organization (WHO) functional class, 6-minute walk test (6MWT), modified Borg dyspnea score, and concomitant medication. At baseline and week 16 St. George’s Respiratory Questionnaire (SGRQ), arterial blood gas (ABG), and pulmonary function test (PFT) were assessed. The median age was 65 years (age range, 56–80 years) and five patients (56%) were men. Among the nine patients, a majority had an increase in 6MWT from baseline to week 16 (median change, 19 m). Only three of the nine patients (33%) had an increase in A-a gradient at week 16 (median change, –7). There was no difference in any of the following: arterial blood gases, WHO functional class, 6MWT results, or SGRQ scores from baseline to week 16. There was a statistically significant decline in several of the PFT measures, including FEV1 (median change, –0.18 L; P = 0.004; median change, –7% of predicted; P = 0.016), FVC (median change, –0.23 L; P = 0.027), and diffusion capacity for carbon monoxide (DLCO) (median change, –5% of predicted; P = 0.023). The small number of patients limits firm conclusions; however, inhaled treprostinil did not seem to adversely impact oxygenation in the majority of the study patients with pre-capillary PH and COPD. While there may have an adverse impact on some pulmonary function parameters, the clinical significance is unclear.
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Affiliation(s)
- Abubakr A Bajwa
- University of Florida College of Medicine, Jacksonville, FL, USA
| | - Adil Shujaat
- University of Florida College of Medicine, Jacksonville, FL, USA
| | - Minal Patel
- University of Florida College of Medicine, Jacksonville, FL, USA
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Ussavarungsi K, Lee AS, Burger CD. Can a Six-Minute Walk Distance Predict Right Ventricular Dysfunction in Patients with Diffuse Parenchymal Lung Disease and Pulmonary Hypertension? Oman Med J 2016; 31:345-51. [PMID: 27602188 DOI: 10.5001/omj.2016.69] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Pulmonary hypertension (PH) is commonly observed in patients with diffuse parenchymal lung disease (DPLD). The purpose of this study was to explore the influence of the 6-minute walk test (6MWT) as a simple, non-invasive tool to assess right ventricular (RV) function in patients with DPLD and to identify the need for an echocardiogram (ECHO) to screen for PH. METHODS We retrospectively reviewed 48 patients with PH secondary to DPLD, who were evaluated in the PH clinic at the Mayo Clinic in Jacksonville, Florida, from January 1999 to December 2014. RESULTS Fifty-two percent of patients had RV dysfunction. They had a significantly greater right heart pressure by ECHO and mean pulmonary arterial pressure (MPAP) from right heart catheterization (RHC) than those with normal RV function. A reduced 6-minute walk distance (6MWD) did not predict RV dysfunction (OR 0.995; 95% CI 0.980-1.001, p = 0.138). In addition, worsening restrictive physiology, heart rate at one-minute recovery and desaturation were not different between patients with and without RV dysfunction. However, there were inverse correlations between 6MWD and MPAP from RHC (r = -0.41,
p = 0.010), 6MWD and RV systolic pressure (r = -0.51, p < 0.001), and 6MWD and MPAP measured by ECHO (r = -0.46, p =0.013). We also found no significant correlation between 6MWD and pulmonary function test parameters. CONCLUSIONS Our single-center cohort of patients with PH secondary to DPLD, PH was found to have an impact on 6MWD. In contrast to our expectations, 6MWD was not useful to predict RV dysfunction. Interestingly, a severe reduction in the 6MWD was related to PH and not to pulmonary function; therefore, it may be used to justify an ECHO to identify patients with a worse prognosis.
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Pinkstaff SO, Burger CD, Daugherty J, Bond S, Arena R. Cardiopulmonary exercise testing in patients with pulmonary hypertension: clinical recommendations based on a review of the evidence. Expert Rev Respir Med 2016; 10:279-95. [DOI: 10.1586/17476348.2016.1144475] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Burger CD, D'Albini L, Raspa S, Pruett JA. The evolution of prostacyclins in pulmonary arterial hypertension: from classical treatment to modern management. Am J Manag Care 2016; 22:S3-S15. [PMID: 26885569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Prostacyclins for the treatment of pulmonary arterial hypertension (PAH) have historically been covered under the insurance medical benefit because they require durable medical equipment and are administered by an intravenous, subcutaneous, or inhalation route. However, more treatment options that target the prostacyclin pathway have become available. As the number and type of options expand, an improved understanding of these drugs will aid managed care decision makers in evaluating new treatment options and making clinically sound and cost-effective treatment decisions. PAH is a progressive disease of pulmonary vascular remodeling that increases pulmonary vascular resistance and often results in right-side heart failure and death if left untreated. Adverse event profiles, the complexity of administration modalities, and potential complications must be considered when administering prostacyclin therapy. Traditional modes of administration, with their potential challenges and complications, may have contributed to the unmet need for an oral agent. Another consideration for managed care decision makers is that oral agents are generally covered under the insurance pharmacy benefit. Access to oral medications with long-term outcomes data, as well as the improved convenience of oral therapy, may help patients with PAH maximize function by maintaining a more convenient and consistent therapeutic regimen.
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Ussavarungsi K, Thomas CS, Burger CD. Prevalence of metabolic syndrome in patients with pulmonary hypertension. Clin Respir J 2015; 11:721-726. [PMID: 26493968 DOI: 10.1111/crj.12406] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 09/24/2015] [Accepted: 10/17/2015] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND AIMS To determine the prevalence of metabolic syndrome (MetS) - a potential phenotypical risk for pulmonary hypertension (PH) - in patients with PH and by PH diagnostic group including group 1 pulmonary arterial hypertension (PAH); group 1.1 idiopathic PAH, groups 1.2 heritable PAH, 1.3 drug and toxin induced, 1.4 associated PAH, group 2 PH with left heart disease, group 3 PH associated with lung disease and/or hypoxemia, group 4 PH owing to chronic thrombotic and/or embolic disease, and group 5 PH from multifactorial mechanisms. METHODS We conducted a retrospective chart review of patients referred to Mayo Clinic in Florida from January 1990 to October 2013 (N = 1287). Only patients whom PH was confirmed by right heart catheterization were included (N = 640). MetS was defined with at least three of the following: systemic hypertension, diabetes mellitus, hyperlipidemia and body mass index > 30. RESULTS MetS was prevalent in 247 of 640 (39%) with PH: 13% in group 1.1 PAH, 12% in groups 1.2-1.4 PAH, 54% in group 2, 55% in group 3, 23% in group 4 and 24% in group 5. After adjusting for age, sex and race, diagnostic subgroup analysis revealed a higher prevalence of MetS in WHO Group 2 PH patients [adjusted odd ratios (OR): 2.58, P < 0.0001] and WHO group 3 PH (adjusted OR: 2.77, P < 0.0001) when compared to group 1 PH. CONCLUSION The prevalence of MetS was observed in 39% of patients with PH; however, among PH patients, the prevalence was higher in group 2 and 3 PH.
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Affiliation(s)
| | - Colleen S Thomas
- Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL, USA
| | - Charles D Burger
- Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA
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Ussavarungsi K, Lee AS, Burger CD. Mosaic Pattern of Lung Attenuation on Chest CT in Patients with Pulmonary Hypertension. Diseases 2015; 3:205-212. [PMID: 28943620 PMCID: PMC5548246 DOI: 10.3390/diseases3030205] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 08/21/2015] [Accepted: 09/02/2015] [Indexed: 11/17/2022] Open
Abstract
A mosaic pattern of lung attenuation on chest computed tomography (CT) may be due to various etiologies. There is limited published data on CT results when used to evaluate pulmonary hypertension (PH). We retrospectively studied the frequency of mosaic pattern in patients with PH and the cause of the PH by diagnostic group, as well as the correlation between the mosaic pattern and the following: demographics, severity of the PH, main pulmonary artery (PA) size, PA/aorta (PA/Ao) ratio, pulmonary function tests (PFT), and ventilation perfusion scan results. Overall, 18% of the cohort had CT mosaic pattern (34/189). Mosaic pattern was present in 17/113 (15%) in Group 1 pulmonary arterial hypertension, 5/13 (28%) in Group 2 pulmonary venous hypertension and 8/50 (16%) in Group 3 PH. Conversely, Group 4 chronic thromboembolic PH was more prevalent in 4/8 (50%). Main PA size, PA/Ao ratio, and segmental perfusion defect were positively associated with mosaic pattern. In contrast, factors such as age, gender, body mass index, functional class, hemodynamic data, and PFT values were not associated with mosaic pattern. Mosaic pattern is not specific as an isolated finding for distinguishing the subtype of PH.
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Affiliation(s)
- Kamonpun Ussavarungsi
- Pulmonary and Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
| | - Augustine S Lee
- Pulmonary and Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
| | - Charles D Burger
- Pulmonary and Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
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Ussavarungsi K, Hu X, Scott JP, Erasmus DB, Mallea JM, Alvarez F, Lee AS, Keller CA, Ryu JH, Burger CD. Mayo clinic experience of lung transplantation in pulmonary lymphangioleiomyomatosis. Respir Med 2015; 109:1354-9. [PMID: 26321137 DOI: 10.1016/j.rmed.2015.08.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 08/13/2015] [Accepted: 08/20/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Lymphangioleiomyomatosis (LAM) is a rare, cystic lung disease that generally results in progressive decline in lung function. Despite advancement of pharmacological therapy for LAM, lung transplantation remains an important option for women with end-stage LAM. METHODS Patients with LAM undergoing lung transplantation at the Mayo Clinic campuses in Rochester, Minnesota and Jacksonville, Florida since 1995 were retrospectively reviewed. RESULTS Overall, 12 women underwent lung transplantation. Nine of 12 (75%) underwent double lung transplant. The mean age was 42 ± 8 years at the time of transplant. One patient (8%) had a chylothorax and 7 (58%) had recurrent pneumothoraces, 4 (33%) of which required pleurodesis. All had diffuse, cystic lung disease on chest CT consistent with LAM which was confirmed in the explant of all patients. The average length of ICU and hospital stays were 5 ± 4 and 19 ± 19 days, respectively. Mild to moderate anastomotic ischemia was evident in all patients but resolved with time. No patient was treated with sirolimus pre-transplant. Seven patients received sirolimus post-transplant; however, clinical benefit was documented in only 2 patients, 1 of which was treated for large retroperitoneal cysts with ureteral obstruction and another with persistent chylothorax and retroperitoneal lymphangioleimyomas. Five patients are deceased. The median survival by Kaplan-Meier analysis was 119 months with a median follow-up of 68 months (range 2-225 months). CONCLUSIONS Lung transplant remains a viable treatment for patients with end-stage LAM. The role of sirolimus peri-transplantation remains ill-defined.
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Affiliation(s)
- Kamonpun Ussavarungsi
- Pulmonary and Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
| | - Xiaowen Hu
- Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55901, USA.
| | - J P Scott
- Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55901, USA.
| | - David B Erasmus
- Transplant Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
| | - Jorge M Mallea
- Transplant Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
| | - Francisco Alvarez
- Transplant Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
| | - Augustine S Lee
- Pulmonary and Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
| | - Cesar A Keller
- Transplant Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
| | - Jay H Ryu
- Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55901, USA.
| | - Charles D Burger
- Pulmonary and Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
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Gupta N, Meraj R, Tanase D, James LE, Seyama K, Lynch DA, Akira M, Meyer CA, Ruoss SJ, Burger CD, Young LR, Almoosa KF, Veeraraghavan S, Barker AF, Lee AS, Dilling DF, Inoue Y, Cudzilo CJ, Zafar MA, McCormack FX. Accuracy of chest high-resolution computed tomography in diagnosing diffuse cystic lung diseases. Eur Respir J 2015; 46:1196-9. [PMID: 26160866 DOI: 10.1183/13993003.00570-2015] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 05/06/2015] [Indexed: 11/05/2022]
Affiliation(s)
- Nishant Gupta
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Riffat Meraj
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Daniel Tanase
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Laura E James
- Research Dept, Shriners Hospital for Children - Cincinnati, Cincinnati, OH, USA
| | - Kuniaki Seyama
- Dept of Respiratory Medicine, Juntendo University, Tokyo, Japan
| | - David A Lynch
- Dept of Radiology, National Jewish Health, Denver, CO, USA
| | - Masanori Akira
- Dept of Radiology, National Kinki-Chuo Chest Medical Center, Osaka, Japan
| | | | - Stephen J Ruoss
- Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Charles D Burger
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Lisa R Young
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Khalid F Almoosa
- Division of Critical Care Medicine, University of Texas Health Science Center, Houston, TX, USA
| | - Srihari Veeraraghavan
- Division of Pulmonary, Allergy and Critical Care, Emory University School of Medicine, Atlanta, GA, USA
| | - Alan F Barker
- Division of Pulmonary and Critical Care, Oregon Health and Science University, Portland, OR, USA
| | - Augustine S Lee
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA
| | | | - Yoshikazu Inoue
- Dept of Diffuse Lung Diseases and Respiratory Failure, National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka, Japan
| | - Corey J Cudzilo
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Muhammad A Zafar
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Francis X McCormack
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
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Burger CD, Long PK, Shah MR, McGoon MD, Miller DP, Romero AJ, Benton WW, Safford RE. Characterization of first-time hospitalizations in patients with newly diagnosed pulmonary arterial hypertension in the REVEAL registry. Chest 2015; 146:1263-1273. [PMID: 24901386 PMCID: PMC4219341 DOI: 10.1378/chest.14-0193] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Hospitalization is an important outcome in pulmonary arterial hypertension (PAH), shown previously to correlate with survival. Using the Registry to Evaluate Early and Long-term PAH Disease Management (REVEAL Registry), we sought to characterize first-time hospitalizations and their effect on subsequent hospitalization and survival in patients with newly diagnosed disease. METHODS Patients with newly diagnosed PAH (n = 862, World Health Organization group 1) were evaluated for first-time hospitalization. The hospitalizations were categorized as PAH related or PAH unrelated based on the case report form. Categories for PAH-related and PAH-unrelated hospitalization were defined before independent review. Patient demographics and disease characteristics are described as well as freedom from hospitalization and survival. RESULTS Of 862 patients, 490 (56.8%) had one or more hospitalizations postenrollment: 257 (52.4%) PAH related, 214 (43.7%) PAH unrelated, and 19 (3.9%) of undetermined causes. The most common causes of PAH-related hospitalization were congestive heart failure and placement/removal of a central venous catheter. Patients with PAH-related hospitalizations were more likely to receive parenteral therapy, be in functional class III/IV, and have higher risk scores before hospitalization at enrollment. Following discharge, 25.4% ± 3.2% and 31.0% ± 4.0% of patients with PAH-related and PAH-unrelated first hospitalization, respectively, remained hospitalization-free for 3 years (P = .11). Survival estimates at 3 years postdischarge were 56.8% ± 3.5% and 67.8% ± 3.6% (P = .037) for patients with PAH-related and PAH-unrelated hospitalization, respectively. CONCLUSIONS In the REVEAL Registry, PAH-related hospitalization was associated with relatively more rehospitalizations and worse survival at 3 years. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT00370214; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Charles D Burger
- From the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL.
| | - Pamela K Long
- Department of Clinical Research, Mayo Clinic, Jacksonville, FL
| | | | | | | | - Alain J Romero
- Actelion Pharmaceuticals US, Inc, South San Francisco, CA
| | - Wade W Benton
- Actelion Pharmaceuticals US, Inc, South San Francisco, CA
| | - Robert E Safford
- Division of Cardiovascular Diseases, Mayo Clinic, Jacksonville, FL
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Ussavarungsi K, Burger CD. Pulmonary arterial hypertension in a patient with β-thalassemia intermedia and reversal with infusion epoprostenol then transition to oral calcium channel blocker therapy: review of literature. Pulm Circ 2015; 4:520-6. [PMID: 25621166 DOI: 10.1086/677367] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 03/29/2014] [Indexed: 01/27/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a potentially life-threatening complication of thalassemia. A sexagenarian with β-thalassemia intermedia presented with new-onset dyspnea and syncope. Right heart catheterization confirmed severe PAH. Her functional class IV symptoms and severely elevated mean pulmonary artery pressure prompted the initiation of continuous epoprostenol therapy. Clinical follow-up documented significant improvement in functional class, 6-minute walk distance, and right ventricular size and function as well as pulmonary arterial pressure on echocardiogram. At the patient's request, epoprostenol was down-titrated and eventually discontinued. The patient was then safely transitioned to nifedipine therapy after verification of vasoresponsiveness.
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Affiliation(s)
| | - Charles D Burger
- Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, Florida, USA
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Abstract
OBJECTIVES To evaluate the utility of anti-nuclear antibody (ANA) levels in distinguishing the cause of pulmonary arterial hypertension as idiopathic (IPAH) or connective tissue disease related (CTD-PAH). METHODS We retrospectively identified patients with IPAH or CTD-PAH seen between 2010 and 2012 at our institution. Medical records were reviewed for demographic and clinical data and laboratory values. RESULTS Of 115 patients identified, 65 (56%) had IPAH and 50 (44%) had CTD-PAH. The mean age was 59 years and most of the patients (76%) were women. Most patients (64%) were in World Health Organization functional class III or IV. Compared with the IPAH group, the CTD-PAH group had significantly increased B-type natriuretic peptide levels (635 vs 325 pg/mL; P = 0.02) and decreased pulmonary vascular resistance (6 vs 9 WU; P = 0.04). The median ANA level was significantly higher in the CTD-PAH group than the IPAH group (7 vs 0 U; P < 0.001). The area under the receiver operating characteristic curve for a positive ANA to predict CTD-PAH was 0.91 (P < 0.001). A cutoff of 5 U for predicting ANA provided an optimal specificity of 94% and a sensitivity of 70%. The resulting likelihood ratio using the same cutoff was 12 (P < 0.001), or a positive predictive value of 91% with a negative predictive value of 79%. CONCLUSIONS In this selected cohort of patients, a quantitative ANA value >5 U may be useful in distinguishing CTD-PAH from IPAH, but a lower level does not confidently exclude CTD-PAH.
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Affiliation(s)
- Ricardo J Pagán
- From the Department of Internal Medicine, Division of Pulmonary and Allergy Medicine, and Department of Critical Care, Mayo Clinic, Jacksonville, Florida
| | - Augustine S Lee
- From the Department of Internal Medicine, Division of Pulmonary and Allergy Medicine, and Department of Critical Care, Mayo Clinic, Jacksonville, Florida
| | - Christopher O Austin
- From the Department of Internal Medicine, Division of Pulmonary and Allergy Medicine, and Department of Critical Care, Mayo Clinic, Jacksonville, Florida
| | - Charles D Burger
- From the Department of Internal Medicine, Division of Pulmonary and Allergy Medicine, and Department of Critical Care, Mayo Clinic, Jacksonville, Florida
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Abstract
Purpose: Among phosphodiesterase type 5 inhibitors, tadalafil offers clinicians a once-daily alternative to 3 times daily sildenafil for the treatment of pulmonary arterial hypertension (PAH). This study assessed the safety and patient satisfaction with conversion from sildenafil to tadalafil. Methods: In this multicenter, prospective, 6-month study, patients with PAH were instructed to take their last dose of sildenafil in the evening and initiate tadalafil 40 mg/d the next morning. Patients completed the Treatment Satisfaction Questionnaire for Medication at baseline and 30, 90, and 180 days after transition to assess PAH symptoms and patient satisfaction. Safety was assessed on the basis of recorded adverse events (AEs). Results: Of the 35 patients who met the study criteria, 56% were receiving ≥2 PAH therapies. At the time of transition, the sildenafil dose ranged from 40 to 300 mg/d, with 20% of the patients on >20 mg of sildenafil 3 times daily. Transition to tadalafil was generally well tolerated, and the incidence of common AEs, except for myalgia, appeared to decrease over time on tadalafil therapy. Five (14%) patients switched back to sildenafil. A greater percentage of patients were satisfied than were dissatisfied after conversion to tadalafil (55% vs 19% at 90 days), while 26% felt about the same degree of satisfaction. Conversion to tadalafil resulted in significant improvement in patient ratings of therapy convenience. Conclusions: Transition of patients from sildenafil to tadalafil was usually well tolerated, with improved convenience and may enhance treatment satisfaction.
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Affiliation(s)
- Robert P. Frantz
- Division of Cardiovascular Diseases, College of Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | - Ronald J. Oudiz
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Robert C. Bourge
- Cardiovascular Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Veronica Franco
- Cardiovascular Medicine, Ohio State University Medical Center, Columbus, OH, USA
| | - Aaron B. Waxman
- Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Susanne McDevitt
- United Therapeutics Corporation, Research Triangle Park, NC, USA
| | - Susan Walker
- United Therapeutics Corporation, Research Triangle Park, NC, USA
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Neal JE, Lee AS, Burger CD. Submaximal exercise testing may be superior to the 6-min walk test in assessing pulmonary arterial hypertension disease severity. The Clinical Respiratory Journal 2014; 8:404-9. [DOI: 10.1111/crj.12085] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Revised: 11/01/2013] [Accepted: 12/02/2013] [Indexed: 12/01/2022]
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