Patients with pulmonary arterial hypertension (PAH) can develop acute medical or surgical conditions requiring an urgent change in the treatment of their PAH. Both Flolan and Remodulin infusions have been shown to be efficacious for the relief of PAH symptoms. When monitoring of exact drug delivery is necessary, a subcutaneous depot of drug may not allow for optimal regulation of drug dosing. We report five PAH patients who required urgent transfer from subcutaneous infusions of Remodulin to intravenous Flolan.
Data was collected from five patients with PAH, including two abdominal transplant patients. All required urgent change of therapy from a subcutaneous to an intravenous delivery system for reasons listed in the tableSEXAGEPAH ETIOLOGYREMODULINTRANSITION REASONDOSEF36PPH3.25 yearsSepsis, low output52ngF40PPH45 daysTreatment Failure23ngF56Scleroderma3 yearsRight Heart Failure42ngF29Lupus4 monthsKidney Transplant40ngF52Hepato-pulmonary3.5 yearsLiver Transplant32ngbelow:All five patients had Remodulin discontinued for 2 hours, then intravenous Flolan was initiated at 50% of their previously stable Remodulin dose. Titration to 100% of the Remodulin dose equivalent was completed over the next 4–8 hours.
All five patients promptly stabilized on the IV Flolan regimen. Only 1 patient required a reduction in the dosing schedule and remained at a lower dose due to headache and vomiting. The first three patients required dobutamine as adjunctive therapy during their transition secondary to clinical right heart failure present at the time of admission.
Rapid transition from Remodulin, with an abdominal subcutaneous delivery system, to intavenous Flolan was accomplished without any sequelae in five patients, including two patients undergoing abdominal cadaveric organ transplantations.
PAH patients at high risk for serious medical illnesses or on active transplant lists can be managed with Remodulin therapy, with a decreased risk for central line infection that is frequently encountered with Flolan therapy. When skin perfusion and drug absorption is in question or the abdominal surface is needed for surgery, rapid transition to intravenous Flolan therapy can be done rapidly and safely.
D.L. Zwicke, United Therapeutics, Grant monies.