SESSION TYPE: Critical Care Student/Resident Case Report Posters II
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Described below is the first report of peri-operative management of a patient with severe pulmonary arterial hypertension (PAH) on oral treprostinil.
CASE PRESENTATION: 68-year-old woman with long-standing, diet-pill associated PAH. She was initially diagnosed in 2004 after a 2 year history of progressive dyspnea and fluid retention; initial right heart catheterization shown in table 1. She was started on sildenafil, furosemide, aldactone, digoxin and warfarin. In 02/2008, ambrisentan was started (table 1). On 03/2008, the patient enrolled in the FREEDOM C study of oral treprostinil. She did well during the initial 16 week randomized placebo controlled portion of the study. She entered the long-term open label extension on 08/2008. In 2011 a routine colonoscopy found 3 polyps, two removed during the procedure. The third, however, located at the apendicial orifice required laparascopic surgery. She was admitted for transition to IV treprostinil in order to avoid discontinuation of the study medication during periods of NPO and the post-operative period. Figure 2 shows the strategy used in the initial PO to IV transition. The patient was monitored with a CVP and central venous oximetry per protocol for PAH patients. The patient underwent a limited right colectomy. After normalization of her arterial CO2, the patient was successfully extubated. The patient was maintained on IV treprostinil at 35ng/kg/min on day of surgery. The following morning, she tolerated a diet and transitioned to oral treprostinil (figure 2). She was discharged home in a stable condition, 30 hours after the completion of her partial colectomy. Daily phone calls and a 1 week post-discharge office visit confirmed that the patient was doing well without any prostanoid excess or PAH symptoms.
DISCUSSION: Oral treprostinil has been shown to improve six-minute walk distance in a 12-week study in treatment naive patients. Two studies in patients receiving background PAH therapy were negative. The abrupt discontinuation of Prostanoid therapy has in the past resulted in acute decline and death. If oral treprostinil is approved, we anticipate the need for IV treprostinil while patients are unable to take oral medication. For maximal absorption, oral treprostinil must be taken with food. The ability to rapidly and safely switch routes between oral and parenteral treprostinil will allow clinicians to prevent acute decompensation during such periods.
CONCLUSIONS: Until there is greater experience with the use of oral treprostinil during periods of NPO, we strongly recommend that PAH patients be admitted and managed by physicians familiar with parenteral prostanoid therapy.
1) UT-15C Treprostinil Diethanolamine Sustained Release Tablets (Oral Treprostinil)
2) FREEDOM-C: Oral Treprostinil in Combination With an Endothelin Receptor Antagonist (ERA) and/or a Phosphodiesterase-5 (PDE-5) Inhibitor for the Treatment of Pulmonary Arterial Hypertension (PAH), United Therapeutics, 2012
DISCLOSURE: Jeremy Feldman: Consultant fee, speaker bureau, advisory committee, etc.: United Therapeutics, Consultant fee, speaker bureau, advisory committee, etc.: Gilead Sciences
The following authors have nothing to disclose: Andres Borja Alvarez, Samer Ibrahim
Oral treprostinil is being studied for use in pulmonary arterial hypertension.St Joseph's Hospital and Medical Center, Phoenix, AZ