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Pulmonary Vascular Disease |

Rapid Inpatient Titration of Intravenous Treprostinil for Pulmonary Arterial Hypertension: Safe and Tolerable

Karim El-Kersh, MD; Kathryn Ruf, PharmD; J Shaun Smith, DO
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University of Louisville, Louisville, KY


Chest. 2014;146(4_MeetingAbstracts):838A. doi:10.1378/chest.1987360
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Abstract

SESSION TITLE: DVT/PE/Pulmonary Hypertension Posters III

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 29, 2014 at 01:30 PM - 02:30 PM

PURPOSE: To describe our experience with inpatient initiation and rapid titration of intravenous treprostinil.

METHODS: We reviewed the data of patients with pulmonary arterial hypertension (PAH) treated at our center who underwent in hospital initiation and rapid up-titration of intravenous treprostinil.

RESULTS: Seven patients were identified over a 22-month period. Four patients were female and three were male with an average age of 50. The population included four patients with idiopathic PAH, one HIV-associated PAH, one connective tissue disease-associated PAH, and one congenital heart disease-associated PAH. All patients were New York Heart Association functional class IV. Hemodynamics reflected advance function class with an average mean right atrial pressure of 11.4 mmHg, average mean pulmonary artery pressure of 62 mmHg, average pulmonary capillary wedge pressure of 11mmHg, and an average cardiac output of 4.9 L/min by thermodilution. Treprostinil was initiated at 2 ng/kg/min with subsequent up titration by 1 ng/kg/min every 6-8 hours as tolerated by side effects, with a goal dosage of 20 ng/kg/min prior to discharge .The mean maximum dose achieved was 21 ng/kg/min (range: 15-26 ng/kg/min). The average up titration interval was 7 days. Typical side effects encountered were nausea, vomiting, diarrhea, and cephalgia. Improvement in b-type natriuretic peptide, and subjective dyspnea were observed with no significant adverse hemodynamic events.

CONCLUSIONS: In patients with PAH, rapid inpatient titration of intravenous treprostinil is safe and tolerable. It can be considered an effective alternative to slow outpatient titration.

CLINICAL IMPLICATIONS: In previous treprostinil studies using standard up titration protocols over 12-week period, it was evident that relief of dyspnea with exertion was greater with more rapid dose escalations. In the initial study by Tapson et al., the mean dose of intravenous treprostinil at discharge (1 to7 days) was 5 ng/kg/min (range: 2 to 8 ng/kg/min). We achieved mean maximum dose of 21 ng/kg/min with average up titration interval of 7 days without serious adverse events. Implementation of rapid inpatient titration allows patients to potentially achieve clinical benefit earlier and provides opportunity for aggressive treatment of common side effects experienced during dose escalation.

DISCLOSURE: J Shaun Smith: Consultant fee, speaker bureau, advisory committee, etc.: united therapeutics and lung biotechnology , Consultant fee, speaker bureau, advisory committee, etc.: Bayer, Consultant fee, speaker bureau, advisory committee, etc.: Gilead, Consultant fee, speaker bureau, advisory committee, etc.: Actelion The following authors have nothing to disclose: Karim El-Kersh, Kathryn Ruf

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