Evaluation of Inhaled Alprostadil in Hospitalized Adult Patients

Abstract

Background: Intermittent inhaled alprostadil (iPGE1) may be a viable alternative to inhaled nitric oxide or epoprostenol for management of right ventricular failure, pulmonary hypertension (pHTN) or acute respiratory distress syndrome (ARDS). However, limited evidence exists regarding iPGE1 use in adults, ideal dosing strategies, or optimal use cases. Objective To describe the clinical characteristics of patients receiving iPGE1 and identify specific sub-populations warranting further research. Methods This was a single-center, retrospective, descriptive analysis of inpatients who received at least one dose of iPGE1. The primary outcome was to describe patient characteristics and alprostadil dosing strategies. Secondary outcomes included changes in respiratory support requirements, hemodynamics, and inotropic/vasoactive use. Outcomes were stratified and compared based on primary therapeutic indication (cardiac or pulmonary). Results Fifty-four patients received iPGE1 40 (75%) for pulmonary (pHTN or ARDS) and 14 (25%) for cardiac indications. There was no difference between indications in the number of patients de-escalated from level of respiratory (53% vs 57%, P = 0.76), inotropic (70% vs 57%, P = 0.39), or vasopressor support (78% vs 57%, P = 0.17). Furthermore, there was no significant improvement in cardiopulmonary parameters at multiple time intervals after iPGE1 initiation. Conclusion and Relevance This is the largest study to date on the use of intermittent iPGE1 in adults. Alprostadil was safely utilized in novel populations; however, efficacy as evaluated by clinical or surrogate endpoints could not be demonstrated and further investigation is needed to determine its potential and optimal place in therapy.

A Narrative Review on the Administration of Inhaled Prostaglandins in Critically Ill Adult Patients With Acute Respiratory Distress Syndrome

“…53 Patients receiving iEPO had a higher 90-day mortality compared with those receiving inhaled iloprost, although the study was underpowered to assess differences in mortality. 53 However, given only 48% of the patients in this analysis were diagnosed with ARDS, it lacks specificity with regards to responses to either of these agents in strictly ARDS patients, similar to Seo et al 52,53…”

“…52 There were 40 patients included with pulmonary indications, including either ARDS or pulmonary hypertension. 52 The baseline P/F ratio in the pulmonary group was 236 and there was no change in P/F ratio with the initiation of inhaled alprostadil. 52 As the pulmonary group in this analysis included patients with both pulmonary hypertension and ARDS, it may lack specificity with regards to the response to alprostadil in only ARDS patients.…”

“…52 As the pulmonary group in this analysis included patients with both pulmonary hypertension and ARDS, it may lack specificity with regards to the response to alprostadil in only ARDS patients. 52…”

“…51 In 2022, Seo et al completed a single-center retrospective descriptive analysis of patients receiving at least 1 dose of inhaled alprostadil for either pulmonary or cardiac indications. 52 There were 40 patients included with pulmonary indications, including either ARDS or pulmonary hypertension. 52 The baseline P/F ratio in the pulmonary group was 236 and there was no change in P/F ratio with the initiation of inhaled alprostadil.…”

Intervention Efficacy of Off-Label use of Alprostadil Lipid Microsphere Injection on Neurosurgical Patients: A Retrospective Before-after Study

“…Alprostadil is a stable prostaglandin E1 analogue with anti-platelet aggregation, peripheral vascular smooth muscle relaxation, anti-oxidation, endothelium protection and liver cell membrane stabilization activities [1][2][3][4][5] . Based on this, alprostadil has been used successfully for the treatment of critical leg ischemia, angiospastic disorders, Raynaud's phenomenon, diabetic peripheral neuropathy, diabetic foot, liver transplantation, etc.…”