The Rapid Initiation, Titration, and Transition from Intravenous to Oral Treprostinil in a Patient with Severe Pulmonary Arterial Hypertension

Abstract

In patients who require urgent initiation of pulmonary arterial hypertension medications due to disease progression, it is customary to start intravenous prostacyclin therapy, typically during a hospital admission. If there are complicating factors or relative contraindications to intravenous and subcutaneous prostanoids, oral treprostinil provides another pathway to prostanoid therapy, but this usually requires a prolonged titration. We describe the case of a thirty-six-year-old male with severe pulmonary arterial hypertension and contraindication to intravenous and subcutaneous prostanoid therapy due to congenital deafness and the risk of not hearing the intravenous pump alarms. Intravenous treprostinil was initiated, titrated to high dose, and then rapidly transitioned to oral treprostinil. A rapid initiation, titration, and transition from intravenous to oral treprostinil can be safely performed under watchful supervision in order to achieve higher and more efficacious doses of oral treprostinil in a timely manner.

Transitioning Parenteral or Inhaled Treprostinil to Oral Treprostinil Diolamine: Case Series and Review of the Literature

“…[5][6][7][8] Favorable outcomes have been described in those transitioned from an alternate route of administration (IV, SQ, and inhaled) to treprostinil diolamine. [9][10][11][12][13] We describe 3 patients who were transitioned from an alternate treprostinil route to treprostinil diolamine as well as a summary of the literature to date on this therapeutic approach.…”

“…Five publications were identified that included a case report, 3 case series, and a prospective, openlabel study. [9][10][11][12][13] These publications describe the transition of 48 patients (36 females and 12 males) to treprostinil diolamine. Of these, 32, 12, and 4 patients were receiving SQ, IV, or inhaled treprostinil, respectively (Table 3).…”

“…Of these, 32, 12, and 4 patients were receiving SQ, IV, or inhaled treprostinil, respectively (Table 3). [9][10][11][12][13] Forty-four (92%) were meeting clinical end points (functional class I/II) and 47 (98%) were receiving at least 1 other PAH medication at the time of transition. The rationale for transition to treprostinil diolamine was reported in 3 of the 5 publications and included patient preference (n ¼ 9), SQ infusion site pain (n ¼ 4), inability to transfer to long-term care facility (n ¼ 1), and catheter infection (n ¼ 1).…”

Extended-release oral treprostinil in the management of pulmonary arterial hypertension: clinical evidence and experience

“… 26 A single case report described a rapid initiation and titration of IV treprostinil with subsequent transition to oral treprostinil in a patient with severe PAH. 27 The patient had been on triple therapy with sildenafil, ambrisentan, and inhaled treprostinil. The authors noted that parenteral treatment was not a suitable option in this patient at that time due to visual and auditory impairments.…”

“…Once hemodynamic stability was reached with IV treprostinil (42 ng/kg/min by 96 h), the patient was then transitioned to oral treprostinil and up-titrated to a dose of 8 mg TID. 27 Finally, a retrospective analysis of specialty pharmacy data found that 275 patients had oral treprostinil dispensed after a prescription for inhaled treprostinil. The mean initial dose of oral treprostinil prescribed was 1.34 ± 1.61 mg/day.…”