Transition from treprostinil to selexipag in patients with pulmonary arterial hypertension: Case series

Fanous, Sherif; Janmohamed, Munir

doi:10.2146/ajhp170814

Cited by 19 publications

(21 citation statements)

References 5 publications

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“…Established guidance on transitions between various formulations within this drug class have not been standardized. A number of case reports and case series have been published describing such transitions but lack consistent processes (6)(7)(8)(9)(10)(11)(12)(13).…”

Section: Introductionmentioning

confidence: 99%

“…The mean dose of inhaled treprostinil at baseline was 59.3 mcg four times daily (13). In a case series of 4 patients on parenteral treprostinil, the highest dose upon initiation of the transition was 46.5 ng/kg/min, which was successfully transitioned to selexipag 1,600 mcg twice daily (11). In another case series of 5 patients, parenteral treprostinil doses up to 96 ng/kg/min were successfully transitioned to selexipag 1,600 mcg twice daily (20).…”

Section: Introductionmentioning

confidence: 99%

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Transitioning Between Prostanoid Therapies in Pulmonary Arterial Hypertension

et al. 2020

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Background: New oral prostacyclin therapies and prostacyclin agonists have become available for the treatment of pulmonary arterial hypertension (PAH). However, methods for transitioning between oral, inhaled, and parenteral formulations are not well-established, except in the form of case reports and case series. Collectively, these emphasize the lack of a standardized process and approach in transitioning patients between PAH prostanoid therapies. In this case series, we report our experience at an accredited Pulmonary Hypertension center in transitioning between various oral, inhaled, and parenteral prostanoids to offer additional guidance on safe transitions in therapy. Methods: All cases of prostanoid transitions at an accredited Pulmonary Hypertension center from March 2018 to September 2019 were included in this report. The transition approach for each case was developed through a review of the literature, extrapolation of available pharmacokinetic data, and collaboration between pharmacists and clinicians. Results: This case series describes the transition of 3 patients from selexipag to parenteral treprostinil; 1 patient transitioning from parenteral treprostinil to selexipag; 1 patient transitioning from oral treprostinil to parenteral treprostinil; and 1 patient transitioning from inhaled treprostinil to selexipag. Four of the 6 patients presented here were transitioned to an alternate prostanoid on account of clinical worsening, while the remaining 2 patients transitioned due to intolerance of parenteral therapy and poor medication adherence. This case series includes patients with various etiologies of PAH including idiopathic PAH, methamphetamine-associated PAH, and scleroderma-associated PAH. All patients successfully completed each transition without serious adverse events. Conclusions: With the increasing utilization and availability of prostanoids, there is a critical need for a standardized approach in transitioning safely between different formulations without compromising treatment efficacy. In this case series, we present our clinical experiences, guided by available pharmacokinetic data, in transitioning between various prostanoid formulations.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Transitioning Between Prostanoid Therapies in Pulmonary Arterial Hypertension

et al. 2020

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“…4 However, there exist only limited data on transitioning patients between infused and oral PPAs. 5,[7][8][9] Two prospective studies have been published to date. Chakinala et al 7 reported results for 33 patients with World Health Organization (WHO) functional class (FC) I or II PAH, classified as low risk, according to the European Society of Cardiology (ESC)/European Respiratory Society (ERS) criteria, who switched from infused to oral treprostinil using a five-day inpatient transition protocol.…”

mentioning

confidence: 99%

Transitions between infused and oral prostacyclin pathway agents in pulmonary arterial hypertension: key considerations

2020

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Prostacyclin pathway agents are a critical treatment for patients with pulmonary arterial hypertension. Seven prostacyclin pathway agents are available, including agents administered by parenteral infusion, by inhalation, and orally. Pulmonary arterial hypertension patients are now transitioned from one prostacyclin pathway agent to another with increasing frequency. Such transitions require careful downtitration and uptitration to avoid decompensation from rapid withdrawal and to achieve a patient's optimal dose based on efficacy and tolerability. Clinical guidance is especially lacking for transitions involving the newer, oral prostacyclin pathway agents; specifically, selexipag and oral treprostinil. We present three case reports of patients with pulmonary arterial hypertension who underwent one or more transition between parenteral and oral prostacyclin pathway agents, including some transitions that were successful and some that were not. These cases illustrate key considerations, such as titration protocols, patient selection, side effect management, and pharmacokinetics.

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“…As seen with Patients 4 and 5, cross-titration from parenteral therapy may be considered when parenteral therapy is not well tolerated or is no longer necessary from a haemodynamic perspective. Most patients undergoing rapid 10 , 11 or outpatient 10 , 12 cross-titration maintain or improve their subjective functional class, 10 , 11 , 13 their objective exercise capacity 11–13 and the levels of NT-proBNP. 11 , 12 In the two case series reporting comprehensive invasive haemodynamics following cross-titration, 11 , 14 PA pressures, right atrial pressures, and PVR were similar however reductions in the CI within the first 6 months persisting to 17 months post-transition were also noted.…”

Section: Discussionmentioning

confidence: 99%

“…Selexipag doses can be increased by 200–400 µg daily while the parenteral therapy is down-titrated. 10 , 11 , 14 …”

Section: Discussionmentioning

confidence: 99%

Contemporary use of Selexipag in pulmonary arterial hypertension associated with congenital heart disease: a case series

Blissett

Blusztein

Mahadevan

2020

European Heart Journal - Case Reports

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Background There are significant risks of parenteral prostacyclin use in patients with pulmonary arterial hypertension associated with congenital heart disease (PAH-CHD), which may limit their use. Selexipag is an oral, selective prostacyclin analogue that has been shown to reduce disease progression and improve exercise capacity in patients with PAH-CHD. Administering Selexipag in patients with PAH-CHD could potentially overcome some of the risks of parenteral therapy while improving clinical outcomes. Case summary We report five cases highlighting the clinical uses of Selexipag in patients with PAH-CHD. In the first two cases, Selexipag was initiated as part of a Treat-to-close strategy. In the third case, initiation of Selexipag improved symptoms and objective exercise capacity in a patient with Eisenmenger syndrome. In the fourth and fifth cases, rapid cross-titration protocols were used to transition from parenteral prostacyclins to Selexipag. In the fourth case, Selexipag was initiated in the context of significant side effects limiting parenteral prostacyclin use. In the fifth case, Selexipag was used to down-titrate from parenteral prostacyclins following closure of a sinus venosus atrial septal defect and redirection of anomalous pulmonary veins. Discussion Selexipag is a promising oral therapy for patients with at various stages of the spectrum of PAH-CHD to improve symptoms, exercise capacity and, in some cases, haemodynamics. Our cases also highlight practical aspects of Selexipag use including targeting the individualized maximally tolerated dose for each patient, managing side effects and managing dose interruptions.

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Transition from treprostinil to selexipag in patients with pulmonary arterial hypertension: Case series

Cited by 19 publications

References 5 publications

Transitioning Between Prostanoid Therapies in Pulmonary Arterial Hypertension

Transitioning Between Prostanoid Therapies in Pulmonary Arterial Hypertension

Transitions between infused and oral prostacyclin pathway agents in pulmonary arterial hypertension: key considerations

Contemporary use of Selexipag in pulmonary arterial hypertension associated with congenital heart disease: a case series

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