Single Center Experience in Transitioning Pulmonary Arterial Hypertension Patients from…

Single Center Experience in Transitioning Pulmonary Arterial Hypertension Patients from…

November 8, 2019 0 By Bertrand Dibbert


My name is Zeenat Safdar. I’m the director of the Pulmonary Hypertension
Program at Houston Methodist Hospital, Weill Cornell Medicine, in Houston, Texas. I’m going to talk about my poster that I presented
at ATS 2017. The title of the poster is “Single Center
Experience in Transitioning PAH Patients from IV Epoprostenol to Oral Selexipag”. The objective of the study was to determine
the safety and efficacy of switching patients from intravenous prostacyclin to oral IP receptor
agonist, as it has become available, in stable PAH patients. PAH patients have severe disease and they
require intravenous prostacyclin therapy, but some patients can be transitioned off
to oral agents, if they are stable. This study was undertaken to determine the
safety of this transition and also the efficacy of this transition. In this study what we did was, we identified
patients who were clinically stable PAH patients, who had repeated line infections or they have
thrombosed vessels with poor access, or a patient’s request to be considered for this
transition. We developed individualized transition plan
that was given to the patient and to the specialty pharmacy with a close follow-up. Patient was started on 200 microgram BID of
selexipag and instructed to go up every week by 200 until they reached the maximum dose
of 1600 mcg BID. At the same time, during this, patients were
instructed to go down on the prostacyclin dose by approximately 2 nanogram per KG, per
minute. Patients were instructed to tell their physicians
and specialty pharmacy if they had any worsening of symptoms. Our main result shows that patients were safely
transitioned and they completed this transitioning protocol, which means going off their IV epoprostenol,
and coming to the lowest IV epoprostenol dose and maximum selexipag dose at home. The time that it took for this was about two
to three months. The dose of epoprostenol before they were
selected for transition, ranged anywhere from 9 nanogram to 38 nanogram per KG, per minute. At the time of taking them off, patient underwent
a right heart cath. The successful transition patients were those
who had normal hemodynamics at the time of the right heart cath. At that time, after reviewing the hemodynamic
numbers, the epoprostenol dose and pump was switched off. Patients were monitored for additional 30
minutes in the cath-lab, and then they were sent home. Patients, who failed transition, were the
patients that at the time of the heart-cath did not have normal hemodynamics and those
patients were instructed to go back on their titration so that they did reverse titration,
going down on their selexipag and going up on their intravenous prostacyclin dose. During this transition period, none of these
patients were admitted to the hospital with worsening symptoms. All of them, even those who failed and those
who were successful, tolerated this transition protocol very nicely. No adverse effect was noted. Patients however, complained of increased
headache or nausea, vomiting. Those patients were instructed to go down
on the intravenous prostacyclin dose at faster pace. Out of these eight patients, four patients
were successfully transitioned off their IV epoprostenol. However, four patients could not be transitioned. The reason for that is the hemodynamics were
not normal at the time of right heart cath. Patients that were successfully transitioned,
on an echocardiogram they had normal RV size and normal RV function. They had no pericardial effusion. Those were two things that were deemed important. There was no correlation between the dose
and the patients that were successfully transitioned. In conclusion, carefully selected, stable
PAH patients who have been on stable intravenous prostacyclin therapy, meaning no change in
there prostacyclin dose, no recent hospitalization, no change in their functional capacity, who
have normal right atrium and right ventricle observed on an echocardiogram, can be safely
transitioned to an oral IP receptor agonist. However, we need long-term follow up to determine
the durability of this transition. Thank you for your attention. I will appreciate any feedback.