Transitioning from parenteral treprostinil to inhaled treprostinil in patients with pulmonary arterial hypertension
Patient 2 was a 46-year-old Caucasian man with an 8-year history of PAH secondary to β-thalassemia and cirrhosis with splenectomy. He was initiated on PAH therapy with SC treprostinil and up-titrated to 61 ng/kg/min in April 2003. Sildenafil 20 mg t.i.d. was added in July 2006 and bosentan 125 mg b.i.d was added in January 2008. His hemodynamics remained stable on this regimen. However, he developed progressive infusion site pain and serial SC abscesses with life-threatening bacteremia in late 2009 and early 2010. He was offered conversion to IV prostanoid therapy, but he refused given concern over continued infectious risk. Again, rather than discontinuing prostacyclin therapy, the patient was offered transition to inhaled treprostinil in the knowledge that this might not be feasible given his relatively high dose of SC treprostinil. He was admitted in April 2010 for transition from SC to inhaled treprostinil with continuous hemodynamic monitoring in light of the higher dose of SC treprostinil. Inhaled treprostinil was initiated at three breaths every six hours and increased by three breaths daily to a maximum of nine breaths every 6 h over a period of three days. Simultaneously, the SC treprostinil infusion dose was decreased by 5 ng/kg/min every six hours until cessation of SC treprostinil by Day 4, with minimal side effects. Clinical parameters, measured before and after the transition to inhaled treprostinil, are noted in .