Transitioning from parenteral treprostinil to inhaled treprostinil in patients with pulmonary arterial hypertension
Patient 1 was a 69-year-old Caucasian woman with a 6-year history of idiopathic PAH. She was initiated on PAH therapy with bosentan 125 mg twice daily (b.i.d.) in October 2005 and sildenafil 20 mg three times daily (t.i.d.) in January 2007. She remained symptomatic, however, with worsening hemodynamics. As a result, IV treprostinil was initiated in April 2008, which was associated with significant improvement in her symptoms and hemodynamics. Unfortunately, she developed recurrent life-threatening central line infections while on IV treprostinil in 2009 and was ultimately transitioned to SC treprostinil (maximum dose 38 ng/kg/min) in January 2010. She experienced intractable infusion site pain on SC treprostinil despite topical anesthesia and analgesics, which markedly impacted her quality of life. After extensive discussion, rather than discontinue prostacyclin therapy, she was electively admitted for transition from SC to inhaled treprostinil in April 2010. A right-heart catheterization was performed pre-and post-transition to assess changes in hemodynamics. Inhaled treprostinil was initiated at three breaths every six hours and increased by three breaths daily to a maximum of nine breaths every 6 hours over three days. Simultaneously, the SC treprostinil infusion dose was decreased by 5 ng/kg/min every six hours until cessation of SC treprostinil, with minimal side effects. The total time for SC to inhaled transition was approximately 72 hours. Clinical parameters before and after the transition to inhaled treprostinil are noted in .