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Staggered Transition to Epoprostenol from Treprostinil in Pulmonary Arterial Hypertension

Pharmacy Practice Resident, University of Nebraska Medical Center, Omaha, NE

Pamela A Coffman, PharmD

Critical Care Pharmacist, The Nebraska Medical Center, Omaha

Anthony A Floreani, MD

Associate Professor, Internal Medicine, Section of Pulmonary & Critical Care, University of Nebraska Medical Center

Christopher J Bultsma, PharmD

Critical Care Pharmacist, The Nebraska Medical Center

Keith M Olsen, PharmD FCCP FCCM

Professor, Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center

Reprints: Dr. Olsen, Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, 986045 Nebraska Medical Center, Omaha, NE 68198-6045, fax 402/559-5673, kolsen{at}unmc.edu

OBJECTIVE: To describe a successful transition process from subcutaneous treprostinil to intravenous epoprostenol after the failure of treprostinil in a patient with idiopathic pulmonary arterial hypertension and present an algorithm to achieve the conversion without significant adverse reactions.

CASE SUMMARY: A 25-year-old white female receiving subcutaneous treprostinil 97 ng/kg/min was admitted to the intensive care unit for transition from subcutaneous treprostinil to a target intravenous epoprostenol dose of 72 ng/kg/min via a staggered interval dose adjustment approach. The patient experienced facial flushing, hot flashes, and headache when dose adjustments of the drugs were made simultaneously; however, when dose adjustments were staggered, the adverse reactions did not occur and larger adjustments could be achieved.

DISCUSSION: This case demonstrates a suboptimal therapeutic response to treprostinil for the treatment of idiopathic pulmonary arterial hypertension. The transition of treprostinil to epoprostenol is rare; however, in the event therapy change is needed, dosing information is minimal. A staggered transition dosing regimen that accounts for the pharmacokinetic differences between epoprostenol and treprostinil was successfully used in this case.

CONCLUSIONS: The approach in this case demonstrates the success of staggered-interval dose adjustments to minimize supratherapeutic symptoms and coincides with the pharmacokinetic profile of the 2 medications.

Key Words: epoprostenol, prostacyclin, pulmonary arterial hypertension, treprostinil

Published Online, March 8, 2005. www.theannals.com, DOI 10.1345/aph.1E418