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Dr. Bourge, you have extensive experience with
subcutaneous treprostinil. How do you decide which patients
should receive this drug versus epoprostenol or bosentan,
and what has been your overall experience?
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 Robert
C. Bourge MD
Professor and Director
Division of Cardiovascular Disease
University of Alabama, Birmingham
Birmingham, Alabama
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The University of Alabama, Birmingham, Pulmonary Vascular
Disease group has extensive experience with the use of
subcutaneous treprostinil. With this use, we also have
extensive experience with addressing the primary cause
of discontinuation of the drug, local site pain. It is
interesting that about two thirds of our patients tolerate
the drug over the long term. We do not find that the local
site pain effects
are necessarily dose-related (at least at a dosage above
about 2.3 ng/kg/min), and it appears that the timing of
the subjective severity of the symptoms is also very variable.
Some patients have symptoms early on and cannot tolerate
the drug, while some have the onset of severe site pain
symptoms late in the course of therapy, as late as 9 to
12 months after drug initiation. We utilize most published
forms of site pain control, including the use of lidocaine
patches, Emla cream, and a variety of other methods, including
the limited use of topical local steroids and the limited
use of both nonopioid (preferred) or even opioid pain
medication.
In general, we prescribe all of our drugs after careful
patient education regarding the risks, potential benefits,
and lifestyle modifications inherent in each drug’s
use. For class IIIa or IIIb patients we usually (after
intense education) offer oral bosentan as the first-line
drug, depending on the hemodynamics. If the cardiac index
is very low and/or the RA pressure very high, we often
start with a prostenoid (most patients choose to try subcutaneous
treprostinil instead of
intravenous treprostinil).
We add a second drug (such as bosentan or treprostinil)
to the subcutaneous or oral drug that the patient is taking
if symptoms or side effects of the first drug are not
tolerated and we think it will have to be discontinued,
or if the cardiac index remains low despite an adequate
trial of the first drug (usually 3 months). We have reported
our generally favorable results in using combination therapy,
and believe
it is safe and efficacious, if the second drug is started
cautiously and titrated slowly.
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