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Understanding and optimizing  pharmacologic agents used in the management of Pulmonary Hypertension. Dr. Christopher J Arendt, PharmD , RPh Assistant Professor of Pharmacy Mayo Clinic College of Medicine Rochester, Minnesota. Disclosure. Nothing to disclose No financial interests.

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  1. Understanding and optimizing  pharmacologic agents used in the management of Pulmonary Hypertension Dr. Christopher J Arendt, PharmD, RPhAssistant Professor of PharmacyMayo Clinic College of MedicineRochester, Minnesota

  2. Disclosure • Nothing to disclose • No financial interests

  3. Objectives • Describe the common mechanisms of action of medications used to treat pulmonary hypertension. • Recognize common drug-drug and drug-herbal interactions with pulmonary hypertension management medications and what to expect. • Identify  the most common adverse effects seen with medications used to manage pulmonary hypertension.

  4. Pulmonary Arterial Hypertension What is it? Mean pulmonary Artery Pressure(mPAP) > 25 mmHg Normal to reduced Cardiac Output (CO) Normal capillary wedge pressure (PCWP) Characterized by : Vascular constriction Cellular proliferation Prothrombotic state Dyspnea, fatigue, weakness, inability to tolerate exertion

  5. World Health Organization classification of functional status for Primary Pulmonary Hypertension

  6. PAH Etiology

  7. Idiopathic Pulmonary Arterial Hypertension • Hereditary (Genetic) Pulmonary Arterial Hypertension • Associated Pulmonary Arterial Hypertension

  8. Grouping of Disease Due to left heart failure (increased back pressure in the pulmonary vessels) • Left ventricular pump failure (heart attack, cardiomyopathy) • Left ventricular stiffness (hypertension, diabetes, metabolic syndrome) • Valve disease (mitral or aortic stenosis or regurgitation) Diseases affecting the whole lung (lung diseases obliterate blood vessels) • Chronic bronchitis and emphysema (combination of loss of lung plus hypoxia) • Interstitial lung diseases (destructive diseases that obliterate vessels, such as pulmonary fibrosis, sarcoidosis, and many others) Hypoxia related (decreased oxygen constricts pulmonary blood vessels) • High-altitude dwelling • Sleep apnea and other hypoventilation syndromes • Hypoxia of chronic bronchitis and emphysema (chronic obstructive pulmonary disease, or COPD) American Thoracic Society http://thoracic.org/education/breathing-in-america/resources/chapter-17-pulmonary-hypertension.pdf

  9. Grouping of Disease Pulmonary arterial hypertension (changes in the structure and function of the pulmonary arteries) • Idiopathic (formerly primary pulmonary hypertension) • Heritable (formerly familial, due to BMPR2 or Alk-1 mutations) • Drug- and toxin-induced (stimulants) • Connective tissue diseases (especially scleroderma) • HIV infection (rare occurrence <1%) • Portal hypertension (cirrhosis and other advanced liver diseases) • Congenital heart disease that allows blood to shunt around the lungs • Pulmonary veno-occlusive disease and pulmonary capillary hemangiomatosis (rare) Primarily obstructing diseases of the pulmonary vessels • Pulmonary thromboembolism • Schistosomiasis • Sickle cell anemia • Tumor emboli • Fibrosingmediastinitis (obstruction by fibrosis related to histoplasmosis) American Thoracic Society http://thoracic.org/education/breathing-in-america/resources/chapter-17-pulmonary-hypertension.pdf

  10. Pathological mechanisms in PAH. PDGF, platelet-derived growth factor; EGF, epidermal-derived growth factor; FGF, fetal-derived growth factor; VEGF, vascular endothelial-derived growth factor; MCP-1, monocyte chemoattractant protein-1; IL, interleukin. Toshner M et al. Br Med Bull 2010;94:21-32

  11. Cellular Mechanisms Am Heart J 2011;162:201-13

  12. Medication Players Dec 2013 • Treprostinil Oral • 390 Patients • Class II or III 2013 (Phosphodiesterase Inhibitor) (Endothelin Receptor )Antagonist Adapted from Am Heart J 2011;162:201-13

  13. Supportive Therapy • Oxygen • Diuretics • Digoxin ( K channel and Calcium ) • Anticoagulants (Warfarin)

  14. Calcium Channel Blockers (CCB) • Use if a Positive response (Vasoreactivity test) • Decrease in mPAP ≥ 10 mmHg to a value ≤ 40 mmHg • Most beneficial in IPAH, FPAH, though limited Mechanism: Inhibits Fast Calcium Channels, Reduces intracellular calcium, thus inhibits vasoconstriction Diltiazem (Start 120 mg/day) Nifedipine (start 30 mg/day) Amlodipine (start 5 mg/day) Adverse effects: Hypotension, constipation, edema PEARL: Frequent follow up ( 50% of pts see loss of benefit). Avoid verapamil Avoid CCB in severe PAH due to high short-term mortality. Start Stool softeners Multiple Drug Interactions Titrate Weekly. 3 month follow up. 1 year cath lab repeat. Figure: Current Opinion in Anaesthesiology 2010, 23:49–56

  15. Prostaglandins • Epoprostenol Mechanism: Direct vasodilation, inhibition of platelet aggregation • Epoprostenol IV (Central line) start at 2 ng/kg/min. Dose increase over 6 months. Range 25-40 ng/kg/min. Bag change every 8 hr. Refrigerated bag good for 28 hrs. Uses special diluent. Establish dosing weight. • Room Temp Stable (RTS) product can be changed daily. No Special Diluent needed Adverse Effects: Flushing, HA, jaw and lower extremity muscular pain, diarrhea, nausea, rash. PEARL: watch for line associated infection and catheter associated venous thrombosis, thrombocytopenia. Back-up bag is necessary. Rebound HTN noted with abrupt DC. RTS and original formulation are not interchangeable.

  16. Prostaglandins • Treprostinil Mechanism: Direct vasodilation, inhibition of platelet aggregation • Treprostinil IV 1.25 ng/kg/min. BAG CHANGE Q48 HRS • TreprostinilSubQ1.25 ng/kg/min: Change every 3 days. • Treprostinil Inhalation; 1 neb 4 times daily. 3 breath start. 9 max/dose. • Treprostinil Oral Extended Release Tab BID Adverse Effects: IV: Flushing, HA, jaw and lower extremity muscular pain, diarrhea, nausea, rash. SubQ: Injection site Pain ( 85%), with 8% stopping therapy. Inh: cough and throat irritation; headache, gastrointestinal effects, muscle, jaw or bone pain, flushing and syncope Oral; Diarrhea PEARL: IV/SubQ Back-up bag is NOT necessary due to the long half-life. No ice packs needed. Rebound HTN noted with abrupt DC. Neb uses 1 tube of drug/day, programming number of breathes on device.- 10 min pause between breaths is allowed. > 15 min pause resets the machine.

  17. Prostaglandins $5,000 neb device • Illoprost Mechanism: Direct vasodilation, inhibition of platelet aggregation • Illoprost 2.5 mcg/mL initial. 6-9 times daily. Adverse Effects: Cough, flushing, HA PEARL: 10-15 min neb. Takes time to admin. Max dose 45 MG/DAY. 3RD OR 4TH Line PAH Agent

  18. Endothelin Receptor Antagonist • Bosentan Mechanism: Blocks Both Endothelin A (ET A) and B (ET B) receptors, reducing exposure to vasoconstrictive and proliferative effects of Endothelin. • Bosentan62.5 mg oral twice daily. Titrate to 125 mg oral twice daily. Adverse Effects: Liver toxicity (If 3x normal aminotransferases , hold therapy), HA, Dizziness, flushing PEARL: Monthly liver function tests are needed. CYP2C9 Interactions! Inhibited by fluconazole ( azoles), ginkobiloba, St. Johns Wort, amidarone. Warfarin, Cyclosporine interactions. 50% dose of sildenafil if given concurrently with bosentan

  19. Endothelin Receptor Antagonist • Ambrisentan Mechanism: Endothelin A (ET A) to B (ET B) receptor selectivity of 77:1. Inhibiting vasoconstriction and proliferation. • Ambresentan 5 mg daily, may increase to 10 mg daily if tolerated Adverse Effects: Liver toxicity (watch for elevated aminotransferases , hold therapy), HA, Decreased hemoglobin (Check at baseline and 1 month) PEARL: Pregnancy Test initial and monthly. P-Glycoprotein interactions (Sildenafil, loperamide), possible CYP2C19 interactions ( Clopidogrel and omeprazole) Amiodaone and cyclosporine interactions

  20. Phosphodiesterase Inhibitors • Sildenafil Mechanism: Inhibit phosphodiesterase-5 and acts to enhance cGMP levels, which will prolong cGMP vasodilating effects in the pulmonary vasculature. • Sildenafil 20 mg oral Three times daily Adverse Effects: HA, abd. Discomfort, constipation, back pain PEARL: APAP premed helps with HA. Interactions CYP3A4 , Itraconazole, Amiodarone, tacrolimus, cyclosporine, SIMVASTATIN(Myopathy) Avoid nitrate, and caution if SBP <90/60 or > 170/90

  21. Phosphodiesterase Inhibitors • Tadalafil Mechanism: Inhibit phosphodiesterase-5 and acts to enhance cGMP levels, which will prolong cGMP vasodilating effects in the pulmonary vasculature. • Tadalafil 40 mg daily Adverse Effects: HA, abd. Discomfort, constipation, back pain, nasopharyngitis PEARL: APAP premed helps with HA. Interactions CYP3A4 , Itraconazole(Reduce tadalafil to 2.5 mg daily), Amiodarone, tacrolimus, cyclosporine, Simvastatin ( Myopathy) Avoid nitrate, and caution if SBP <90/60 or > 170/90

  22. Choice of therapy (PAH) Lourenco A et al. Int J Card 155 (2012) 350-361

  23. PAH drug and Herbal Interactions • CYP P450 Enzyme interactions ( 2C9, 3A4, 2C19, 2C8) • Over 90 possible herbal interactions • Major Interactions: Epoprostenol + L-Arginine= HoTN • Treprostinil + Danshen or Dong Quai ir Evening Primrose, or Willow Bark or Policosanol =Bleed • Sildenafil + St. Johns Wort= reduced effectiveness of sildenafil • Tadalafil or sildenafil + Sweet Orange= reduced P-Glycop transport= lower sildenafil and tadalafil levels. • Others: • Epo +Licorice= less effectiveness (HTN) • Epo + Blue Cohosh= less effective (HTN) • Epo +European Mistletoe=HoTN

  24. Wrapping it up • 3 recognized pathological contributors to pulmonary arterial hypertension… and more to come! • Recent advances in medical management have improved survival

  25. Understanding and optimizing  pharmacologic agents used in the management of Pulmonary Hypertension Dr. Christopher J Arendt, PharmD, RPhAssistant Professor of PharmacyMayo Clinic College of MedicineRochester, Minnesota Arendt.christopher@mayo.edu

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