Breathing Easy: Cases of Transitioning Between Inhaled Prostacyclin Products

Introduction: Patients with pulmonary hypertension (PH) frequently require hospitalization for management and optimization of maintenance medications. Due to medication formulary status and patient condition, this can involve implementing nebulized epoprostenol therapy for acute management. Once optimized, patients are often transitioned back to maintenance medications, however there is minimal to no evidence to guide the transition from nebulized epoprostenol to inhaled treprostinil products.


Description: We present 3 patients with PH who were successfully transitioned from nebulized epoprostenol to inhaled treprostinil DPI (Tyvaso DPI®) or nebulizer (Tyvaso®) using multiple approaches. Patient 1 was transitioned immediately off nebulized epoprostenol with their first dose of treprostinil DPI. Given poor lung compliance associated with their PH and suspected poor DPI administration technique, the first transition attempt failed. During the second attempt, Patient 1 transitioned immediately from nebulized epoprostenol to treprostinil nebulized solution successfully, avoiding treprostinil DPI. Patient 2 was started on nebulized epoprostenol pending Treprostinil DPI availability. Once delivered, epoprostenol 50 ng/kg/min was weaned per respiratory therapy’s discretion and the patient started treprostinil DPI 1.5 hours later without any issues. Patient 3 received 8 hours of overlap of nebulized epoprostenol and inhaled treprostinil, with the epoprostenol dose reduced from 50 ng/kg/min to 20 ng/kg/min after the 2nd dose of treprostinil DPI. Four hours later, the epoprostenol dose was reduced to 10 ng/kg/min and continued for 1 hour before discontinuing the nebulized epoprostenol.


Discussion: Given the paucity of data to guide transitioning from nebulized epoprostenol to inhaled treprostinil products, an individualized approach based on patient-specific factors and pharmacokinetic profiles of the medications should be recommended. Pulmonologists specialized in PH and pharmacists are uniquely suited to develop treatment plans for transitioning patients between these high-risk medications. Further research and discussion regarding transitions between these inhaled agents would be beneficial to inform patient specific strategies in the future.