Different efficacy of inhaled and oral medications in pulmonary hypertension.
Batool J AbuHalimeh, Joseph G Parambil, Adriano R Tonelli
PMID 28527831WHAT IT FOUND
In two pulmonary hypertension patients, switching from inhaled treprostinil to oral treprostinil or selexipag was followed by worsening symptoms, echocardiographic or catheter findings; returning to inhaled treprostinil improved them.
This cannot prove the oral drugs caused deterioration.
Key findings
01After inhaled treprostinil was added to sildenafil, the man had improved six-minute walk distance and lower pulmonary vascular resistance; after switching to oral treprostinil while also on tadalafil and bosentan he developed symptoms, right ventricular dilation and catheter deterioration, then improved hemodynamically after returning to inhaled treprostinil.
02In the woman treated with bosentan, tadalafil and inhaled treprostinil, switching to oral selexipag was followed by diarrhea, worsening breathlessness and echocardiographic worsening; she improved clinically and on echocardiography after returning to inhaled treprostinil.
03Both patients reported difficulty using inhaled treprostinil four times daily, which led to oral therapy switches.
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What it does not show
These are two case reports without a control group, so they describe what happened in two people rather than showing that one treatment caused the change. The patients were also receiving other pulmonary hypertension medications, so the effect of switching from inhaled treprostinil to oral treprostinil or selexipag cannot be separated from the other therapy. The authors state that adherence to either route was believed but not measured, and that information on transitioning between inhaled and oral prostacyclin-pathway treatments is limited. The paper does not explain why the oral route differed; reduced absorption, local pulmonary effects or drug differences are possible explanations. Improvement after switching back was reported clinically, echocardiographically or hemodynamically, but not as a controlled outcome.
Declared interests
The supplied text states that the named authors have no significant conflicts of interest with companies or organizations whose products or services may be discussed. No funding source is stated.
The easy way to misread this
Do not conclude that oral treprostinil or selexipag generally worsens pulmonary hypertension. These are two case reports without a control group, and the patients were also receiving other pulmonary hypertension medications, so the contribution of the oral switch alone cannot be separated.