Multidisciplinary Approach to Pulmonary Arterial Hypertension Therapy Transitions

Document Type

Conference Proceeding

Publication Date

10-2024

Publication Title

Chest

Abstract

INTRODUCTION: Pulmonary arterial hypertension (PAH) is a rare, incurable disease that causes vasoconstriction of the pulmonary vasculature. Pharmacologic therapies range from oral to inhaled to parenteral agents to improve hemodynamics, alleviate symptoms, and increase exercise capacity. PAH treatment teams often transition medications to reach therapy goals and patient's comfort. During these therapy transition phases, a multidisciplinary approach, including pharmacists, physicians, and nurse practitioners (NP), is critical to achieve success and improve patient care. CASE PRESENTATION: A 46-year-old female presented to ED with dizziness, dyspnea, nausea, and lower extremity edema. A right heart catheterization confirmed the diagnosis of Group I PAH secondary to limited scleroderma with mean PA pressure of 61 mmHg, PCWP of 13 mmHg, cardiac output of 1.8 L, and PVR of 26.67 WU. Patient was started on epoprostenol IV. Pharmacists played a significant role in the execution of the protocol for dose titration under the Cardiac Intensive Care (CICU) team's supervision. She remained on epoprostenol continuous IV for two years with noted hemodynamics and functional ability improvements; during that time, the NP followed the patient periodically, assessed for side effects and efficacy, and helped with insurance approval issues. The decision was made to transition from epoprostenol continuous IV to treprostinil oral therapy for ease of use and improved quality of life. She was admitted to the CICU for transition & de-escalated from epoprostenol continuous IV to treprostinil PO with help from a pharmacist, and treprostinil oral therapy was titrated by the NP as an outpatient. She remained on treprostinil oral therapy for three years with stable hemodynamics and exercise capacity. Due to gastrointestinal side effects related to treprostinil oral therapy, the decision was made to transition from treprostinil oral therapy to treprostinil inhaled therapy. She has successfully remained on treprostinil inhaled therapy with stable hemodynamics and exercise capacity. DISCUSSION: This case illustrates a comprehensive, multidisciplinary approach to transition therapy in the PAH patient population. The physician-approved and supervised the therapy transitions. The NP developed the therapy transition plans, received authorization through insurance for all the therapies, arranged for and coordinated the two inpatient admissions, coordinated education sessions with the specialty pharmacy, counseled and educated the patient, managed the outpatient transition and side effects, and performed all follow-ups. The pharmacist collaborated inpatient with the multidisciplinary team to optimize pharmacotherapy, ensure patient safety, and improve clinical outcomes. The pharmacist also facilitated transitions from one medication formulation to another, determined appropriate dose adjustments and equivalences, established safe infusion concentrations, placed medication orders in the electronic medical record, monitored and managed side effects related to medications, and served as a valuable resource to nursing staff and healthcare providers. Therefore, this form of multidisciplinary approach added to a patient's success in therapy, including during the transition phase. Each discipline addressed an area of need regarding this patient, leading to effective, successful, and safe transitions. CONCLUSIONS: Multidisciplinary approach and teamwork are the key for successful transition of PAH therapies as PAH therapies are complex, have lots of side effects, and difficult insurance approval processes.

Volume

166

Issue

4 Suppl

First Page

A5786

Last Page

A5787

Comments

Chest 2024 Annual Meeting, October 6-9, 2024, Boston, MA

DOI

10.1016/j.chest.2024.06.3431

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