General Principles of PH Medication Transitions Martha Kingman DNP, FNP-C Nurse Practitioner Pulmonary Hypertension Center Dallas, TX

Why the Need to Make a Transition? Some General Considerations Transitions may occur due to… Efficacy concerns Patient tolerability Patient preference Compliance issues Transitions can occur between… Drugs in the same pathway Drugs in different pathways Routes of administration, ie. SQ to IV Prior to making a drug transition: Decide on hospital vs. clinic vs. home Patient stability and dosing both factor into risk profile Recommend hospital for IV transitions Experienced PH providers (with double check on all calculations) Decide on dosing plan in advance Complete specialty pharmacy teaching prior to hospitalization to shorten stay Nursing education in place/priming line

Transitioning Between PCs, PDE5i, and Riociguat Transitioning Between Prostacyclins: Issues Dosing: Treprostinil doses are up to 2x epoprostenol dose IV to IV: Under-dose the new med and then up-titrate quickly Rapid switch True IV rapid switch easier for epoprostenol to treprostinil  Half-life a problem for the reverse (tre to epo): if done, would MARKEDLY under-dose epoprostenol first few hours PDE5i’s Transition to Riociguat: Approaches We stop sildenafil for 24 hours and then start riociguat We stop tadalafil for 48 hours and then start riociguat

Nursing Considerations in PAH Medication Transitions Do not make any changes until the new medication has been approved by insurance Ensure specialty pharmacy teaching is complete before admission to the hospital Make sure nursing staff is trained on line priming and difference between side effects and PH symptoms Provide patients with instructions/Rx for managing side effects ondansetron for nausea acetaminophen for pain. Tramadol if Tylenol is not effective Imodium for diarrhea ranitidine for GERD gabapentin for leg pain

Take-Home Messages Ideally, patient should be stable prior to transition There are no established transition guidelines; however, numerous publications exist Know the differences in dosing between epoprostenol and treprostinil Admit patients for IV switches Decide if rapid switch is appropriate vs. simultaneous increases in new drug and decreases of prior drug If transitioning from IV to oral: Prepare patient for possible failure and need to return to IV therapy