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

2. 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

3. 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

4. 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

5. 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