From the Guidelines
The most effective treatment approach for Pulmonary Hypertension (PH) involves a combination of medications targeting different pathways, including phosphodiesterase-5 inhibitors, endothelin receptor antagonists, and prostacyclin analogs, along with supportive measures and lifestyle modifications. For pulmonary arterial hypertension (PAH), first-line therapies often include phosphodiesterase-5 inhibitors like sildenafil (20mg every 8h) or tadalafil (40mg once daily), or endothelin receptor antagonists such as ambrisentan (5 or 10mg once daily), bosentan (125mg twice daily), or macitentan (10mg once daily) 1.
Key Medications
- Prostacyclin derivatives:
- Epoprostenol (IV infusion, 2 ng/kg/min, increased as tolerated)
- Iloprost (inhalation, 2.5 or 5.0 mg, 6-9 inhalations/d)
- Treprostinil (oral, 0.25 mg bid or 0.125 mg tid, increased 0.125 mg bid every 3-4 d; inhaled, 18–54 mg, 4 times daily; subcutaneous or IV infusion, 1.25 ng/kg/min, increased 1.25 ng/kg/min per week)
- Endothelin receptor antagonists:
- Bosentan (oral, 125 mg twice daily)
- Ambrisentan (oral, 5 or 10 mg once daily)
- Macitentan (oral, 10 mg once daily)
- Phosphodiesterase type-5 inhibitors:
- Sildenafil (oral, 20 mg every 8 h)
- Tadalafil (oral, 40 mg once daily)
- Soluble cGMP stimulators:
- Riociguat (oral, 0.5-1.0 mg every 8 h, increased 0.5 mg every 2 wk as tolerated to maximum dose 2.5 mg)
- Prostacyclin receptor agonists:
- Selexipag (oral, 200 mg twice daily, increased as tolerated to maximum dose of 1,600 mg twice daily)
Supportive Care and Lifestyle Modifications
In addition to pharmacotherapy, supportive measures and lifestyle modifications play a crucial role in managing PH. This includes oxygen therapy for hypoxemia, diuretics for fluid overload, and anticoagulation in select cases 1. Patients should also participate in supervised exercise activity, maintain current immunization against influenza and pneumococcal pneumonia, avoid pregnancy, and avoid exposure to high altitude or non-essential surgery. Regular monitoring of symptoms, exercise capacity, and right heart function is essential to assess treatment response and adjust therapy accordingly. Combination therapy using multiple drug classes is increasingly common for better outcomes, and treatment should address underlying causes when possible, such as left heart disease, lung disease, or chronic thromboembolic disease.
From the FDA Drug Label
Epoprostenol for injection is indicated for the treatment of pulmonary arterial hypertension (PAH) (WHO Group 1) to improve exercise capacity. Sildenafil tablets are a prescription medicine used in adults to treat pulmonary arterial hypertension (PAH).
The best treatment options for Pulmonary Hypertension (PH) include:
- Epoprostenol (IV): indicated for the treatment of pulmonary arterial hypertension (PAH) to improve exercise capacity 2
- Sildenafil (PO): used to treat pulmonary arterial hypertension (PAH) to improve the ability to exercise and can slow down worsening changes in physical condition 3
From the Research
Treatment Options for Pulmonary Hypertension (PH)
The treatment options for Pulmonary Hypertension (PH) have evolved over the years, with various therapies targeting different pathogenic pathways. Some of the key treatment options include:
- Endothelin receptor agonists, prostacyclin therapies, and nitric oxide pathway modulators, which have distinct mechanisms of action leading to pulmonary vasodilation, and improvement in exercise capacity, hemodynamic measures, and clinical outcomes for patients with PAH 4
- Phosphodiesterase type-5 inhibitors, such as tadalafil, which increases cGMP, the final mediator in the nitric oxide pathway, and has been shown to improve exercise capacity and quality of life measures in patients with PAH 5
- Prostacyclin analogs, such as epoprostenol, beraprost, and iloprost, which are useful for the treatment of severe pulmonary arterial hypertension and early stages of the disease 6
- Endothelin-receptor antagonists, such as bosentan, which are especially useful for the treatment of early stages of the disease and have shown good results in patients with chronic renal failure 6
Combination Therapies
Combination therapies are now the standard of care for PAH, with dual combination therapy involving agents targeting the endothelin and nitric oxide pathways being the most common approach 7. Therapies targeting the prostacyclin pathway should be added for patients receiving dual combination therapy who do not achieve a low-risk status 7.
Treatment Decision Making
Treatment decisions should be guided by each patient's risk status, which should be assessed using multiple prognostic parameters 7. Regular assessments are essential to ensure that any change in risk is detected in a timely manner and treatment is adjusted accordingly 7. A holistic approach to treatment, beyond pharmacological therapies, is also necessary to ensure that PAH patients receive maximal benefit from currently available therapies 7.
Emerging Treatments
There are emerging treatments for other forms of pulmonary hypertension, but current therapy primarily targets the underlying cause 8. Further research is needed to better characterize, detect, and effectively treat all forms of pulmonary hypertension, with a focus on vulnerable populations 8.