Treprostinil

INTRODUCTION

Indications

Treatment of pulmonary arterial hypertension in patients with New York Heart Association (NYHA) class II–IV symptoms.

Action

Treprostinil is a prostacyclin that produces direct vasodilation of pulmonary and systemic arterial vascular beds. Also inhibits platelet aggregation. Therapeutic Effects: ↓ exercise-associated symptoms in patients with pulmonary arterial hypertension.

Adverse Reactions/Side Effects

CNS: dizziness, headache. CV: vasodilation, hypotension, edema. GI: diarrhea, nausea. Derm: rash, pruritus, flushing. Local: infusion site pain/reaction. MS: jaw pain.

PHYSICAL THERAPY IMPLICATIONS

Examination and Evaluation

• Assess signs and symptoms of CHF (dyspnea, rales/crackles, jugular venous distention, exercise intolerance) to help document whether drug therapy is effective in reducing these symptoms.

• Assess peripheral edema using girth measurements, volume displacement, and measurement of pitting edema (See Appendix N). Report increased swelling in feet and ankles due to vasodilation.

• Assess blood pressure periodically and compare to normal values (See Appendix F). Report low blood pressure (hypotension), especially if patient experiences dizziness, fatigue, or other symptoms.

• Assess any jaw pain to rule out musculoskeletal pathology; that is, try to determine if pain is drug induced rather than caused by anatomic or biomechanical problems.

• Assess dizziness that might affect gait, balance, and other functional activities (See Appendix C). Report balance problems and functional limitations to the physician and nursing staff, and caution the patient and family/caregivers to guard against falls and trauma.

• Monitor subcutaneous injection site for pain, swelling, and irritation. Report prolonged or excessive injection site reactions to the physician.

Interventions

• Design and implement aerobic exercise and endurance training programs as tolerated to help improve myocardial pumping ability.

• Use caution during aerobic exercise and endurance conditioning. Terminate exercise if patient exhibits untoward symptoms (chest pain, shortness of breath, unusual fatigue), or displays other criteria for exercise termination (See Appendix L).

• Avoid physical therapy interventions that cause systemic vasodilation (large whirlpool, Hubbard tank). Additive effects of this drug and the intervention may cause a dangerous fall in blood pressure.

• Do not apply physical agents (heat, cold, electrotherapeutic modalities) or massage at or near the injection site; these interventions will alter drug absorption from subcutaneous tissues.

• To minimize orthostatic hypotension, patient should move slowly when assuming a more upright position.

Patient/Client-Related Instruction

• Counsel patients about additional interventions to help cardiac dysfunction, including regular exercise, weight loss, sodium restriction, stress reduction, moderation of alcohol consumption, and smoking cessation.

• Instruct patient or family/caregivers to report other troublesome side effects such as severe or prolonged headache, skin problems (rash, itching, flushing), or GI problems (nausea, diarrhea).

Pharmacokinetics