Initiation and titration

To help ensure a successful start on Remodulin

  1. Set expectations for the patient.
  2. Complete the Patient Referral Form and submit documentation.
  3. Take advantage of UT support resources for your practice and patients.
  4. Develop a follow-up protocol for the patient.

Titrate up and down as needed to achieve clinical response

Dose adjustment can be used to establish a dose that improves PAH symptoms while minimizing excessive pharmacologic effects of Remodulin (ie, headache, nausea, emesis, restlessness, anxiety, and infusion site pain or reaction).1

  • In the pivotal, randomized, controlled studies of subcutaneous Remodulin, the mean dose at week 12 was 9.3 ng/kg/min1,2
  • Dose adjustments can be made more frequently as tolerated1
Initiate
First 4 weeks
After week 4
Initiate
Remodulin at 1.25ng/kg/min
(or 0.625 ng/kg/min
if not tolerated)1
Increase in
increments of1.25ng/kg/min
per week1
Increase in
increments of2.5ng/kg/min
per week1
median dose real world

Based on Specialty Pharmacy shipment data through March 2017

Titrate slowly in patients with hepatic or renal insufficiency. Such patients will likely be exposed to greater systemic concentrations relative to patients with normal hepatic or renal function.1

Dose adjustment may be necessary if inhibitors or inducers of CYP2C8 are added or withdrawn. Co-administration of Remodulin with a CYP2C8 inhibitor increases exposure to treprostinil and with an inducer decreases exposure to treprostinil.1

Talk to your patients about the potential benefits and risks of Remodulin before initiating therapy.

Remodulin open-label extension study1

Duration

1.6 years mean duration
of therapy (max 4.6 years)
Dosing

29% of patients achieved
a dose of ≥40 ng/kg/min
(max 290 ng/kg/min)
Safety

Similar safety profile to that of the 12-week placebo-controlled studies except for the following adverse drug reactions, which occurred in ≥3% of patients:
  • Anorexia
  • Vomiting
  • Infusion site infection
  • Asthenia
  • Abdominal pain

Important Safety Information for Remodulin

Warnings and Precautions

  • Chronic intravenous (IV) infusions of Remodulin are delivered using an indwelling central venous catheter. This route is associated with the risk of blood stream infections (BSI) and sepsis, which may be fatal. Therefore, continuous subcutaneous (SC) infusion is the preferred mode of administration.
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Important Safety Information for Remodulin

Warnings and Precautions

  • Chronic intravenous (IV) infusions of Remodulin are delivered using an indwelling central venous catheter. This route is associated with the risk of blood stream infections (BSI) and sepsis, which may be fatal. Therefore, continuous subcutaneous (SC) infusion is the preferred mode of administration.
  • Avoid abrupt withdrawal or sudden large reductions in dosage of Remodulin, which may result in worsening of PAH symptoms.
  • Titrate slowly in patients with hepatic or renal insufficiency because such patients will likely be exposed to greater systemic concentrations relative to patients with normal hepatic or renal function.
  • Remodulin dosage adjustment may be necessary if inhibitors or inducers of CYP2C8 are added or withdrawn. Co-administration of Remodulin with a CYP2C8 inhibitor increases exposure to treprostinil, or with an inducer, decreases exposure to treprostinil.

Drug Interactions/Specific Populations

  • Remodulin is a potent pulmonary and systemic vasodilator. Concomitant administration of Remodulin with blood pressure lowering agents, such as diuretics, antihypertensive agents, or other vasodilators, may increase the risk of symptomatic hypotension.
  • Since Remodulin inhibits platelet aggregation, there may be an increased risk of bleeding, particularly among patients receiving anticoagulants.
  • Safety and effectiveness of Remodulin in pediatric patients have not been established. It is unknown if geriatric patients respond differently than younger patients. Caution should be used when selecting a dose for geriatric patients.
  • There are no adequate and well-controlled studies with Remodulin in pregnant women. It is not known whether treprostinil is excreted in human milk.

Adverse Reactions

  • Adverse Reactions: In clinical studies of SC Remodulin infusion, the most common adverse events reported were infusion site pain and infusion site reaction (redness and swelling). These symptoms were often severe and sometimes required treatment with narcotics or discontinuation of Remodulin. The IV infusion of Remodulin has been associated with a risk of blood stream infections, arm swelling, paresthesias, hematoma, and pain. Other common adverse events (≥3% more than placebo) seen with either SC or IV Remodulin were headache, diarrhea, nausea, jaw pain, vasodilatation, and edema.

Indication

Remodulin is a prostacyclin vasodilator indicated for the treatment of pulmonary arterial hypertension (PAH; WHO Group 1) to diminish symptoms associated with exercise. Studies establishing effectiveness included patients with NYHA Functional Class II-IV symptoms and etiologies of idiopathic or heritable PAH (58%), PAH associated with congenital systemic-to-pulmonary shunts (23%), or PAH associated with connective tissue diseases (19%). It may be administered as a continuous subcutaneous infusion or continuous intravenous infusion; however, because of the risks associated with chronic indwelling central venous catheters, including serious blood stream infections, continuous intravenous infusion should be reserved for patients who are intolerant of the subcutaneous route or in whom these risks are considered warranted.

In patients with PAH requiring transition from Flolan® (epoprostenol sodium), Remodulin is indicated to diminish the rate of clinical deterioration. The risks and benefits of each drug should be carefully considered prior to transition.

References: 1. Remodulin [package insert]. Research Triangle Park, NC: United Therapeutics Corporation; 2014. 2. Simonneau G, Barst RJ, Galie N, et al; Treprostinil Study Group. Continuous subcutaneous infusion of treprostinil, a prostacyclin analogue, in patients with pulmonary arterial hypertension: a double-blind, randomized, placebo-controlled trial. Am J Respir Crit Care Med. 2002;165(6):800-804.