Transition from Flolan® (epoprostenol sodium) protocol1

  • Transition from Flolan to Remodulin is accomplished by initiating and increasing the infusion of Remodulin while simultaneously reducing the dose of intravenous (IV) Flolan. During the transition, Remodulin is initiated at a recommended dose of 10% of the current Flolan dose, then escalated as the Flolan dose is decreased
  • The transition to Remodulin should take place in a hospital with constant observation of response. This may include observation of vital signs and symptoms of disease progression
  • Patients are individually titrated to a dose that allows transition from Flolan therapy to Remodulin while balancing prostacyclin-limiting adverse reactions. Increases in the patient’s symptoms of PAH should be first treated with increases in the dose of Remodulin. Side effects normally associated with prostacyclin analogues are to be first treated by decreasing the dose of Flolan

Dosing transition from Flolan to Remodulin1

Step Flolan dose Remodulin dose
1 Unchanged 10% starting Flolan dose
2 80% starting Flolan dose 30% starting Flolan dose
3 60% starting Flolan dose 50% starting Flolan dose
4 40% starting Flolan dose 70% starting Flolan dose
5 20% starting Flolan dose 90% starting Flolan dose
6 5% starting Flolan dose 110% starting Flolan dose
7 0 110% starting Flolan dose + additional
5%-10% increments as needed

Transitioning your patients from Flolan® (epoprostenol sodium)

Remodulin is approved to diminish the rate of clinical deterioration in patients requiring transition from Flolan.1,2

  • Remodulin SC prevented clinical deterioration* in patients who were transitioned from Flolan
  • An 8-week, multicenter, randomized, placebo-controlled, withdrawal trial of 22 patients stable on epoprostenol therapy who were transitioned to Remodulin SC or placebo (2:1)
  • Safety findings were consistent with previous clinical trials of Remodulin SC

*Clinical deterioration was defined as an increase in Flolan dose, hospitalization due to PAH, or death (no patient died during this study).1

transition chart
transition chart

Figure adapted from Rubenfire M, et al. Chest. 2007, with permission.2

Transitioning from Flolan to Remodulin IV3

  • In a 12-week, multicenter, open-label, investigator-initiated trial, 31 patients receiving optimal doses of conventional therapies for PAH as well as a stable dose of IV epoprostenol for ≥1 month were transitioned from IV epoprostenol to Remodulin IV
  • 6MWD was maintained in patients transitioning from Flolan to Remodulin IV (438 m vs 439 m, respectively)
  • Borg dyspnea scores: no significant change from baseline to week 12

6MWD=6-minute walk distance; IV=intravenous; PAH=pulmonary arterial hypertension; SC=subcutaneous.

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.
+

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. Rubenfire M, McLaughlin VV, Allen RP, et al. Transition from IV epoprostenol to subcutaneous treprostinil in pulmonary arterial hypertension: a controlled trial. Chest. 2007;132(3):757-763. 3. Gomberg-Maitland M, Tapson VF, Benza RL, et al. Transition from intravenous epoprostenol to intravenous treprostinil in pulmonary hypertension. Am J Respir Crit Care Med. 2005;172(12):1586-1589.