PMC:3750932 / 77335-82613 JSONTXT

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\nEndothelium-derived prostaglandin I2 (PGI2), or prostacyclin, is an arachidonic acid produced by endothelial cells. Prostacyclin is a powerful systemic and pulmonary vasodilator and an inhibitor of platelet aggregation through the increase in intracellular cyclic adenosine monophosphate (cAMP) [206,207]. Moreover, prostacyclin plays an important role in antiproliferative, antithrombotic, antimitogenic and immunomodulatory activity [208]. Prostanoids are a family of prostacyclin analogues available in intravenous, subcutaneous, or inhaled form.\nEpoprostenol In the 1980s, intravenous epoprostenol was the first prostanoid evaluated in PAH [209]. As the half-life of epoprostenol is \u003c5 minutes, it requires an indwelling central venous catheter which is connected to an infusion pump for continuous intravenous administration. Treatment with epoprostenol is complex, uncomfortable and expensive and cannot be considered as an ideal treatment despite its evident clinical benefit. Common side effects associated with treatment include headache, flushing, jaw pain and gastrointestinal disturbance [201,210]. The efficacy of continuous i.v. administration of epoprostenol has been tested in three unblinded RCTs in idiopathic PAH [207,211] and PAH associated with systemic sclerosis [212].\nBarst and colleagues [183] showed improvement in exercise capacity with an increase in 6-MWD of 47meters after 12 months of epoprostenol treatment in 81 patients with idiopathic PAH. Moreover, a significant improvement of survival was observed (no death at three months of treatment in the group with epoprostenol against 8 deaths in the group receiving conventional treatment including diuretics and anticoagulants [213]. Long-term persistence of efficacy has also been shown [201,214] in idiopathic PAH, as well as in other associated PAH [215,216] and in non operable CTEPH [217]. Long term effectiveness has never been evaluated prospectively but retrospective analysis comparing patients treated by intravenous epoprostenol with data from patients treated with conventional therapy find meaningful clinical benefit for patients in NYHA FC III or IV [201,214,218,219]. Functional class, hemodynamic parameters and long term survival were all improved in the group treated with i.v. epoprostenol.\nEpoprostenol had initially been proposed as a bridging therapy for lung transplantation but it is currently regarded as the treatment of choice for patients in NYHA FC IV. If treatment with epoprostenol is necessary, it will be started at low dose of 2-4 ng/kg/min and is gradually increased to 10-16 ng/kg/min according to side effects [201]. Treatment interruption secondary to pump dysfunction or the rupture of the catheter, although rare, can induce serious adverse events [201]. Because of its route of administration, central venous catheter bloodstream infections can occur, and should be systematic searched in the context of unexplained clinical deterioration.\nTreprostinil Due to complications related to the central venous catheter used for the i.v. administration of epoprostenol, other prostacyclin agonists have been developed. Treprostinil is a prostacyclin analogue which benefits from a longer half-life of 58–83 minutes by subcutaneous administration [220]. It is delivered by a minipump similar to those used for insulin [221]. A multicenter randomized trial evaluated subcutaneous administrated treprostinil versus placebo over three months in patients in NYHA functional class II-IV suffering from idiopathic PAH, PAH related to CHD with a shunt or PAH associated with CTD [221]. Patients treated with treprostinil increased 6-MWD and had benefits like quality of life, pulmonary hemodynamics and improvement of clinical symptoms. Unfortunately, local side-effects such as pain and inflammation at the injection site are present in the majority of patients treated with treprostinil which often lead to limitation of increasing dose or treatment cessation. Intravenous treprostinil is only licensed for the use in the USA and provides the advantage of less frequent need for drug reservoir replacement [220]. Inhaled treprostinil was examined in a placebo-controlled TRIUMPH-1 study [222], but results of this formulation were not convincing and this product is not yet licensed outside the USA.\nInhaled Iloprost Iloprost is a prostacyclin analogue administered by inhalation or the intravenous route. The pulmonary vasodilating effects of inhaled iloprost lasts nearly 45 minutes, therefore six to nine inhalations daily are needed, with each of them requiring approximately 30 minutes [223,224]. Common side effects of treatment were cough, flushing, jaw pain and headache [223]. In the AIR study [223] conducted in at 37 European pulmonary hypertension centers, study participants (idiopathic PAH, PAH associated to systemic sclerosis, anorexigen associated PAH or non operable CTEPH) in functional class III or IV were assessed during a three month period. Patients received a daily inhalation of 2.5 μg or 5.0 μg of iloprost 6 or 9 times a day or placebo. After 3 months of treatment, 17% of patients receiving iloprost reached the combined endpoint of improvement in functional class and 10% gain in 6-MWD as compared to 5% in the placebo group."}