Specialty pharmacy data reveal trends in oral treprostinil initiations and persistence with therapy
Presenter:
Daniel J. Lachant, DO, Assistant Professor of Medicine, University of Rochester Medical Center, Rochester, NY
Insights from a specialty pharmacy data set show that transitioning from parenteral treprostinil may be an effective strategy to facilitate tolerability of oral treprostinil—and may in turn lead to higher persistence with therapy.
The mean starting dose of oral treprostinil in patients with pulmonary arterial hypertension has increased steadily in recent years, suggesting that more patients are transitioning from parenteral treprostinil than starting de novo, according to a recent analysis of specialty pharmacy data.
In addition, patients transitioning to oral treprostinil had a higher rate of persistence with therapy at 6 months relative to de novo starts, according to the analysis, which was presented in a poster session at CHEST 2024.
Poster authors said an induction approach of parenteral-to-oral treprostinil transition may be suitable for patients with pulmonary arterial hypertension who need to reach effective oral treprostinil doses in a shorter period of time with careful consideration for adverse event management.
“In patients who don't have 6 months to wait to titrate up to a therapeutic dose with oral treprostinil, induction allows for that dose to be achieved in less than 4 weeks,” investigator Daniel J. Lachant, DO, said in an interview. “The side effects are also much less, which improves tolerability.”
In their evaluation of specialty pharmacy shipment data, investigators found an increase in patients receiving an initial starting dose of oral treprostinil that Dr. Lachant said could only be achieved after transitioning from parenteral treprostinil.
Oral treprostinil, approved for the treatment of pulmonary artery hypertension, can be initiated de novo. However, results of the EXPEDITE study showed that induction with parenteral treprostinil was a faster and better tolerated approach to achieving therapeutic dosing with oral treprostinil, according to Dr. Lachant.
“We are also observing that patients who have a good clinical response to parenteral treprostinil (> 6 months) are being transitioned to oral treprostinil when appropriate,” said Dr. Lachant in the interview.
“We think this data shows that both strategies are being utilized effectively in the real-world setting, and that incorporating parenteral treprostinil is likely a better way to achieve therapeutic dosing with oral treprostinil in select patients,” he added.
In their study, Dr. Lachant and colleagues utilized specialty pharmacy shipment data to characterize real-world oral treprostinil initiations, the starting oral treprostinil total daily dose, persistence with therapy, and trends over time.
The shipment data was collected from a representative sample of 500 randomly selected patients per year from 2017, 2020, and 2023, for a total of 1,500 patients.
De novo patients were defined as those with a first oral treprostinil total daily dose of less than 6 mg. Stable transition/induction patients were defined as patients with a first oral total daily treprostinil dose of at least 6 mg. These dosing thresholds align with previously published data of starting total daily dose for stable transition/induction patients, according to the authors.
In the specialty pharmacy data set, the proportion of patients classified as de novo decreased over time, from 78% of the total population in 2017, to 68% in 2020, and 61% in 2023. Accordingly, the proportion of stable transition/induction patients increased from 22% in 2017, to 32% in 2020, and 39% in 2023.
In addition, the mean starting oral treprostinil total daily dose increased over time, which the authors say reflects a greater proportion of patients transitioning from parenteral treprostinil rather than starting oral treprostinil de novo.
Overall, the mean total daily doses increased from 6.0 mg in 2018, to 8.1 mg in 2020, and 9.0 mg in 2023.
Mean starting total daily doses were in the 1.3–1.5 mg range in the de novo group, and 21.2–22.5 mg in the stable transition/induction group.
Transitioning from parenteral treprostinil may also lead to higher persistence with therapy, according to investigators.
Mean persistence at 3 months was 75% for de novo patients and 78% for stable transition/induction patients. At 6 months, mean persistence was 61% in the de novo patients and 68% in the stable transition/induction patients.
Taken together, the results suggest that induction and transition are effective strategies in real-world settings, according to Dr. Lachant.
“Incorporating parenteral treprostinil—either with induction or transition—is a better way, with less side effects, to achieve therapeutic dosing with oral treprostinil,” he said.
Disclosures:
The study was sponsored by United Therapeutics.
Suggested Reading:
Kingrey JF, Miller CE, Franco V, et al. Implementing the EXPEDITE parenteral induction protocol: Rapid parenteral treprostinil titration and transition to oral treprostinil. Pulm Circ 2023; 13(3):e12255. doi: 10.1002/pul2.12255.
Miller CE, Franco V, Smith JS, et al. Parenteral treprostinil induction for rapid attainment of therapeutic doses of oral treprostinil. Respir Med 2023; 218:107374. doi: 10.1016/j.rmed.2023.107374.