Novel use of riociguat in infants with severe pulmonary arterial hypertension unable to wean from inhaled nitric oxide
IntroductionRiociguat, an oral soluble guanylate cyclase stimulator, has been approved for use in adults with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension. However, there is limited data on its therapeutic use in children.Case PresentationWe report the case...
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Frontiers Media S.A.
2022-12-01
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| Series: | Frontiers in Pediatrics |
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| Online Access: | https://www.frontiersin.org/articles/10.3389/fped.2022.1014922/full |
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| author | L. T. Domingo D. D. Ivy S. H. Abman A. M. Grenolds J. T. MacLean J. A. Breaux K. J. Minford B. S. Frank |
| author_facet | L. T. Domingo D. D. Ivy S. H. Abman A. M. Grenolds J. T. MacLean J. A. Breaux K. J. Minford B. S. Frank |
| author_sort | L. T. Domingo |
| collection | DOAJ |
| description | IntroductionRiociguat, an oral soluble guanylate cyclase stimulator, has been approved for use in adults with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension. However, there is limited data on its therapeutic use in children.Case PresentationWe report the case of two infants with severe suprasystemic pulmonary hypertension who were successfully treated with riociguat after failure to wean off inhaled nitric oxide (iNO) despite combination PAH therapy. Case 1 is a 6-month-old term male with TBX4 deletion who presented with severe hypoxemic respiratory failure and severe PAH immediately after birth. Initial cardiac catheterization showed PVRi 15.5 WU*m2. Marked hypoxemia and PAH persisted despite aggressive therapy with sildenafil, bosentan, intravenous treprostinil, and milrinone. The infant required high doses of inhaled nitric oxide (60 ppm) and manifested significant post-ductal hypoxemia and hemodynamic instability with any attempt at weaning. After discontinuation of sildenafil, initiation, and very slow uptitration of riociguat, the patient was able to maintain hemodynamic stability and wean from nitric oxide over 6 weeks with persistently severe but not worsened pulmonary hypertension. Case 2 is a 4-month-old term male with compound heterozygous SLC25A26 mutation and severe pulmonary hypertension. Initial cardiac catheterization showed PVRi 28.2 WU*m2. After uptitration of sildenafil, bosentan, and IV treprostinil, serial echocardiograms continued to demonstrate near-systemic pulmonary hypertension. He failed multiple attempts to wean off typical doses of iNO (10–20 ppm) over the following weeks with tachypnea, hypoxemia, and worsening pulmonary hypertension on echocardiogram despite continued aggressive combination targeted therapy. After a 24-h sildenafil washout, he was initiated and uptitrated on riociguat with concomitant, successful wean of nitric oxide over one week that was well tolerated. No serious adverse effects in the titration period were observed.ConclusionRiociguat may be considered as an adjuvant therapeutic agent in selected children with severe PAH who are poorly responsive to sildenafil therapy and unable to wean from iNO. |
| first_indexed | 2024-04-11T07:54:29Z |
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| id | doaj.art-11bfa1b253744b86ba5fef737de2dfac |
| institution | Directory Open Access Journal |
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| language | English |
| last_indexed | 2024-04-11T07:54:29Z |
| publishDate | 2022-12-01 |
| publisher | Frontiers Media S.A. |
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| spelling | doaj.art-11bfa1b253744b86ba5fef737de2dfac2022-12-22T04:35:58ZengFrontiers Media S.A.Frontiers in Pediatrics2296-23602022-12-011010.3389/fped.2022.10149221014922Novel use of riociguat in infants with severe pulmonary arterial hypertension unable to wean from inhaled nitric oxideL. T. Domingo0D. D. Ivy1S. H. Abman2A. M. Grenolds3J. T. MacLean4J. A. Breaux5K. J. Minford6B. S. Frank7Department of Pediatrics, Primary Children's Hospital, University of Utah, Salt Lake, UT, United StatesDepartment of Pediatrics, Children's Hospital of Colorado, University of Colorado, Aurora, CO, United StatesDepartment of Pediatrics, Children's Hospital of Colorado, University of Colorado, Aurora, CO, United StatesDepartment of Pediatrics, Children's Hospital of Colorado, University of Colorado, Aurora, CO, United StatesDepartment of Pediatrics, Children's Hospital of Colorado, University of Colorado, Aurora, CO, United StatesDepartment of Pediatrics, Children's Hospital of Colorado, University of Colorado, Aurora, CO, United StatesDepartment of Pediatrics, Primary Children's Hospital, University of Utah, Salt Lake, UT, United StatesDepartment of Pediatrics, Children's Hospital of Colorado, University of Colorado, Aurora, CO, United StatesIntroductionRiociguat, an oral soluble guanylate cyclase stimulator, has been approved for use in adults with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension. However, there is limited data on its therapeutic use in children.Case PresentationWe report the case of two infants with severe suprasystemic pulmonary hypertension who were successfully treated with riociguat after failure to wean off inhaled nitric oxide (iNO) despite combination PAH therapy. Case 1 is a 6-month-old term male with TBX4 deletion who presented with severe hypoxemic respiratory failure and severe PAH immediately after birth. Initial cardiac catheterization showed PVRi 15.5 WU*m2. Marked hypoxemia and PAH persisted despite aggressive therapy with sildenafil, bosentan, intravenous treprostinil, and milrinone. The infant required high doses of inhaled nitric oxide (60 ppm) and manifested significant post-ductal hypoxemia and hemodynamic instability with any attempt at weaning. After discontinuation of sildenafil, initiation, and very slow uptitration of riociguat, the patient was able to maintain hemodynamic stability and wean from nitric oxide over 6 weeks with persistently severe but not worsened pulmonary hypertension. Case 2 is a 4-month-old term male with compound heterozygous SLC25A26 mutation and severe pulmonary hypertension. Initial cardiac catheterization showed PVRi 28.2 WU*m2. After uptitration of sildenafil, bosentan, and IV treprostinil, serial echocardiograms continued to demonstrate near-systemic pulmonary hypertension. He failed multiple attempts to wean off typical doses of iNO (10–20 ppm) over the following weeks with tachypnea, hypoxemia, and worsening pulmonary hypertension on echocardiogram despite continued aggressive combination targeted therapy. After a 24-h sildenafil washout, he was initiated and uptitrated on riociguat with concomitant, successful wean of nitric oxide over one week that was well tolerated. No serious adverse effects in the titration period were observed.ConclusionRiociguat may be considered as an adjuvant therapeutic agent in selected children with severe PAH who are poorly responsive to sildenafil therapy and unable to wean from iNO.https://www.frontiersin.org/articles/10.3389/fped.2022.1014922/fullriociguatpediatric pulmonary arterial hypertensionpulmonary vasodilatortargeted therapypulmonary vasoreactivityTBX4 mutation |
| spellingShingle | L. T. Domingo D. D. Ivy S. H. Abman A. M. Grenolds J. T. MacLean J. A. Breaux K. J. Minford B. S. Frank Novel use of riociguat in infants with severe pulmonary arterial hypertension unable to wean from inhaled nitric oxide Frontiers in Pediatrics riociguat pediatric pulmonary arterial hypertension pulmonary vasodilator targeted therapy pulmonary vasoreactivity TBX4 mutation |
| title | Novel use of riociguat in infants with severe pulmonary arterial hypertension unable to wean from inhaled nitric oxide |
| title_full | Novel use of riociguat in infants with severe pulmonary arterial hypertension unable to wean from inhaled nitric oxide |
| title_fullStr | Novel use of riociguat in infants with severe pulmonary arterial hypertension unable to wean from inhaled nitric oxide |
| title_full_unstemmed | Novel use of riociguat in infants with severe pulmonary arterial hypertension unable to wean from inhaled nitric oxide |
| title_short | Novel use of riociguat in infants with severe pulmonary arterial hypertension unable to wean from inhaled nitric oxide |
| title_sort | novel use of riociguat in infants with severe pulmonary arterial hypertension unable to wean from inhaled nitric oxide |
| topic | riociguat pediatric pulmonary arterial hypertension pulmonary vasodilator targeted therapy pulmonary vasoreactivity TBX4 mutation |
| url | https://www.frontiersin.org/articles/10.3389/fped.2022.1014922/full |
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