Scleroderma and PAH Overview. PH Resource Network Martha Kingman, FNP C UTSW Medical Center at Dallas

Transcription

1 Scleroderma and PAH Overview PH Resource Network 2007 Martha Kingman, FNP C UTSW Medical Center at Dallas

2 Scleroderma and PAH Outline: Lung involvement in scleroderma Evaluation of the scleroderma patient Clinical trials in scleroderma Unique complications and considerations of PAH treatment in these patient Q and A

3 Scleroderma and the Lung Alveolitis Inflammation of lungs air sacs Interstitial fibrosis Thickening (fibrosis) of space between air sacs and capillaries in lungs Recurrent aspiration Recurring gastroesophageal back-up into respiratory pathway Pulmonary vasculopathy Disorder of or damage to pulmonary blood vessels The major clinical issue is defining the relative contribution of o each process and choosing the appropriate therapy

4 Scleroderma and the Lung % Neither Isolated PAH Isolated fibrosis Both PAH and fibrosis Chang B et al. J Rheumatol. 2006;33:

5 Profiles of Lung Disease in Scleroderma Diffuse Scleroderma Limited Scleroderma (CREST)

6 Evaluation of PAH in Scleroderma: Basic Principles Screening, early evaluation Accurate diagnosis, full evaluation Serial monitoring

7 Evaluation of PAH in Scleroderma History, exam Pulmonary Function Test (PFT) Radiology (chest X-ray, high resolution CT) 6-minute-walk (6MW) test Echocardiography/Doppler Right Heart Catheterization

8 Causes of Shortness of Breath in Scleroderma Interstitial Lung Disease Pulmonary Arterial Hypertension Left Heart Disease Anemia Physical deconditioning

9 Scleroderma and PAH Recommended Screening Patient newly diagnosed with scleroderma Perform baseline ECHO and PFT* Patient with existing diagnosis of scleroderma Consider annual ECHO and PFT* *Full PFTs with DLCO. McGoon M et al for the American College of Chest Physicians. Chest. 2004;126:14S-34S.

10 PAH in Scleroderma: Survival 1.0 May Be Improving 0.8 Bosentan-treated group (CTE) Survival Historical control group (HCG) Time since diagnosis (yrs) Williams DH et al. Heart. 2006;92:

11 Epoprostenol Effect on Exercise Capacity Scleroderma With PAH: Treated Versus Control Median Change in 6MWD (m) Conventional (55) Flolan (56) P= P=0.001 Week 1 Week 6 Week MWD=Six minute walk distance. Barst RJ, et al. N Eng J Med. 1996;334: Badesch DB, et al. Ann Int Med. 2000;132:

12 PAH in Scleroderma: Take-home Messages Early recognition necessitates regular screening Full-expert evaluation and accurate diagnosis: integrated, multidisciplinary team approach Pulmonologist, cardiologist, gastroenterologist, rheumatologist Right heart catheterization is required for accurate diagnosis

13 PAH in Scleroderma: Take-home Messages Early treatment may be important Both supportive and specific therapies used Which is the best treatment? Combination? Close monitoring, assessment of response Best care provided in specialized centers

14 PAH Treatment in Systemic Sclerosis: Cautionary Tales Catherine J. Markin, MD Oregon Health & Sciences University

15 PAH in SScl IPAH

16 SScl PAH vs. IPAH The same but different Worse survival PAH +/- interstitial lung disease Multi-organ involvement Skin (Raynaud s) Cardiac Renal GI

17 Nail fold Capillaroscopy increased diameter reduced numbers increased visibility bushy and bizarre shapes punctate hemorrhages

18 Common Vascular Pathology

19 Evidenced-Based Treatment Continuous Intravenous Epoprostenol in PH Due to Scleroderma Spectrum of Diseases. Badesch, et al. Ann Int Med Treprostinil, a prostacyclin analogue, in pulmonary arterial hypertension associated with connective tissue disease. Oudiz, et al. Chest Bosentan: BREATHE-1, BREATHE-2 Sildenafil: SUPER-1, SUPER-2 Ambrisentan: ARIES-1, ARIES-2

20 Anticoagulation in SScl No prospective, randomized trials Vascular ectasias predispose pts to bleeding Epistaxis GI bleeding High flow oxygen Sildenafil or prostanoid therapy may increase bleeding risk

21 Bacteremia Risks SScl alone does not increase risk Immunosuppressive medications Cyclophosphamide, methotrexate, mycophenylate T cell dysfunction Bone marrow suppression Continuous infusion prostanoid therapy

22 Liver Toxicity Question: Is there an increased risk of liver toxicity with use of endothelin-1 blockade in systemic sclerosis patient? Answer: Liver involvement in SScl is uncommon No significant increased risk for SScl group in large clinical trials Pts with significant liver disease (elevated transaminases) were excluded from pivotal trials

23 Cardiac Involvement Coronary Artery Vasospasm/Sudden death Pericardial fibrosis Myocardial involvement Fixed deficits on myocardial perfusion studies 69% diffuse SScl, 64% limited SScl Involvement: RV > septum > LV Preserved LV systolic function, impaired diastolic

24 LV Diastolic Dysfunction Stiff, non-compliant ventricle Impaired relaxation Elevated end-diastolic pressure May result in pulmonary edema Made worse with shortened diastole (high HR) Potential complications with PAH meds Endothelin-1 blockade: Na/water retention Prostanoid therapy: elevated LVEDP

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26 Raynauds/Digital Ulcers Digital ulcers in systemic sclerosis: Prevention by treatment with bosentan, an oral endothelin receptor antagonist. Korn, et al. Arth Rheum RAPIDS-1 Phosphodiesterase Type 5 Inhibition is a novel therapeutic option in Raynauds disease. Caglayan E, et al. Arch Int Med Multiple reports of tx of Raynaud s crisis with prostanoid therapy.

27 Questions?