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Inhaled prostacyclin offers cost-effective way to save lives

Skyrocketing costs for nitric oxide, the standard of care for patients requiring inhaled pulmonary vasodilator therapy, generated interest in finding a new way to safely and effectively treat pulmonary hypertension. In February 2010, Dr. Newton Seiden, pediatric anesthesiologist and intensivist, Children's Hospital Central California, attended a presentation at the University of Virginia that introduced the use of inhaled prostacyclin as an alternative pathway for pulmonary vasodilation.

Dr. SeidenChildren's Hospital spends $2,700 per day for each patient receiving treatment with nitric oxide. Prostacyclin, marketed under the brand name Flolan, costs less than $200 a day per patient. Dr. Seiden returned to the Hospital’s pediatric intensive care unit (PICU) eager to investigate the possibility of using nebulized Flolan to widen blood vessels in the vascular system in a safe and controlled modality.

“We started using it in PICU first,” said Larry Nicol, registered respiratory therapist and clinical educator at Children’s. “We had a complete buy-in with the intensivists, cardiac surgeons and cardiologists. All the PICU doctors were excited about giving it a try.”

Successful trial run

By April 2010 the experiment proved successful. Of the 25 patients receiving Flolan in increasing doses while being progressively weaned from nitric oxide, 19 were completely transitioned from gas to Flolan with no adverse events.

Initially the neonatology group was reluctant to deviate from the current standard of care for their babies in the neonatal intensive care unit (NICU). But when a critically ill infant was not responding to treatment with nitric oxide, the positive results in PICU convinced them to give Flolan a try. “We added the second pathway of inhaled prostacylin while keeping the patient on the maximum dose of nitric oxide,” said Nicol. “We were able to make a change in the patient we hadn’t seen on nitric oxide alone and that’s very exciting.”

In a second NICU case, a neonate was weaned from nitric oxide within four hours after starting Flolan and continued with the nebulized drug for 13 days. “We’re sharing our protocols and outcomes with approximately 40 other US hospitals,” said Nicol. “We’ve received requests for information from all over the world.” Nitric oxide remains the first line (rescue) drug at Children’s Hospital for pulmonary hypertension. However, after the gas is running, Flolan can be added at any time as determined by the attending physician. If a patient is completely weaned from nitric oxide, the gas is kept inline for backup.

Higher standard of care

“This alternate pathway for pulmonary vessel dilation has helped Children's raise the standard of care and reduce costs at the same time,” said Nicol. For example, the NICU patient’s 13 days of inhaled pulmonary vasodilator therapy at $200 per day for Flolan rather than $2,700 per day for nitric oxide resulted in $32,500 savings. Since introducing the use of inhaled prostacyclin two years ago at Children’s Hospital, 37 patients have received Flolan with no adverse events, and our total savings have surpassed $335,000.