Version July 2025
Acute vasodilator testing in patients with pulmonary arterial hypertension (off-label use):
Note: Acute vasodilator testing is recommended in patients with idiopathic, heritable, or drug-induced pulmonary arterial hypertension to assess eligibility for treatment with a calcium channel blocker (eg, ER nifedipine) (Ref).
Inhalation: 5 to 10 mcg delivered over 10 to 15 minutes (Ref).
Frostbite:
Note: Dosage based on actual body weight.
Days 1 through 3:
IV: Initial: 0.5 ng/kg/minute; increase infusion rate by 0.5 ng/kg/minute every 30 minutes as tolerated up to a maximum dose of 2 ng/kg/minute; administer IV infusion over 6 hours each day.
Days 4 through 8:
IV: Initial: Start infusion at highest tolerated dose from previous day; adjust rate as needed based on tolerability. Administer IV infusion over 6 hours each day for a maximum of 8 days (total treatment).
Dose adjustments for adverse effects (eg, headache, flushing, jaw pain, myalgia, nausea, vomiting): IV: For dose-limiting adverse reactions that cannot be tolerated, decrease dose by 0.5 ng/kg/minute at 30-minute intervals until a tolerated dose is reached. If a dose-limiting adverse effect occurs at 0.5 ng/kg/minute, discontinue infusion and then consider reinitiation after adverse effect has resolved. If infusion is stopped at any point for a dose-limiting adverse effect, reinitiate at a previously tolerated infusion rate once the event has resolved and then maintain maximum tolerated dose for the remainder of the 6-hour infusion.
Pulmonary arterial hypertension:
Note: Consult a pulmonary arterial hypertension specialist for all management decisions; choice of therapy is dependent on etiology, risk stratification, cardiopulmonary comorbidities, and response to other agents. Prostacyclin analogues are generally reserved for initial therapy in high-risk patients or used as adjunctive therapy in patients who continue to deteriorate on oral agents (Ref).
Inhalation: Initial: 2.5 mcg/dose; if tolerated, increase to 5 mcg/dose. Administer each dose 6 to 9 times per day (dosing at intervals ≥2 hours while awake according to individual need and tolerability). Maintenance dose: 2.5 to 5 mcg/dose; maximum total daily dose: 45 mcg (ie, 5 mcg/dose 9 times daily).
Inhalation: There are no dosage adjustments provided in the manufacturer's labeling (has not been studied).
IV:
Altered kidney function:
Frostbite: Note: Dosage based on actual body weight.
eGFR ≥30 mL/minute: No dosage adjustment necessary.
eGFR <30 mL/minute: No dosage adjustment necessary; however, if patient cannot tolerate the starting dose of 0.5 ng/kg/minute then the dose can be lowered to 0.25 ng/kg/minute.
Hemodialysis, intermittent (thrice weekly): No dosage adjustment provided in manufacturer’s labeling (has not been studied). If possible, administer iloprost after the hemodialysis session has ended. Alternatively, can administer iloprost and wait at least 1 hour after the infusion has ended before beginning hemodialysis.
Inhalation: There are no dosage adjustments provided in the manufacturer's labeling (has not been studied).
IV:
Frostbite: Note: Dosage based on actual body weight.
Child-Turcotte-Pugh class A: There are no dosage adjustments provided in the manufacturer's labeling (has not been studied).
Child-Turcotte-Pugh class B and C (moderate to severe impairment): Initial: 0.25 ng/kg/minute; increase infusion rate by 0.5 ng/kg/minute every 30 minutes as tolerated to a maximum dose of 2 ng/kg/minute. Administer IV infusion over 6 hours each day for a maximum of 8 days.
Refer to adult dosing.
(For additional information see "Iloprost: Pediatric drug information")
Note: Avoid abrupt withdrawal or sudden large dose reductions when discontinuing therapy to prevent rebound pulmonary hypertension.
Pulmonary arterial hypertension (PAH): Limited data available: Infants, Children, and Adolescents: Inhalation: Initial: 2.5 mcg/dose; if initial dose is tolerated, titrate up to 5 mcg/dose; lower initial doses (ie, 1.25 mcg/dose) have been recommended for infants and small children by some experts. Administer 6 to 9 times daily with dosing intervals of every 2 to 3 hours while awake (Ref); highest reported daily dose: 100 mcg/day (Ref); usual adult maximum daily dose: 45 mcg/day.
Pulmonary hypertensive crisis, postoperative: Very limited data available: Note: Efficacy may be impacted by drug delivery system (eg, type of nebulizer, placement in ventilator circuit, mode of ventilation) (Ref).
Infants, Children, and Adolescents: Inhalation: Initial: 0.5 mcg/kg over 10 minutes; if no response seen, increase to 1 mcg/kg over 10 minutes and then to a maximum dose of 2 mcg/kg over 10 minutes; administer doses every 30 minutes up to 5 doses; dosing based on a prospective open label study that evaluated 8 pediatric patients (age range: 1 month to 13 years) who developed pulmonary hypertensive crisis following repair of congenital heart defects; all patients responded to iloprost as evidenced by a significant decrease in their mean arterial pressure and increase in oxygen saturation and were weaned off ventilation and discharged home. No adverse effects were observed (Ref).
There are no pediatric-specific recommendations; based on experience in adult patients, no adjustment is required in patients with renal impairment who are not on dialysis (the effect of dialysis on iloprost exposure is unknown).
There are no pediatric-specific recommendations; based on experience in adult patients, dosing adjustment may be considered in patients with moderate to severe impairment.
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Reported adverse reactions are for inhalation administration in adults unless otherwise indicated.
>10%:
Cardiovascular: Flushing (27%), hypotension (11%)
Gastrointestinal: Nausea (13%)
Nervous system: Headache (30%), trismus (12%)
Respiratory: Flu-like symptoms (14%), increased cough (39%)
1% to 10%:
Cardiovascular: Palpitations (7%), syncope (8%)
Gastrointestinal: Glossalgia (4%), vomiting (7%)
Hepatic: Increased gamma-glutamyl transferase (6%), increased serum alkaline phosphatase (6%)
Nervous system: Insomnia (8%)
Neuromuscular & skeletal: Back pain (7%), muscle cramps (6%)
Respiratory: Hemoptysis (5%), pneumonia (4%)
Frequency not defined:
Cardiovascular: Chest pain, heart failure, peripheral edema, supraventricular tachycardia
Renal: Kidney failure
Respiratory: Dyspnea
Postmarketing (any formulation):
Dermatologic: Skin rash
Gastrointestinal: Diarrhea, dysgeusia, oral irritation, tongue irritation
Hematologic & oncologic: Thrombocytopenia
Hypersensitivity: Hypersensitivity reaction
Nervous system: Dizziness
Respiratory: Bronchospasm, epistaxis, nasal congestion, wheezing
There are no contraindications listed in the manufacturer's labeling.
Concerns related to adverse effects:
• Hypotension: Hypotension may occur. Correct hypotension prior to administration. Consider temporary discontinuation of concomitant vasodilator of antihypertensive medications. If hypotension occurs during administration, consider down-titration or discontinuation.
• Pulmonary edema: If pulmonary edema occurs during administration, discontinue therapy immediately; may be a sign of pulmonary venous hypertension.
• Rebound pulmonary hypertension: Abrupt withdrawal/large dosage reductions may worsen symptoms of PAH. Immediate access to medication and back-up inhalation device is essential to prevent treatment interruptions.
• Syncope: Hypotension leading to syncope has been observed. Dosage or therapy adjustment may be required if exertional syncope occurs. Use caution with concurrent conditions or medications that may increase risk of syncope.
Disease-related concerns:
• Bleeding disorders: Use with caution in patients with active bleeding or at increased risk of bleeding (eg, concomitant anticoagulation); mild inhibitor of platelet aggregation when administered as an aerosol.
• Hypotension: Do not use in patients with hypotension (systolic BP <85 mm Hg).
• Respiratory disease: Safety and efficacy have not been established in patients with other concurrent pulmonary diseases (eg, COPD, severe asthma, or acute pulmonary infections); may induce bronchospasm in patients with hyper-reactive airways.
Other warnings/precautions:
• Administration: Intended for inhalation administration using only the I-neb AAD System. Solution should not come in contact with skin or eyes. Monitor vital signs during initiation.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution, Inhalation [preservative free]:
Ventavis: 10 mcg/mL (1 mL); 20 mcg/mL (1 mL) [contains alcohol, usp, tromethamine]
Solution, Intravenous:
Aurlumyn: 100 mcg/mL (1 mL) [contains alcohol, usp]
No
Solution (Aurlumyn Intravenous)
100 mcg/mL (per mL): $6,600.00
Solution (Ventavis Inhalation)
10 mcg/mL (per mL): $179.91
20 mcg/mL (per mL): $179.91
Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.
Inhalation: Immediate access to medication and a back-up inhalation device is essential to prevent treatment interruptions. Do not mix with other medications. For inhalation use only via the I-neb AAD System. Refer to the I-neb AAD System instructions for adding ampul contents to the medication chamber. The 20 mcg/mL concentration is intended for patients who are maintained at the 5 mcg dose and who have repeatedly experienced extended treatment times. After use, discard any solution remaining in I-neb AAD medication chamber and do not reuse, then clean the system. Do not orally ingest solution.
IV: Administer through a peripheral line or peripherally inserted central catheter using an infusion set with an in-line 0.22- or 0.2-micron filter. Infuse through an infusion pump that can deliver rates of 0.1 to 99.9 mL/hour, be adjustable at increments of 0.1 mL/hour, be accurate to within 5% of programmed rate, and uses positive continuous or pulsatile pressure. Use a PVC reservoir and infusion line set. Do not administer by IV bolus. Do not flush the catheter without withdrawing residual drug.
Inhalation: Immediate access to medication and a back-up inhalation device is essential to prevent treatment interruptions. Do not mix with other medications. Per the manufacturer, iloprost is for inhalation only via the I-neb AAD System. Refer to the I-neb AAD System instructions for adding ampule contents to the medication chamber. The 20 mcg/mL concentration is intended for patients who are maintained at the 5 mcg dose and who have repeatedly experienced extended treatment times. After use, discard remainder of the medicine; not for reuse. In neonatal patients, dilution of doses in 1 mL of NS has been reported (Ref). Efficacy may be impacted by drug delivery system (eg, type of nebulizer, placement in ventilator circuit, mode of ventilation) (Ref).
Frostbite (Aurlumyn): Treatment of severe frostbite in adults to reduce the risk of digit amputations.
Pulmonary arterial hypertension (Ventavis): Treatment of pulmonary arterial hypertension (World Health Organization group I) in patients with New York Heart Association functional class III or IV symptoms to improve exercise tolerance, symptoms, and diminish clinical deterioration.
Acute vasodilator testing in pulmonary arterial hypertension
None known.
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program by clicking on the “Launch drug interactions program” link above.
Alfuzosin: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Amifostine: Blood Pressure Lowering Agents may increase hypotensive effects of Amifostine. Management: When used at chemotherapy doses, hold blood pressure lowering medications for 24 hours before amifostine administration. If blood pressure lowering therapy cannot be held, do not administer amifostine. Use caution with radiotherapy doses of amifostine. Risk D: Consider Therapy Modification
Amisulpride (Oral): May increase hypotensive effects of Hypotension-Associated Agents. Risk C: Monitor
Antipsychotic Agents (Second Generation [Atypical]): Blood Pressure Lowering Agents may increase hypotensive effects of Antipsychotic Agents (Second Generation [Atypical]). Risk C: Monitor
Arginine: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Barbiturates: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Benperidol: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Blood Pressure Lowering Agents: May increase hypotensive effects of Hypotension-Associated Agents. Risk C: Monitor
Blood Pressure Lowering Agents: Prostacyclin Analogues may increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Brimonidine (Topical): May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Bromperidol: May decrease hypotensive effects of Blood Pressure Lowering Agents. Blood Pressure Lowering Agents may increase hypotensive effects of Bromperidol. Risk X: Avoid
Diazoxide: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
DULoxetine: Blood Pressure Lowering Agents may increase hypotensive effects of DULoxetine. Risk C: Monitor
Herbal Products with Blood Pressure Lowering Effects: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Hypotension-Associated Agents: Blood Pressure Lowering Agents may increase hypotensive effects of Hypotension-Associated Agents. Risk C: Monitor
Iloperidone: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Levodopa-Foslevodopa: Blood Pressure Lowering Agents may increase hypotensive effects of Levodopa-Foslevodopa. Risk C: Monitor
Lormetazepam: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Metergoline: May decrease antihypertensive effects of Blood Pressure Lowering Agents. Blood Pressure Lowering Agents may increase orthostatic hypotensive effects of Metergoline. Risk C: Monitor
Molsidomine: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Naftopidil: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Nicergoline: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Nicorandil: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Nitroprusside: Blood Pressure Lowering Agents may increase hypotensive effects of Nitroprusside. Risk C: Monitor
Obinutuzumab: May increase hypotensive effects of Blood Pressure Lowering Agents. Management: Consider temporarily withholding blood pressure lowering medications beginning 12 hours prior to obinutuzumab infusion and continuing until 1 hour after the end of the infusion. Risk D: Consider Therapy Modification
Pentoxifylline: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Pholcodine: Blood Pressure Lowering Agents may increase hypotensive effects of Pholcodine. Risk C: Monitor
Phosphodiesterase 5 Inhibitors: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Prostacyclin Analogues: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Quinagolide: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Silodosin: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Data related to the use of inhaled iloprost during pregnancy are limited (Elliot 2005; Horng 2016; Luo 2020; Rudienė 2022; Streit 2009; Terek 2013; Zhang 2018). Untreated pulmonary arterial hypertension (PAH) in pregnancy increases the risk for maternal heart failure, stroke, preterm delivery, low birth weight, and maternal/fetal death. Patients with PAH are encouraged to avoid becoming pregnant. Based on limited data, treatment with inhaled prostacyclin analogues may be acceptable when treatment during pregnancy is needed (ESC/ERS [Humbert 2022]).
It is not known if iloprost is present in breast milk.
Due to the potential for serious adverse reactions in the breastfed infant, breastfeeding is not recommended by the manufacturer.
Heart rate, BP, respiratory rate and adverse effects (eg, flushing, headache, nausea, jaw pain) at baseline and with dosage adjustment. Monitor for improvements in pulmonary function, decreased exertional dyspnea, fatigue, syncope and chest pain, and quality of life.
Acutely, iloprost dilates systemic and pulmonary arterial vascular beds. With longer-term use, alters pulmonary vascular resistance and suppresses vascular smooth muscle proliferation. In addition, it is a mild endogenous inhibitor of platelet aggregation when aerosolized (Beghetti 2002).
Duration: 30 to 60 minutes
Distribution: Vd: IV: 0.7 to 0.8 L/kg
Protein binding: ~60%, primarily to albumin
Metabolism: Hepatic via beta oxidation of the carboxyl side chain; main metabolite, tetranor-iloprost (inactive in animal studies)
Half-life elimination: 20 to 30 minutes (effect), 7 to 9 minutes (elimination)
Time to peak, serum: Within 5 minutes after inhalation
Excretion: Urine (68% as metabolite); feces (12%)
Altered kidney function: Inhaled iloprost has not been evaluated in subjects with impaired renal function. In a study with IV infusion of iloprost in patients with ESRD requiring intermittent dialysis treatment, the mean AUC0-4h was 230 pg•h/mL compared with 54 pg•h/mL in patients with renal failure not requiring intermittent dialysis, and 48 pg•h/mL in healthy patients. The half-life was similar in both groups.
Hepatic function impairment: Inhaled iloprost has not been evaluated in subjects with impaired hepatic function. In an IV iloprost study in patients with liver cirrhosis, the mean Cl in Child-Pugh class B subjects was approximately 10 mL/min/kg (half that of healthy patients). Following oral administration, the mean AUC0-8h in Child-Pugh class B patients was 1,725 pg•h/mL compared with 117 pg•h/mL in healthy subjects receiving the same oral iloprost dose. In Child-Pugh class A subjects, the mean AUC0-8h was 639 pg•h/mL. Although exposure increased with hepatic impairment, there was no effect on half-life.
