Version May 2024
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) (ACCF/AHA [McLaughlin 2009]; ESC/ERS [Humbert 2022]).
Inhalation: 5 to 10 mcg delivered over 10 to 15 minutes (ESC/ERS [Humbert 2022]; Hernández-Oropeza 2018; Jing 2009).
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 (ACCP [Klinger 2019]; ESC/ERS [Humbert 2022]).
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).
There are no dosage adjustments provided in the manufacturer's labeling (has not been studied).
There are no dosage adjustments provided in the manufacturer's labeling (has not been studied).
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 (AHA/ATS [Abman 2015]; Hansmann 2016); highest reported daily dose: 100 mcg/day (Mulligan 2012); 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) (DiBlasi 2016).
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 (Limsuwan 2008).
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.
>10%:
Cardiovascular: Flushing (27%), hypotension (11%)
Central nervous system: Headache (30%), trismus (12%)
Gastrointestinal: Nausea (13%)
Neuromuscular & skeletal: Jaw pain (12%)
Respiratory: Cough (39%), flu-like symptoms (14%)
1% to 10%:
Cardiovascular: Syncope (8%), palpitations (7%)
Central nervous system: Insomnia (8%)
Endocrine & metabolic: Increased gamma-glutamyl transferase (6%)
Gastrointestinal: Vomiting (7%), glossalgia (4%)
Hepatic: Increased serum alkaline phosphatase (6%)
Neuromuscular & skeletal: Back pain (7%), muscle cramps (6%)
Respiratory: Hemoptysis (5%), pneumonia (4%)
<1%, postmarketing, and/or case reports: Bronchospasm, cardiac failure, chest pain, dizziness, dyspnea, dysgeusia, epistaxis, hypersensitivity reaction, mouth irritation, paradoxical reaction (increased post-void residual urine volume), renal failure, skin rash, supraventricular tachycardia, thrombocytopenia, tongue irritation, wheezing
There are no contraindications listed in the manufacturer's labeling.
Concerns related to adverse effects:
• 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]
No
Solution (Ventavis Inhalation)
10 mcg/mL (per mL): $169.72
20 mcg/mL (per mL): $169.72
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.
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 (Kahveci 2014). Efficacy may be impacted by drug delivery system (eg, type of nebulizer, placement in ventilator circuit, mode of ventilation) (DiBlasi 2016).
Pulmonary arterial hypertension: 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 Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.
Agents with Antiplatelet Properties (e.g., P2Y12 inhibitors, NSAIDs, SSRIs, etc.): Prostacyclin Analogues may enhance the antiplatelet effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy
Alfuzosin: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy
Amifostine: Blood Pressure Lowering Agents may enhance the hypotensive effect 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 enhance the hypotensive effect of Hypotension-Associated Agents. Risk C: Monitor therapy
Anticoagulants: Prostacyclin Analogues may enhance the adverse/toxic effect of Anticoagulants. Specifically, the antiplatelet effects of these agents may lead to an increased risk of bleeding with the combination. Risk C: Monitor therapy
Antipsychotic Agents (Second Generation [Atypical]): Blood Pressure Lowering Agents may enhance the hypotensive effect of Antipsychotic Agents (Second Generation [Atypical]). Risk C: Monitor therapy
Arginine: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy
Barbiturates: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy
Benperidol: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy
Blood Pressure Lowering Agents: Prostacyclin Analogues may enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy
Blood Pressure Lowering Agents: May enhance the hypotensive effect of Hypotension-Associated Agents. Risk C: Monitor therapy
Brimonidine (Topical): May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy
Bromperidol: May diminish the hypotensive effect of Blood Pressure Lowering Agents. Blood Pressure Lowering Agents may enhance the hypotensive effect of Bromperidol. Risk X: Avoid combination
Diazoxide: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy
DULoxetine: Blood Pressure Lowering Agents may enhance the hypotensive effect of DULoxetine. Risk C: Monitor therapy
Herbal Products with Blood Pressure Lowering Effects: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy
Hypotension-Associated Agents: Blood Pressure Lowering Agents may enhance the hypotensive effect of Hypotension-Associated Agents. Risk C: Monitor therapy
Levodopa-Foslevodopa: Blood Pressure Lowering Agents may enhance the hypotensive effect of Levodopa-Foslevodopa. Risk C: Monitor therapy
Lormetazepam: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy
Molsidomine: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy
Naftopidil: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy
Nicergoline: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy
Nicorandil: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy
Nitroprusside: Blood Pressure Lowering Agents may enhance the hypotensive effect of Nitroprusside. Risk C: Monitor therapy
Obinutuzumab: May enhance the hypotensive effect 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 enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy
Pholcodine: Blood Pressure Lowering Agents may enhance the hypotensive effect of Pholcodine. Risk C: Monitor therapy
Phosphodiesterase 5 Inhibitors: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy
Prostacyclin Analogues: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy
Quinagolide: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy
Silodosin: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy
Thrombolytic Agents: May enhance the adverse/toxic effect of Prostacyclin Analogues. Specifically, the antiplatelet effects of prostacyclin analogues may lead to an increased risk of bleeding when combined with thrombolytic agents. Risk C: Monitor therapy
Information related to the use of iloprost in pregnancy is limited (Elliot 2005; Horng 2016; Zhang 2018). Women with pulmonary arterial hypertension are encouraged to avoid pregnancy (McLaughlin 2009; Taichman 2014).
It is not known if iloprost is excreted in breast milk.
Due to the potential for serious adverse reactions in the breastfed infant, breastfeeding is not recommended by the manufacturer.
Heart rate, blood pressure, respiratory rate and adverse effects (eg, flushing, headache, nausea) 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.
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