Practical Considerations for Managing Transitions from Parenteral Prostacyclins to Oral Selexipag in Pulmonary Arterial Hypertension

The prostacyclin pathway represents a foundational pathway in the treatment of patients with pulmonary arterial hypertension (PAH). Parenteral prostacyclin pathway agents (PPAs) are often used for treatment of severe PAH but their broader use is limited by administration difficulties, including a need for continuous infusion, administration side effects, and complexities of a chronic indwelling catheter. Administration of the prostacyclin receptor agonist selexipag, an oral therapy with more than 10 years' clinical experience, may be more favorable for some patients. However, treatment protocols for transitioning from parenteral PPAs to oral selexipag are lacking. Here, we describe practical considerations for managing such transitions. The transition process requires an individualized and shared decision-making approach between the patient and multidisciplinary team to optimize treatment outcomes. Key considerations include patient selection criteria, setting expectations, transition setting (inpatient vs outpatient), transition speed, dose adjustment, and clinical follow-up. Appropriate patient candidates for transition to oral selexipag should be clinically stable and selected based on a comprehensive evaluation using validated risk scores and hemodynamic parameters. Expectations and realistic treatment goals should be discussed collaboratively and must include the possibility of returning to parenteral PPAs if clinically indicated. Transition protocols should be flexible and tailored to each patient. Outpatient transition may be considered depending on transition speed, the patient's ability to follow dosing instructions, and access to emergency care if needed. Speed of the transition to oral selexipag varies based on individual patient needs. Close monitoring and long-term follow-up are essential following transitions to maximize success and patient safety. In summary, transitioning from parenteral PPAs to oral selexipag can be challenging and complex. However, success is achievable for suitable patients through careful planning, setting transparent expectations, and an individualized approach with close monitoring and long-term follow-up.Graphical abstract available for this article.