Vol. 48. No. 8, 2006
`Journal of the American College of Cardiology
`ISSN 0735-109TIW532ID
`9 2006 by the American College of Carrliolngr Foundation
`
`Published by Elsevier Inc. doi:10.1016fj.jacc.2006.06.062
`
`Pulmonary Vascular Disease
`
`Favorable Effects of Inhaled
`Treprostinil in Severe Pulmonary Hypertension
`Results From Randomized Controlled Pilot Studies
`
`Robert Voswinckel, MD,* Beate Enke, MD,* Frank Reichenberger, MD,* Markus Kohstall, MD,*
`Andree Kreckel, MD,* Stefanie Krick, MD,* Henning Gall, MD,* Tobias Gessler, MD, PHD,*
`Thomas Schmehl, PHD,’ Hossein A. Ghofrani, MD,‘ Ralph Theo Schermuly, PI—ID,*
`Friedrich Grimminger, MD, PHD,‘ Lewis] Rubin, MD,‘I‘ Werner Seeger, MD,‘ Horst Olschewski, MD’i
`
`Grease, Germany; La folio, Caffimr'a; and Graz, Austria
`OBJEC‘IWES
`
`BACKGROUND
`
`IIIEI'HOIJS
`
`RESULTS
`
`DONOLUSIONS
`
`This study sought to investigate the effects of inhaled treprostinil on pulmonary hemody—
`namics and gas exchange in severe pulmonary hypertension.
`Inhaled iloprost therapy has a proven clinical efficacy in pulmonary arterial hypertension, but
`this therapy necessitates 6 to 9 inhalation sessions per day. Treprostinil has a longer plasma
`half—life and might provide favorable properties when applied by inhalation.
`Three different studies were conducted on a total of 123 patients by means of right heart
`catheterization: 1) a randomized crossover—design study (44 patients), 2) a dose escalation
`study (31 patients), and 3) a study of reduction of inhalation time while keeping the dose fixed
`(48 patients). The primary end point was the change in pulmonary vascular resistance (PVR).
`The mean pulmonary arterial pressure of the enrolled patients was approximately 50 mm Hg
`in all studies. In study 1, both treprostinil and iloprost at an inhaled dose of 7.5 pg displayed
`a comparable PVR decrease, with a significantly different time course (p < 0.001), treprostinil
`showing a more sustained effect on PVR (p < 0.0001) and fewer systemic side effects. In
`study 2. effects of inhalation were observed for 3 h. A near—maximal acute PVR decrease was
`observed at 30 lrag treprostinil. In study 3, treprostinil was inhaled at increasing concentrations
`with a pulsed ultrasonic nebulizcr, mimicking a metered dose inhaler. A dose of 15 pg
`treprostinil was inhaled with 18, 9, 3, 2 pulses, or 1 pulse, each mode achieving comparable,
`sustained pulmonary vasodilation without significant side effects.
`Inhaled treprostinil exerts sustained pulmonary vasodilation with excellent tolerability at
`relatively low doses and may be inhaled in a few breaths. G Am Coll Cardiol 2006;48:
`1672—81) © 2006 by the American College of Cardiology Foundation
`
`New therapies for pulmonary arterial hypertension have
`shown clinical efficacy, but there remains a need for further
`improvement
`(1). Continuous intravenous infusion of
`epoprostenol improves hemodynamies, quality of life, and
`survival. The stable prostacyclin analog treprostinil might
`
`From the 'Dcpartment of internal Medicine. University Hospital Gicsscn, Gius-
`scn. Germany, the ‘I‘Division of Pulmonary and Critical Care Medicine, University of
`California. San Diego School of Medicine. La Jolla, California; and the :I:Division of
`l‘ulmonelegy. Medical University Graz, Graz, Austria. Drs. Gcsslcr and Sclnnehl are
`holders ofa patent ofthc technology of the IloNeb ultrasonic nebulization device. Dr.
`Ghofrani received grant and. contract support from Pfizer Ltd.., Altana Pharma AG.
`Schcring AG, and served on the advisory board of Pfizer Ltd. Dr. Grimmingcr
`received grant and contract support from Pfizer Ltd. and Altana Pharma AC. Dr.
`Rubin received research grants from the NIH and industry-sponsored grams; served
`as a consultant for Actclion, United 'I'hcrapc‘utics, Pfizer, Myogcn, Schcring, Nitrox,
`MondoBiotech, and CoTherix; and received stock options in United Therapeutics for
`service on the Scientific Advisory Board. Dr. Sccgcr received grant and contract
`support from Schering. Altana Pharma. Myogen Inc. Westminster, LungRX. and
`Avent-is Pharrna. Dr. Olschewski was a consultant and investigator for ScheringAG.
`LungRX, CoThcrix, Encysive. and Myngcn; received research grants from Scherin-
`gAG and LungRX; received treprostinil from Lung RX and inhalation devices from
`nchu—tcc; and used iloprost, sildcnafil, and treprostinil off—label for treatment 0F
`pulmonary hypertension. This work was financially supported by Lung RX Inc..
`Satellite Beach. Florida. Dr. Bruce H. Brundagc acted as the guest editor fiat this
`paper.
`Manuscript received February 21, 2006; revised manuscript received May 30. 2006.
`accepted June 13. 2006.
`
`intravenous
`have comparable clinical effects (2-4), but
`therapy is prone to catheter-related infections, drug toler-
`ance, and major systemic side effects. The inhalation of
`iloprost
`is clinically eflieaeious in patients with severe
`pulmonary arterial hypertension (5) and was recently ap-
`proved for use in Europe, Australia, and the US. However,
`6 to 9 iloprost inhalation sessions daily with 6— to 12—min
`inhalation times are recommended, consuming considerable
`time every day.
`The stable prostaeyelin analog treprostinil has been
`approved in the U.S., Israel, Australia, and Canada for
`treatment of pulmonary arterial hypertension (New York
`Heart Association functional class II to IV) and by the
`European Medical Agency for idiopathic PAH (New
`York Heart Association functional class III) via contin-
`uous subcutaneous infusion (6) and continuous intrave-
`nous infusion (4). Subcutaneous application circumvents
`septic events caused by catheter infections related to
`intravenous infusion; however,
`local pain and tissue
`reaction at the infusion site may limit efibctive dosing and
`long-term treatment. Treprostinil possesses
`a longer
`plasma half—life than iloprost (7) and may show alterna—
`tive tissue binding characteristics that could result
`in
`
`UNITED THERAPEUTICS, EX. 2059
`
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`Page 1 of 10
`
`

`

`JACC Vol. 48, No. 8, 2006
`October 17. 2006:1672—81
`
`Voswindtel ef al.
`Inhaled Treprnsfinl in Pulmonary Hypertension
`
`1673
`
`
`
`Abbreviations and Acronyms
`.
`:33]: = pulmoncaltry viscular resustanee
`=areaunerteeurve
`ABC 2 areas between curves
`.
`.
`PAP
`pulmonary arterial pressure
`SAP
`systemlc arterial pressure
`
`.
`.
`.
`favorable pharmacodynarnIc features when delIvered Vla
`the Inhaled route. A recent case report suggests that
`.
`..
`.
`.
`.
`inhaled treprostInII mIght be tolerable and efl'icaCIous In
`.
`.
`.
`the long term (8).
`-
`-
`-
`-
`-
`We asked whether Inhaled treprostrnrl had acute pul-
`rnonary vasodIlatIve propertIes and whether It rnIght be
`.
`.
`.
`.
`.
`superIor to Inhaled Iloprost In terms of duratIon ofeffect
`.
`.
`.
`and systemlc sIde effects. We then Increased both the
`total Inhaled dose to define a threshold for systemlc stde
`effects, and the drug concentration to reduce the inhala—
`.
`.
`non tIme.
`
`METHODS IND PATIHIITS
`.
`.
`.
`.
`.
`All studIes were approved by the InstItutIonal ethIcs come
`.
`.
`.
`.
`.
`.
`rnIttee of the UruverSIty of GIessen, and ertten Informed
`consent was obtained from all 123 enrolled patients. All
`.
`.
`.
`.
`.
`.
`Inhalatrons were performed w1th the OptIneb ultrasomc
`nebulIzer (Nebutec, Elsenfeld, Germany).
`'
`_
`'
`_
`'
`Study 1 was a ran-dornIzedt open label,
`sIngle bhnd
`.
`.
`.
`crossover study. The pnrnary ObJCCthC was to compare the
`acute hemodynamlc effects and the systemIc sIde effects of
`.
`.-
`-
`-
`-
`Inhaled treprostlml w1th Inhaled Iloprost at comparable
`.
`.
`doses. A total number of 44 patrents w1th moderate to
`.
`.
`.
`.
`.
`.
`severe precapIIIary pulmonary hypertensIon were enrolled.
`PatIent characterIstIcs and hemodynamIc as well as gas
`.
`.
`.
`.
`exchange parameters are outlined in Table 1.
`Each patIent underwent nght heart cathetenzatron and
`.
`.
`.
`.
`.
`.
`.
`.
`.
`Inhaled both Iloprost and treprostmIl on the same day
`durrng hemodynamrc momtormg. The drugs were admIn-
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`1stered consecutIvely w1th a 1—h Interval between the drug
`u
`u
`u
`u
`u
`admmrstratrons. One-half of the study patIents InItIally
`Inhaled treprostInIl and then Inhaled Iloprost (r1 = 22), and
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`the other half InItIally Inhaled Iloprost and then Inhaled
`treprostrml (n = 22). Patrents were random-need to 1 of the
`.
`.
`.
`.
`2 groups and blmded regardlng the sequence of the study
`drugs. Drug effects were monrtored for 60 mm after each
`.
`.
`.
`.
`.
`Inhalatron sessron. Iloprost was Inhaled at a concentratron of
`.
`.
`.
`.
`.
`.
`4 ,ug/ml (6 mm InhalatIon tIme; n = 44) and treprostInIl
`-
`-
`-
`-
`-
`was Inhaled at concentratIons 0f4 ,ILg/ml (6 mln Inhalatlon;
`2
`-
`-
`-
`.
`:
`n
`l4), 8 Jag/ml (6 mm InhalatIon, n
`l4) or '16 pghnl
`(3 mm Inhalatron; n = 16). Based on prewous brophysrcal
`_
`.
`.
`.
`.
`.
`characterIzatIon of the ultrasonIc deVIce w1th Iloprost and
`.
`.
`.
`.
`.
`treprostInIl solutIon, thIs corresponds to total Inhaled doses
`.
`.
`.
`of 7.5 pg Iloprost and treprostInIl (4 ,ILg/Inl) and 15 ,ILg
`.
`.
`.
`.
`.
`.
`treprostInIl (8 tag/ml and 16 ug/ml), respeetwely.
`Study 2 was a randomrzed, open-label, srngle-blmd,
`_
`.
`_
`placebo-controlled study. The pnmary ObJCCtIVCS were to
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`WATSON LABORATORIES v. UNITED THERAPEUTICS, |PR2017—01621
`
`UNITED THERAPEUTICS, EX. 2059
`
`Page 2 of 10
`
`

`

`1674
`
`Voswinckel et at.
`Inhaled Tremostinil in Pulmonary Hypertension
`
`JACC Vol. 48. N0. 8. 2006
`October 17, 2006:1672-81
`
`describe the pharmacodynamic and pharmacokinetic elfects
`of inhaled treprostinil at a well—tolerated dose (30 rig) and
`to explore the highest tolerated single dose. A total number
`of 31 patients inhaled either placebo or treprostinil; each
`patient underwent 1 inhalation session. The first 16 patients
`were randomized to 30 pg treprostinil (16 lug/ml, n = 8)
`or placebo (stock solution containing the same buffer and
`preservative concentrations as treprostinil 16 rig/ml).
`Subsequent patients received 60 pg treprostinil
`(32
`|rig/ml; n = 6), 90 ,u.g treprostinil (48 rig/ml; n = 6) and
`120 ,ug treprostinil (64 pig/ml; n = 3). Inhalation time
`was 6 min for all groups. Hemodynamics, gas exchange,
`and arterial treprostinil concentrations were recorded for
`180 min.
`
`Study 3 was a randomized, open-label, single—blind study.
`The primary objective was to explore the shortest possible
`inhalation time for a 15 — pig dose of inhaled treprostinil. A
`total of 48 patients inhaled 1 dose of treprostinil during
`hemodynamic monitoring. The drug was applied in 18, 9, 3,
`2 or 1 breaths. The aerosol was generated by a pulsed
`ultrasonic nebulizer (Ventancb; Nebutcc, Elsenfeld, Ger—
`
`many) in cycles consisting of 2—s aerosol production (pulse)
`and a 4—s pause. The device included an optic—acoustical
`trigger enabling the patient to Synchronize the inspiration to
`the end of the aerosol pulse, thereby providing exact dosage.
`The treprostinil dose of 15 pig was either generated during
`18 cycles (Optineb filled with 100 I(Lg/ml treprostinil, n =
`6), 9 Cycles (200 pig/ml treprostinil, n = 6), 3 cycles (600
`plg/ml treprostinil, n = 21), 2 cycles (1,000 ,ug/ml trepro—
`stinil, n = 7), or 1 cycle (2,000 lgag/ml treprostinil, n = 8).
`Hemodynamics and gas exchange were recorded for 120 to
`180 min.
`
`Treprostinil plasma concentrations were assessed in study
`2 at 10, 15, 30, 60, and 120 min after inhalation. Trepro—
`stinil quantification was performed by Alta Analytical Lab-
`orat01y(El Dorado Hills, California) with avalidated liquid
`chromatography atmospheric—pressure ionization tandem
`
`mass spectrometry as previously described (9). Mixed ve-
`nous blood was drawn at 10, 15, 30, 60, 120, and 240 min
`
`after inhalation, centrifiiged, and the plasma frozen at
`—80°C until temperature-controlled shipping on dry ice.
`Statistics. For statistical analysis of study 1, the repeated
`pulmonary vascular resistance (PVR) measurements after
`inhaled iloprost and treprostinil were subjected to a
`3-factorial analysis of variance (factors: time [A], drug [B],
`treprostinil concentration [C]) to avoid multiple testing.
`The time to maximum PVR decrease after inhalation of
`
`iloprost versus treprostinil was compared by paired t test.
`The area under the curve (AUC) was calculated from the
`start of inhalation until 60 min after inhalation. Means,
`standard error of the mean, and 95% confidence intervals
`were calculated. For studies 2 and 3, areas between curves
`
`(ABC) were calculated between placebo inhalation (study
`2) and the respective treprostinil inhalation until 180 min
`(study 2) and 120 min (study 3) after the end of
`inhalation.
`
`RESULTS
`
`The inhalation of both iloprost and treprostinil in study 1
`resulted in a rapid decrease in PVR and pulmonary arterial
`pressure (PAP) (Figs. 1 to 3). No significant differences
`were observed for the AUC of PVR decrease after inhala—
`
`tion of 7.5 ,ug treprostinil in 6 min (AUC —12.6 i 7.0%),
`15 pig treprostinil in 6 min (AUC —13.3 i 3.2%), and 15
`,u.g treprostinil in 3 min (AUC —13.6 i 4.3%). The AUC
`for PVR after the inhalation of 7.5 pg iloprost in 6 min was
`—7.7 i 3.7% (mean i 95% confidence interval). An
`
`overview of the pooled data of treprostinil inhalation com-
`pared with iloprost inhalation is given in Figure 3. The
`maximum effects of iloprost and treprostinil on PVR were
`comparable, but this effect was reached significantly later
`after treprostinil inhalation (18 i 2 min) compared with
`iloprost (8 i 1 min; mean 1 SEM, p < 0.0001) and lasted
`
`PVR
`
`{- ileum
`+ treprostinil
`
`1
`
`.nA
`
`.-
`
`A
`
`
`
`‘Ioofbaselinevalue
`
`PVR
`
`-I-Ilnpm
`-—1‘-— treprostinil
`
`B
`
`1
`A .-
`
`
`
` .5%ofbaselinevalue
`
`F—l—l—l—_'—_'I—'—I
`0
`20
`40
`so
`time [ruin]
`
`7 '—I'—'—l_—H——|
`o
`m
`no
`no
`time [rnln]
`
`Figure 1. Response of'pulmonary vascular resistance (PV R) to inhaled treprostinil versus iloprost: period effects. (A) First inhalation session with treprostinil
`(n = 22) versus first inhalation session with iloprost (n = 22). (3) Second inhalation session with treprostinil (n = 22) versus second inhalation session
`with iloprost (n = 22). The PVR decrease with treprostinil was delayed and prolonged compared with that for iloprost. Because of carryover cifects from
`the first period, in the second period, the ellbcts of both drugs appeared shortened. Data are shown as percent of baseline values (mean 1 95% confidence
`interval).
`
`WATSON LABORATORIES v. UNITED THERAPEUTICS, |PR2017—01621
`
`UNITED THERAPEUTICS, EX. 2059
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`Page 3 of 10
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`

`

`JACC Vol. 48, No. 8, 2006
`October 17, 2005:1672—81
`
`Voswinclrel et al.
`Inhaled Treprnstinil in Pulmonary Hypertension
`
`1675
`
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`7 fl—fi—fi—fl—I—l—I—l—Ifi
`.10
`a
`in
`an
`an
`40
`so
`no
`time [min]
`
`B I1 wi- 7.5wiopMIA8nin
`+ 15% tmrvoahml - 6 min
`
`110
`
`fl
`5 1
`
`5o
`
`.E
`'5If}a
`
`a "
`
`a
`a?
`
`100
`
`
`
`Vaofbaselinevalue
`
`
`
`tlme [min]
`
`7
`
`l—l'""I"—"—'I—'—l—'—l—'—l—'—l—'—l
`an
`o
`10
`20
`as
`no
`so
`so
`time [mln]
`
`C no
`
`*— ?.5miapmb&rdn
`+ 15 pg Immerse"! - mo
`
`
`
`
`
`8%ofbaselinevalue
`
`11
`
`S r
`3O
`E.
`7:a
`aa
`‘5
`35
`
`time [mln]
`
`f—Wfiqfi—I—l—I—l—I—l—I—l—t
`an
`n
`in
`an
`an
`40
`so
`so
`lime [min]
`
`Figure 2. Response of pulmonary vascular resistance (PVR) and systemic arterial pressure (SAP) to inhalation ot‘treprostinil versus iloprost: dose
`eH’iscts. (A) Inhalation DF?.5 FE iloprost (in 6 min) versus 7.5 pg treprostinil (6 min) (:1 = 14, in randomized order). (B) Inhalation oF'lS FE iloprost
`{6 min) versus 15 pg treprostinil (IS min) (n = 14, in randomized order). (C) Inhalation of 7.5 pig iloprost (6 rnin) versus 15 pg treprostinil (3 min)
`(n = 16,
`in randomimd order). Data are shown as percent ot'haselinc values (mean i 95% confidence interval). Circles = ilopmst; triangles =
`treprostinil.
`
`(after 60 min, PVR values in the
`considerably longer
`treprostinil group had not yet returned to baseline). The
`increase in cardiac output was less brisk but more sustained
`after
`treprostinil
`inhalation. Systemic arterial pressure
`(SAP) was unaffected by treprostinil inhalation, whereas a
`transient decrease was observed after iloprost inhalation.
`Neither iloprost nor treprostinil alfected gas exchange.
`Three-factorial analysis of variance for PVR showed a
`significant dilfercncc between repeated measurements after
`inhalation (p[A] *1 0.0001), no significant difference be—
`tween drugs (p[B] = 0.1), no difference between treprostinil
`concentrations (p[C] = 0.74), and a significant drug >< time
`
`interaction (pLA X B] < 0.0001). This translates into a
`significant effect of both drugs on PVR with comparable
`drug potency, but a prolonged drug elfect of treprostinil
`compared with iloprost.
`In study 1, mild side effects were observed in some
`patients with iloprost inhalation at the 7.5—ug dose (tran—
`sient flush, headache) but were not observed with inhaled
`treprostinil at 7.5 or 15 ug. Bad taste was reported by most
`of the patients after inhalation of treprostinil. This was
`subsequently found to be attributable to the metacresol
`preservative contained in the treprostinil solution, which
`was then left out in study 3.
`
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`
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`
`Page 4 of 10
`
`

`

`1676
`
`Voswineltel at at
`Inhaled 'I'reprostinil in Pulmonary Hypertension
`
`JACC Vol. 48, No. 8. 2006
`October 17. 2006:1672—81
`
`"
`
`—§— iloptost
`—+— lreP’osIInil
`
`1‘
`
`.;. ”uproar
`+ treprosliml
`
`3 1E:I-
`o
`.E
`
`EIn«I1:
`
`"6
`3'3
`
`
`
`
`o
`20
`so
`at
`
`time [min]
`
`g 1
`'s'II
`.5
`Tuu
`Eh
`D
`=2
`
`7
`
`
`ll
`20
`IO
`Bil
`time [min]
`
`t!
`
`.
`i— Home!
`+ Ireproslinil
`
`‘
`
`{— flopmst
`+ treproslinil
`
`i
`
`a:
`:‘I
`E:-
`c 11
`.E
`3
`km
`.2 1
`
`0 a
`
`!
`
`g 1
`s".o
`.E
`3a:
`.D
`"6
`32
`
`0
`
`20
`
`«I
`
`60
`
`a
`
`an
`
`on
`
`an
`
`time [mln]
`
`time [min]
`
`Figure 3. Hemodynamic response to inhalation of treprostinil versus iloprost. Data from 44 patients who inhaled both dmgs in randomized order, shown
`as percent of baseline values (mean i 95% confidence interval). Abbreviations as in Table 1.
`
`In study 2, the pharmacodynamics of inhaled placebo or
`treprostinil were observed for 180 min. Placebo inhalation
`was followed by a gradual increase in PVR over the entire
`observation time. Because of reduced patient numbers in the
`120—pg treprostinil group (because of side effects,
`see
`below), the hemodynamic values for this group were not
`included in the graphs of this study (Figs. 4 and 5). All
`treprostinil doses led to comparable maximal decreases of
`PVR to 76.5 i 4.7% (30 pg), 73.7 t 5.8% (60 pg), 73.3 i
`4.3% (90 pg), and 65.4 i 4.1% (120 pg) of baseline values.
`An extended duration of pulmonary vasodilation was noted,
`surpassing the 3—h observation period for the 60—pg and
`90-pg (and 120-pg) treprostinil doses, whereas in the
`30-pg dose group the hemodynamic changes had returned
`to baseline by the end of this period. Even at the highest
`doses, treprostinil had only minor effects on SAP (Fig. 4).
`Maximal cardiac output was 106.8 : 3.2% (30 pg), 122.9 :
`4.3% (60 pg), 114.3 '1 4.8% (90 pg) and 111.3 i 3.9%
`(120 pg) of baseline values. The areas between the re—
`sponse curves after placebo versus treprostinil inhalation
`were calculated for PVR, PAP, systemic vascular resis-
`tance, and SAP (Fig. 5). A nearly maximal eEect on PVR
`was already observed with 30 pg treprostinil, and areas
`between the curves for PVR were not significantly dif—
`ferent for 30, 60, and 90 pg treprostinil. Effects on PAP
`and SAP were small and did not show a dose-response
`
`relationship. Gas exchange was not affected at doses up to
`90 pg treprostinil, but arterial oxygen saturation was
`significantly decreased at a dose of 120 pg treprostinil in
`all 3 patients. Further dose increments above 120 pg were
`not performed because of this desaturation and a severe
`headache in 1 patient.
`Bad taste of the treprostinil aerosol was again reported by
`most patients. Other side efiéets were flushing (n = 1; 30
`pg), mild transient cough (n = 3; 60 pg), mild transient
`bronchoconstriction that resolved after fenoterol adminis-
`
`tration (n = 1', 30 pg), and moderate bronehoconstriction
`that resolved after fenoterol administration (r1 = 1; 120 pg).
`The bad taste, the bronchoconstriction, and the decrease in
`
`Sao2 was attributed to metacresol contained in the original
`treprostinil solution. With the use of a metaeresol—free
`solution of treprostinil (University Hospital Giessen, Ger—
`many; produced according to the manufacturer‘s protocol)
`in the subsequent study, these side effects no longer oc-
`curred.
`
`Study 3 was performed with metacresol—free treprosti—
`nil solution, which was tasteless and odorless. A total of
`48 patients were enrolled. This study aimed at
`the
`reduction of inhalation time and aerosol volume needed
`
`for pulmonary drug delivery. A modified Optineb (Nebu—
`tec, Elsenfeld, Germany)
`inhalation device was pro-
`grammed to produce a constant amount of aerosol during
`
`UNITED THERAPEUTICS, EX. 2059
`
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`
`Page 5 of 10
`
`

`

`JACC Vol. 48, No. 8, 2006
`October 17, 2005:1672—81
`
`lloswinckel et at.
`Inhaled Treprostinil in Pulmonary Hypertension
`
`1677
`
`PAP
`
`t placebo
`t an 119 Irenroolinli
`$— 80m ”mun!
`tanpguapmstinll
`
`
`
`
`n
`no
`40
`so ao1oomm1ao1ao
`time [min]
`
`PVR
`
`value
`%ofbaseline
`
`II
`
`20
`
`40
`
`60
`
`so
`
`1W
`
`110
`
`140
`
`180
`
`I00
`
`time [min]
`
`CO
`
`
`
` 11%ofbaselinevalue
`
`
`e
`an
`an
`no ummmmm
`
`
`II
`20
`40
`80
`W 1W
`III! m 1W 1W
`
`time [min]
`
`SaOz
`
`time [min]
`
`SvO2
`
`1|
`
`
`
`%ofbaselinevalue
`
`o2 g
`ET
`
`: E"
`
`5
`s?-
`
`1Wo
`
`.5
`
`.n
`
`g
`E 11
`a»
`
`E 1
`
`3 E.
`
`_O
`
`32
`
`a2 g
`
`E7
`
`1 5Ba
`
`?
`
`1o
`
`a
`
`1 1
`
`1
`
`7 a
`
`n
`
`1 1
`
`1
`
`,_.'_...1_._l_._l—._l_._'—._l_p_|—q—Tq—1
`0
`20
`‘0
`1-0
`80
`100
`120
`140
`18“
`180
`time [min]
`
`r—fi—fl—h-h—r—u—fi—fi—l—fi—u—l
`II
`2|!
`‘0
`60
`30
`{I10
`120
`1‘0
`1611
`‘IIO
`
`time {min}
`
`Figure 4. Pharmaoodynamics after rreprostinil inhalation versus placebo. Placebo or treprostinil in doses of 30, 60, or 90 pg were inhaled (mean 1‘ 95%
`confidence interval). Maximal decrease of pulmonary vascuL'lr resistance (PVR) was comparable for all doses. The duration of pulmonary vasodilation
`(PVR decrease) seemed to be dose dependent. Abbreviations as in Table 1.
`
`repeatable pulses of aerosol generation. With this device,
`treprostinil could be safely administered up to a concen—
`tration of 2,000 lug/m1 without considerable side eflects.
`There was no relationship between the number or type of
`side effects and treprostinil concentration. Reported side
`effects were mild and consisted of transient cough (n =
`6), headache (n = 2), and jaw pain (n = 1).
`The reduction of PVR and PAP was comparable among
`all groups (Fig. 6). Treprostinil inhalation reduced PVR to
`76.3 i 5.6% (18 pulses, 100 |gag/ml), 72.9I : 4.9% (9 pulses,
`
`200 pg/ml), 71.2 i 6.0% (3 pulses, 600 |lag/ml), 77.4 i
`4.5% (2 pulses, 1,000 pig/ml) and 80.3 i 5.2% (1 pulse,
`2,000 ILeg/ml), The PAP was reduced to 84.2 i 4.5% (18
`pulses, 100 ug/ml), 84.2 i 4.1% (9 pulses, 200 |leg/ml),
`81.1 i 4.1% (3 pulses, 600 leg/ml), 86 i 4% (2 pulses,
`1,000 ,ug/ml), and 88 i 5.4% (1 pulse, 2,000 pg/ml) of
`baseline. Cardiac output was moderately increased in all
`groups, whereas SAP was not significantly affected.
`The ABCs for changes in hemodynamic and gas-
`exchange parameters after inhalation of 15 pg treprostinil
`
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`
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`
`Page 6 of 10
`
`

`

`1678
`
`lloswinckel et al.
`Inhaled Tmnmstinil in Pulmonary Hypertension
`
`JACC Vol. 48. No.8. 2006
`October 17. 2005:1672—81
`
`PVR
`
`PAP
`
`Es
`
`Es
`
`Es
`
`t‘”
`
`8‘9
`
`Es
`
`ABC[96]
`
`ABC['56]
`
`
`ABC[99]
`
`SAP
`
`is
`
`s ,s
`
`-25
`
`Figure 5. Arc-.15 between the placebo and the treprostinil curves (ABC).
`The ABC was calculated for a 3-I1 period after application of inhaled
`treprosti nil or placebo from the relative changes of hemodynamic param-
`eters (mean i 95% confidence interval). Abbreviations as in Table 1.
`
`versus placebo were calculated for an observation time of
`120 min (Fig. 7). The ABCs for both PVR and PAP were
`comparable among all groups.
`Phannacokinetic results from study 2. Peak plasma con—
`centrations of treprostinil were achieved 10 to 15 min after
`inhalation. Maximal
`treprostinil plasma concentrations
`(Cmax) for the 30—, 60—, 90—, and 120—ug doses were
`0.65 i 0.28 ng/ml (n = 4), 1.59 i 0.17 ng/ml (n = 4), 1.74
`ng/ml (n = 1}, and 3.51 i 1.04 ng/ml (n = 2), respectively
`(mean 1 SEM; Fig. 8).
`
`DISCUSSION
`
`In these studies we asked whether: 1) the acute eflects of
`inhaled treprostinil would be comparable to or superior to
`inhaled iloprost in pulmonary hypertensive patients, 2)
`the inhaled prostanoid dose might be increased without
`substantial local or systemic side effects, and 3) the time of
`inhalation, which is 6 to 12 min for iloprost, c0uld be
`reduced significantly by increasing the concentration of
`treprostinil aerosol.
`The patient population in these studies included people
`with dilFerent forms ofprecapillary pulmonary hypertension.
`
`All of these patients had a need for therapy of pulmonary
`hypertension, and this reflects the typical population of a
`pulmonary hypertension center. There were no major dif-
`ferences in patient characteristics or baseline hemodynamic
`values among the different groups (Table 1).
`In study 1, we showed that the inhalation of treprostinil
`and iloprost
`in similar doses resulted in a comparable
`maximum pulmonary vasodilatory effect. However, marked
`diferences in the response profile were noted. The onset of
`the pulmonary vasodilatory efi‘ect of inhaled treprostinil was
`slower but more sustained compared with that for iloprost,
`with the PVR decrease extending beyond the 1—h observa—
`tion period. Although the average dose of treprostinil was
`higher than that of iloprost, no systemic effects were noted
`after treprostinil
`inhalation, whereas flush and transient
`SAP decrease, accompanied by a more prominent cardiac
`output increase, occurred after iloprost inhalation. These
`side effects were more prominent than in prior studies with
`inhaled iloprost, perhaps because the iloprost dose used in
`this study was 50% higher than the recommended single
`aerosolized dose (5 |lug); additionally, it is possible that the
`preceding treprostinil inhalation may have added to the
`systemic side effects caused by the iloprost
`inhalation.
`Interestingly,
`there were no systemic side effects with
`treprostinil, although the average effect on PVR was come
`parable to that observed with iloprost.
`This study used a crossover design to minimize the effects
`of interindividual differences in response to prostanoids.
`The short observation period of 1 h was used to avoid an
`uncomfortably long eatheterization session. A limitation
`of this study is that the short observation interval may
`have resulted in a carryover of edects from the first to the
`second period, as suggested by Figure 1. However, we
`believe that this does not alter our conclusions that both
`
`drugs are potent pulmonary vasodilators and that the
`effects of treprostinil are more sustained compared with
`those ofiloprost.
`The longer duration of action and the virtual absence of
`side effects (except for the bitter taste of treprostinil aerosol,
`subsequently attributed to metacresol) encouraged us to
`increase the treprostinil dose in study 2 and to extend the
`observation time to 3 h to obtain precise pharmacodynamic
`data. Compared with placebo inhalation, inhaled treprosti-
`nil,
`in doses up to 90 pig, produced a strong pulmonary
`vasodilator effect that outlasted the observation time of 3 h.
`
`Although no pulmonary or systemic vasodilation was ob—
`served after placebo inhalation, there was a gradual increase
`in PVR and PAP accompanied by a decrease in cardiac
`output beyond 3 h after treprostinil
`inhalation. This
`finding is consistent with our previous experience from
`long-term catheterization studies, in which PVR tended
`to increase gradually after catheter insertion over the
`morning hours. This might be attributed to local effects
`of the catheter in the pulmonary artery, pain from the
`insertion site, or general discomfort from the investiga-
`tion. In study 2, inhalation with metacresol-containing
`
`UNITED THERAPEUTICS, EX. 2059
`
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`
`Page 7 of 10
`
`

`

`JACC Vol. 48, No. 8, 2006
`October 17, 2006:1672—81
`
`Voswinekel et at.
`Inhaled Tleplostinil in Pulmonary Hypertension
`
`1679
`
`1|
`
`+ISQgTRE-Ipuhst-
`
`o
`a:
`an
`so
`so
`100
`1211
`1411151111111
`time [min]
`
`I}
`
`2 g
`
`EEoH
`
`.n..
`o
`3’3
`
`1O
`
`
`
` 0
`
`N
`
`40
`
`50
`
`'0
`
`1”
`
`120
`
`14¢
`
`160
`
`180
`
`time [min]
`
`aE g
`
`E E.
`
`.o
`
`3-2
`
`1a
`
`Y
`
`1 1
`
`1
`
`
`
`u
`
`an
`
`an
`
`1m 1211 m sun
`so
`on
`lime [min]
`
`tan
`
`1 1
`
`g 12
`Ta
`11
`:1
`E.
`3 1o
`.3“—
`o
`it!
`
`1
`
`1
`
`PAP
`
`a 1‘
`
`3 O
`
`3 9o
`
`.E
`'5a
`.3g
`
`o 3
`
`1
`
`20
`
`40
`
`so ao1w1au1wmm
`time [mln]
`
`'l'hc inhalation time was minimized by increasing treprostinil
`Figure 6. Hemodynamic responses to the application of 15 pg inhaled treprostinil.
`concentration. A pulse of aerosol was generated every 6 s. Treprostinil aerosol was inhaled in concentrations of 100 pian‘Jl (18 pulses; n = 6), 200 rag/ml
`(9 pulses; n = 6), 600 ,ug/ml (3 pulses; n = 21), 1,000 itgr’rnl (2 pulses; n = 3"], and 2,000 lug/ml (1 pulse; 11 = 3). Placebo data correspond to Figure 4.
`Data are shown as mean i 95% confidence interval. Abbreviations as in Table 1.
`
`solution might have added to this effect, but this expla-
`nation seems vcry unlikely because of the gradual onset of
`the PVR increase.
`
`The long duration of pulmonary vasodilation after a
`single inhalation of treprostinil may be partially explained by
`the stability of this prostanoid. We speCulate that trepros-
`tinil is stored in the lung tissue after inhalation, providing a
`slow release from the alveolar lining layer or the interstitial
`compartment
`to the pulmonary vascular smooth muscle
`cells. Peak plasma concentrations of treprostinil were ob—
`served 10 to 15 min after inhalation (Fig. 8). This is
`considerably later compared to inhaled iloprost, with which
`peak plasma levels were found immediately after the com-
`pletion of the inhalation session and plasma half—life was
`only about 8 min (10). This might explain the slower rate of
`onset of the pulmona