Pharmacotherapy of lung transplantation: an overview.

Lung transplantation has become a viable treatment therapy for end-stage lung disease patients. The most common etiologies of end-stage lung disease, which can require a transplant are chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis (IPF), pulmonary arterial hypertension (PAH), and pulmonary fibrosis (PF). Listing criteria are institution and program specific. Approximately 1500 lung transplants were performed in 2008; and at 5 years post transplant, one-half are expected to survive. The surgery itself is associated with various complications, including surgical, infectious, and mechanical. Immunosuppression is paramount to the management of these patients, the goal being prevention of T cell activation to prevent rejection of the new organ. The patients commonly receive an induction agent with a T cell depleting antibody and high-dose corticosteroids. Maintenance immunosuppression begins immediately after the surgery, consisting of a combination of a calcineurin inhibitor, antimetabolite, and corticosteroids. Side effect profiles from the various agents will determine the choice of agents, and patients may have modifications throughout the therapy. The role of the pharmacist spans the inpatient management of acute complications to medication selection, management of maintenance immunosuppression, as well as monitoring for adverse drug reactions and drug-drug interactions. A multidisciplinary collaborative approach must be taken to ensure the best outcomes for this patient population.

Use of combination therapy with a beta-blocker and milrinone in patients with advanced heart failure.

OBJECTIVE: To review the literature evaluating the clinical effects of combination therapy with a beta-blocker and milrinone in patients with severe heart failure (HF). DATA SOURCES: Literature was accessed through MEDLINE (1950-June 2009), PubMed (1966-June 2009), and International Pharmaceutical Abstracts (1970-June 2009), with combinations of the following terms: positive inotrope, milrinone, dobutamine, and beta-receptor blocker. In addition, reference citations from publications identified were reviewed. STUDY SELECTION AND DATA EXTRACTION: All articles that examined the effect of combination therapy with a beta-blocker and milrinone on clinical endpoints in patients with advanced HF were assessed. DATA SYNTHESIS: A search of the literature revealed 4 studies examining the clinical effects of combination therapy with a beta-blocker and milrinone. Three of these studies were retrospective reviews, while one was a post hoc subgroup analysis from the OPTIME-CHF study. Concomitant therapy with milrinone and a beta-blocker was well tolerated, with no significant increase in adverse events or deterioration in clinical status in any study. Tolerability rates for combination therapy ranged from 88% to 92%. In 2 of the studies, roughly 50% of the patients in the combination arm were able to be weaned off milrinone. One study suggested a mortality reduction in favor of combination therapy over milrinone alone, while another study suggested no difference in mortality with combination therapy versus milrinone monotherapy. One study suggested a potential increase in mortality when beta-blocker therapy was withdrawn in patients who were started on milrinone. None of the studies demonstrated any significant differences in hospitalization rates. All of the studies were limited by their retrospective nature and small sample size. CONCLUSIONS: Data are insufficient to make firm conclusions on the clinical benefit of combination therapy with a beta-blocker and milrinone in patients with advanced HF, although it appears that this regimen is well tolerated and may allow weaning of inotropic support.