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Medikamentöse Therapie der pulmonalen Hypertonie

Therapy of pulmonary arterial hypertension

  • Arzneimitteltherapie
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Zusammenfassung

Neue Medikamente zur Therapie der pulmonal arteriellen Hypertonie (PAH) haben ihre Wirksamkeit in randomisierten kontrollierten Studien belegt. Die größte praktische Bedeutung haben hier Endothelinrezeptorantagonisten und Prostanoide. Bosentan ist die erste zugelassene oral verfügbare Therapie der PAH. Das Medikament ist abgesehen von einer seltenen Hepatotoxizität meist gut verträglich. Das zuerst zugelassene Prostanoid, Epoprostenol, ist nur noch für die dekompensierte Rechtsherzinsuffizienz das Mittel der ersten Wahl, da es nur kontinuierlich intravenös appliziert werden kann und durch Komplikationen, Nebenwirkungen und sehr hohe Kosten belastet ist. Als Alternative steht die subkutane Dauerinfusion des weniger risikoreichen und preiswerteren Treprostinil zur Verfügung. Dieses Prostanoid hat eine längere Halbwertszeit, verursacht aber vielfach Schmerzen an der Injektionsstelle. Inhalatives Iloprost verbindet die Vorzüge des Prostanoids mit einer (intra)pulmonal selektiven Wirkung. Iloprost wird alternativ auch als Dauerinfusion angewendet. Der Phosphodiesterase-5-Inhibitor Sildenafil zeigte eine signifikante Wirksamkeit in 2 randomisierten kontrollierten Studien, steht aber noch vor der Zulassung zur Therapie der PAH.

Abstract

New drugs for pulmonary arterial hypertension have shown efficacy in randomized controlled trials. Endothelin receptor antagonists (ERA) and prostanoids are most important for clinical practice. Bosentan represents the first approved orally active therapy for PAH. Besides its hepatotoxicity it is mostly well tolerated. The first approved prostanoid, epoprostenol, is currently first choice only for decompensated right heart failure in PAH. It has to be delivered continuously intravenously and is prone to complications, side effects and very high costs. Alternatively, subcutaneous treprostinil can be applied. It is less risky and expensive but may cause local pain at the infusion site. Inhaled iloprost combines the features of a prostanoid with pulmonary and intrapulmonary selectivity. Alternatively, iloprost is being used as continuous intravenous infusion. The phosphodiesterase-5 inhibitor sildenafil was effective in two randomized controlled trials but has not been approved for PAH therapy.

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Danksagung.

Dank gilt den Mitgliedern der Arbeitsgemeinschaft pulmonale Hypertonie (AGPHT), mit Marius Höper; Mathias Borst, Christian Opitz, Dietmar Schranz, Ingram Schulze-Neick, Ralph Ewert, Ekkehard Grünig, Franz-Xaver Kleber, Bruno Kopp, Frank Reichenberger, Alexander Schmeisser, Heinrike Wilkens, Jörg Winkler und Heinrich Worth.

Interessenkonflikt:

Der korrespondierende Autor weist auf eine Verbindung mit folgender Firma/Firmen hin: HO: Berater für Schering, Unither, CoTherix, Myogen. Studien: Schering, Unither, Myogen

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Authors and Affiliations

  1. Medizinische Klinik, Klinikum der Justus-Liebig-Universität Giessen

    H. Olschewski, A. Ghofrani, B. Enke, F. Reichenberger, R. Voswinckel, A. Kreckel, S. Ghofrani, R. Wiedemann, R. Schulz, F. Grimminger & W. Seeger

  2. Klinische Abteilung für Pulmonologie, Medizinische Universität Graz, Graz

    H. Olschewski

  3. Klinische Abteilung für Pulmonologie, Medizinische Universität Graz, Auenbruggerplatz 20, A-8036, Graz, Österreich

    H. Olschewski

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  1. H. Olschewski
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  2. A. Ghofrani
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  3. B. Enke
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  4. F. Reichenberger
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  7. S. Ghofrani
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  9. R. Schulz
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  10. F. Grimminger
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  11. W. Seeger
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Correspondence to H. Olschewski.

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Olschewski, H., Ghofrani, A., Enke, B. et al. Medikamentöse Therapie der pulmonalen Hypertonie. Internist 46, 341–349 (2005). https://doi.org/10.1007/s00108-004-1350-0

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  • DOI: https://doi.org/10.1007/s00108-004-1350-0

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