Advances in and Clinical Experience with Subcutaneous Infusion Pump Therapy for Pulmonary Arterial Hypertension

Pulmonary arterial hypertension (PAH) is characterized by progressive pulmonary vascular remodeling and a deficiency of endogenous prostacyclin, a potent vasodilator with antiproliferative effects. Prostacyclin analogues (PCAs) target this deficiency and are integral to the PAH treatment algorithm. Parenteral PCA therapy is recommended for patients at intermediate-high and high risk, and early initiation-particularly in combination regimens-is associated with improved survival in real-world and post hoc analyses.The 2002 approval of the parenteral PCA treprostinil (Remodulin®) marked a significant advancement in PCA therapy. Compared with epoprostenol, treprostinil offers greater chemical stability at room temperature and a longer half-life, enabling subcutaneous (SC) infusion and minimizing the complications and challenges associated with intravenous delivery. Despite robust evidence demonstrating its benefits on morbidity and mortality and risk-based guideline recommendations, parenteral PCA therapy remains underutilized. Contributing factors include concerns about the complexity and perceived burden of pump-based delivery systems.Here we review the place for parenteral prostacyclin in PAH therapy, and the evolution of SC PCA pumps over time, with a focus on recent enhancements intended to overcome practical limitations of older devices and thereby improve usability. Key features such as simplified cassette filling, automated priming, a larger and more intuitive touchscreen remote, and expanded flow rate options aim to reduce the perceived challenges of SC therapy and support broader adoption among patients and prescribers. The article also provides perspectives and practical guidance from experienced practitioners on the initiation and maintenance of SC PCA therapy, emphasizing how improvements in pump technology can help overcome barriers to use. Addressing these challenges through improved design, education, and support may help bridge the gap between evidence-based recommendations and real-world practice.Graphical abstract available for this article.