Characterization of prostacyclin-associated leg pain in patients with pulmonary arterial hypertension

Gabriel L. Pagani-Estevez, Keith M. Swetz, Michael D. McGoon, Robert Frantz, Susan K. Tointon, Ann M. Karnyski, Louise A. Durst, James Watson

Research output: Contribution to journalArticle

2 Citations (Scopus)

Abstract

Rationale: Prostacyclin-associated leg pain is a potentially debilitating adverse effect of prostacyclin therapy for patients with pulmonary arterial hypertension (PAH). However, to our knowledge, this entity has not been systematically studied. Objectives: To characterize the clinical features and metabolic risk factors for prostacyclin-associated leg pain. Methods: At one academic medical center, we assembled and analyzed a case series of patients with PAH and prostacyclinassociated leg pain. Measurements and Main Results: Over a period of 2 years, we identified 11 patients with PAH and prostacyclin-associated leg pain who agreed to participate in this study. Subjects underwent a standardized clinical evaluation, electrodiagnostic assessment, and serologic screen for metabolic causes of peripheral neuropathy. All 11 patients were female; their mean (SD) age was 50 (69) years; their median (interquartile range) PAH duration was 56 (20-96) months; and their prostacyclin therapy duration was a median (interquartile range) of 20 (14-36) months. All patients reported leg pain beginning soon after prostacyclin initiation and varying with dose. All described a neuropathic pain in a symmetric, distal, stocking distribution. Neurologic examination revealed a sensory, small-fiber, predominantly peripheral neuropathy in seven (78%) patients. Results of autonomic reflex testing and thermoregulatory sweat testing were abnormal in 82% and 90% of patients, respectively, suggesting small-fiber neuropathy. Serologic evaluation identified a new, previously unrecognized contributor to neuropathy in eight (73%) patients, including vitamin B12 deficiency in six (55%), uncompensated hypothyroidism in three (27%), and diabetes mellitus in one (9%). Conclusions: Chronic prostacyclin-associated leg pain is associated with a small-fiber neuropathy. Treatable metabolic contributors (vitamin B12 deficiency, thyroid dysfunction, or diabetes) appear to be common possible "second hits" that may be underrecognized. We recommend screening for possible metabolic contributors in patients who have otherwise unexplained leg pain in the setting of PAH and current or anticipated prostacyclin therapy.

Original languageEnglish (US)
Pages (from-to)206-212
Number of pages7
JournalAnnals of the American Thoracic Society
Volume14
Issue number2
DOIs
StatePublished - Feb 1 2017

Fingerprint

Epoprostenol
Pulmonary Hypertension
Leg
Pain
Vitamin B 12 Deficiency
Peripheral Nervous System Diseases
Sweat
Neurologic Examination
Neuralgia
Hypothyroidism
Reflex
Diabetes Mellitus
Thyroid Gland
Therapeutics

Keywords

  • Metabolic
  • Neuropathy
  • Pain
  • Prostacyclin
  • Pulmonary hypertension

ASJC Scopus subject areas

  • Medicine(all)
  • Pulmonary and Respiratory Medicine

Cite this

Characterization of prostacyclin-associated leg pain in patients with pulmonary arterial hypertension. / Pagani-Estevez, Gabriel L.; Swetz, Keith M.; McGoon, Michael D.; Frantz, Robert; Tointon, Susan K.; Karnyski, Ann M.; Durst, Louise A.; Watson, James.

In: Annals of the American Thoracic Society, Vol. 14, No. 2, 01.02.2017, p. 206-212.

Research output: Contribution to journalArticle

Pagani-Estevez, Gabriel L. ; Swetz, Keith M. ; McGoon, Michael D. ; Frantz, Robert ; Tointon, Susan K. ; Karnyski, Ann M. ; Durst, Louise A. ; Watson, James. / Characterization of prostacyclin-associated leg pain in patients with pulmonary arterial hypertension. In: Annals of the American Thoracic Society. 2017 ; Vol. 14, No. 2. pp. 206-212.
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abstract = "Rationale: Prostacyclin-associated leg pain is a potentially debilitating adverse effect of prostacyclin therapy for patients with pulmonary arterial hypertension (PAH). However, to our knowledge, this entity has not been systematically studied. Objectives: To characterize the clinical features and metabolic risk factors for prostacyclin-associated leg pain. Methods: At one academic medical center, we assembled and analyzed a case series of patients with PAH and prostacyclinassociated leg pain. Measurements and Main Results: Over a period of 2 years, we identified 11 patients with PAH and prostacyclin-associated leg pain who agreed to participate in this study. Subjects underwent a standardized clinical evaluation, electrodiagnostic assessment, and serologic screen for metabolic causes of peripheral neuropathy. All 11 patients were female; their mean (SD) age was 50 (69) years; their median (interquartile range) PAH duration was 56 (20-96) months; and their prostacyclin therapy duration was a median (interquartile range) of 20 (14-36) months. All patients reported leg pain beginning soon after prostacyclin initiation and varying with dose. All described a neuropathic pain in a symmetric, distal, stocking distribution. Neurologic examination revealed a sensory, small-fiber, predominantly peripheral neuropathy in seven (78{\%}) patients. Results of autonomic reflex testing and thermoregulatory sweat testing were abnormal in 82{\%} and 90{\%} of patients, respectively, suggesting small-fiber neuropathy. Serologic evaluation identified a new, previously unrecognized contributor to neuropathy in eight (73{\%}) patients, including vitamin B12 deficiency in six (55{\%}), uncompensated hypothyroidism in three (27{\%}), and diabetes mellitus in one (9{\%}). Conclusions: Chronic prostacyclin-associated leg pain is associated with a small-fiber neuropathy. Treatable metabolic contributors (vitamin B12 deficiency, thyroid dysfunction, or diabetes) appear to be common possible {"}second hits{"} that may be underrecognized. We recommend screening for possible metabolic contributors in patients who have otherwise unexplained leg pain in the setting of PAH and current or anticipated prostacyclin therapy.",
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AU - Tointon, Susan K.

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AU - Watson, James

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