Nebulized Milrinone: Choosing Next Steps Wisely

Imagine a future where advanced heart failure (HF) patients no longer need a chronic indwelling catheter to receive intravenous (IV) inotropic therapy. For decades, IV milrinone has remained the cornerstone of inotropic therapy for patients with advanced HF. Milrinone is a phosphodiesterase-3 inhibitor and an inodilator, effecting cardiac inotropy, lusitropy and peripheral vasodilation. Continuous IV milrinone can be used as a bridge to heart transplant, durable mechanical circulatory support, or palliative therapy in patients with advanced HF who are unable to be weaned from inotropes. Milrinone is particularly preferred in patients with concomitant pulmonary hypertension due to its inodilatory property – reducing pulmonary artery (PA) pressures and improving right ventricular (RV) function. 1 Anderson JL Baim DS Fein SA Goldstein RA LeJemtel TH Likoff MJ. Efficacy and safety of sustained (48 hour) intravenous infusions of milrinone in patients with severe congestive heart failure: a multicenter study. J Am Coll Cardiol. 1987; 9 (Apr): 711-722https://doi.org/10.1016/s0735-1097(87)80223-1 Crossref PubMed Google Scholar However, its administration is associated with logistic challenges and financial cost. Typically, chronic central venous catheterization and home infusion services are required for safe administration, along with frequent laboratory monitoring. Complications such as infection (bacteremia) and thrombosis are not uncommon. Eliminating the need for an indwelling catheter would eliminate the infection and thrombotic risks, and, at a minimum, alternative delivery systems should not increase the risk for arrhythmias and sudden death. Consequently, an efficacious nebulized formulation of milrinone could facilitate transplant listing without the attendant risks of IV milrinone. Onyedika J. Ilonze MD,MPH Peter S. Pang, MD MS Novel Nebulized Milrinone Formulation for the Treatment of Acute Heart Failure Requiring Inotropic Therapy: A Phase 1 StudyJournal of Cardiac FailurePreviewIntravenous (IV) inotropic therapy is recommended for patients with advanced (Stage D) heart failure (HF) as either a “bridge” to durable mechanical cardiac support/heart transplantation or as palliative therapy.[1,2] Yet the delivery of continuous infusion IV inotropic therapy outside the hospital is accompanied by significant logistical burdens that diminish quality of life for patients and increase the financial burden on the healthcare system by requiring home infusion services, infusion equipment, and invasive central venous catheter access. Full-Text PDF