Pharmacy Support of a Pediatric Patient Receiving Milrinone at Home.

Heart failure in children is a progressive clinical syndrome characterized by symptoms that may include respiratory distress, poor growth, edema, fatigue, feeding difficulties, and exercise intolerance.1,2 The predominant causes of pediatric heart failure in developed countries are cardiomyopathy (including the dilated, hypertrophic, and restrictive cardio myopathies) and congenital heart disease.2,3 As heart failure progresses in severity, the child experiences worsening of symptoms and increasing frequency of exacerbations, emergency department visits, and hospital admissions.4 In end-stage heart failure, the symptoms become refractory to oral medications, and the child becomes dependent on IV therapies.4 For children who are eligible for cardiac transplant, bridging therapy with a continuous inotropic infusion (to maintain end-organ perfusion) is often required while awaiting a suitable organ.4 For those who are ineligible for transplant, a continuous inotropic infusion may be used as palliative therapy.5 Milrinone, a potent inhibitor of phosphodiesterase type III, stimulates cardiac function independently of ß-adrenergic receptors. It improves cardiac output via its positive inotropic effects with little chronotropic effect, and it reduces afterload by concomitant vasodilation.6,7 Milrinone is also an effective lusitropic agent and augments ventricular diastolic relaxation in addition to systolic contractility.7 As a result, milrinone has become the first-line therapy for infants and children with heart failure to prevent low cardiac output syndrome after cardiac surgery.3,6,7 The concept of outpatient inotropic therapy has been around for several decades, and there are multiple reports of patients with heart failure being managed at home on a continuous infusion of milrinone (see Table 1).4,5 Alberta Children’s Hospital is a freestanding pediatric facility in Calgary, Alberta, with about 140 acute care beds. Each year, 1–3 children with end-stage heart failure who are being followed in the hospital’s Cardiology Clinic are listed for heart transplant (with the surgery being performed in Edmonton, Alberta); therapies for these children may include multiple oral medications and IV milrinone. Alberta Children’s Hospital began offering home milrinone therapy to patients in 2013 according to the criteria listed in Box 1. The benefits of home milrinone therapy are numerous, including reductions in emergency department visits and hospital admissions for cardiac indications, and improvements in estimated ejection fraction.4,5 Perhaps most importantly, home milrinone therapy also improves quality of life by allowing children to resume a modified normal lifestyle (which may include return to school), by supporting improvements in psychosocial health, and by reducing parenteral and family stress.5 Finally, home milrinone therapy carries a significant financial advantage for health care systems. According to Berg and others,5 the total daily cost (in 2005 US dollars) of inotropic therapy for a pediatric patient awaiting heart transplant was $745 as a hospital inpatient and $134 for home therapy. Despite the numerous benefits that home milrinone therapy offers, there are also potential risks. This medication can cause