What is an appropriate next step for a patient with PAH showing only mild improvement with oral combination therapy?

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The appropriate next step for a patient with pulmonary arterial hypertension (PAH) who exhibits only mild improvement with oral combination therapy is to consider escalation to parenteral therapy. This approach is warranted because the goal of PAH management is to achieve significant clinical improvement and functional capacity. When patients are on a combination of oral therapies and still show only modest progress, it signals that the current regimen may not be sufficient to manage the severity of the condition adequately.

Parenteral therapies, such as intravenous or subcutaneous options, often have a more rapid onset of action and can be more effective than oral therapies in patients who are not responding adequately to their current regimens. Options like prostacyclins delivered parenterally have been shown to improve hemodynamics and clinical outcomes in more severe cases of PAH.

While monitoring the current treatment is a valid option, it does not actively address the patient's need for improved management and quality of life, especially when the response has been less than satisfactory. Adding oxygen therapy might help in alleviating symptoms but does not target the underlying pathophysiology of PAH. Switching therapies altogether may not always be necessary if the current therapy could be optimized instead.

Therefore, escalating to a more aggressive treatment with parenteral therapy

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