Pavel Jansa

Introduction In the A DUE study, a fixed-dose combination of macitentan 10 mg and tadalafil 40 mg (M/T FDC) as a single tablet significantly improved pulmonary vascular resistance at Week 16 versus corresponding monotherapies in patients with pulmonary arterial hypertension (PAH). Safety was consistent with known profiles of macitentan and tadalafil. The open-label (OL) period of A DUE provides long-term safety/efficacy data for M/T FDC. Methods In A DUE (NCT03904693), patients were randomized (2:1:1) to double-blind M/T FDC, macitentan 10 mg or tadalafil 40 mg and followed for 16 weeks. They then transitioned to OL M/T FDC and were followed for up to 2 years to end of study (EOS). Efficacy analyses, including survival, changes in six-minute walk distance (6MWD) and N-terminal pro-brain natriuretic peptide (NT-proBNP) from baseline, are reported in patients randomized to M/T FDC at start of A DUE (efficacy set). Safety is reported for all patients receiving M/T FDC at any time during the double-blind (DB) and/or OL (safety set). Results In A DUE, 185 patients received M/T FDC for median (range) of 105.1 (0.6, 182.6) weeks. In the efficacy set, 91% of patients were alive at EOS. Mean (SD) change in 6MWD from M/T FDC initiation to OL Week 120 was 60.5 m (84.2). For NT-proBNP, geometric mean percent of baseline was 50.2% at OL Week 120. In the safety set, adverse events (AEs) occurred in 94.1% and serious AEs in 33.5% of patients; 10.3% discontinued study treatment due to an AE. Seven on-treatment deaths occurred in those receiving M/T FDC; all were evaluated as unrelated to treatment. Conclusions Long-term treatment with single-tablet combination of macitentan/tadalafil was well tolerated, with no new safety findings identified. Most patients were alive at EOS. Incremental improvements in 6MWD and NT-proBNP observed in the DB with M/T FDC were sustained over 2 years. Trial Registration ClinicalTrials.gov Identifier NCT03904693. A graphical abstract is also available for this article.

This exploratory analysis assessed whether plasma biomarkers predict the response to switching from phosphodiesterase type 5 inhibitors (PDE5is) to the soluble guanylate cyclase stimulator riociguat in patients with pulmonary arterial hypertension. Selected biomarkers at baseline and their changes to Week 24 were evaluated in patients with and without a favorable response to riociguat in two trials: RESPITE, in which patients with an inadequate response to PDE5i were switched to riociguat; and REPLACE, in which patients at intermediate risk of 1‐year mortality despite a PDE5i were randomized to remain on PDE5i or were switched to riociguat. A response was defined as absence of clinical worsening and at least two of the following criteria: 6‐min walk distance increase by 10% or ≥ 30 m, World Health Organization functional class I/II, or N‐terminal prohormone of brain natriuretic peptide reduction of ≥ 30% at Week 24. In REPLACE, responders had significantly higher baseline cyclic guanosine monophosphate (cGMP) and significantly lower baseline asymmetric dimethylarginine, and growth/differentiation factor 15 (GDF‐15) than nonresponders. In RESPITE, responders had lower baseline GDF‐15 than nonresponders, and nonresponders showed a significantly greater decrease in cGMP than responders. No baseline threshold value of any biomarker provided a good likelihood of predicting the response to riociguat. Overall, the biomarkers evaluated did not help to identify patients who were more likely to respond to switching from PDE5is to riociguat.

Plicn? hypertenze je definov?na jako syndrom charakterizovan? zv??en?m st?edn?ho tlaku v plicnici > 20 mm Hg. Plicn? arteri?ln? hypertenze (PAH) je vz?cn? onemocn?n?, kter? tvo?? p?ibli?n? 1 % v?ech p??pad? chronick? plicn? hypertenze. V pa...

The aim of the open label extension (OLE) of CTREPH study was to characterize multimodal treatment in patients with severe inoperable CTEPH, to describe long‐term subcutaneous (SC) treprostinil safety and tolerability, and to evaluate change in functional class and exercise capacity over 24 months since completion of the blinded phase of CTREPH. The target population in the OLE consisted of patients who completed 24 weeks of blinded treatment with either high‐dose treprostinil of around 30 ng/kg/min (former high‐dose group), or low‐dose treprostinil of around 3 ng/kg/min (former low‐dose group) in the CTREPH study. From the start of OLE, treprostinil dose and any additional therapy were chosen according to the standard of care and physician's discretion. Out of 47 enrolled patients, 20 patients received other PH drugs during OLE and 17 patients underwent at least 1 BPA session. Number of treprostinil‐related AEs was substantially higher in the former low‐dose group in comparison to the former high‐dose group. Related AEs were also more frequent during the first 6 months of the preceding blinded trial than over 24 months of OLE, especially infusion site pain and all local infusion site reactions. No new safety signal was detected. Evaluated clinical outcomes show sustained benefit from long‐term treprostinil treatment. Long‐term SC treprostinil is a safe and effective component of multimodal treatment for patients with severe CTEPH. Patients who tolerate treprostinil after initiation are likely to continue tolerating it over time, with the clinical benefit maintained over 24 months.

Introduction This study explored patient and clinician perspectives on a new fixed-dose combination of macitentan and tadalafil (M/T FDC) in a once-daily single tablet for treatment of pulmonary arterial hypertension (PAH). Methods Qualitative semi-structured interviews were conducted during the open-label period of the global, phase 3 A DUE clinical trial that evaluated M/T FDC. A subset of enrolled patients (N = 26) and site investigators (N = 18 clinicians) were interviewed. Patients received four tablets during double-blind treatment and could be in one of three arms (macitentan + placebo; tadalafil + placebo; M/T FDC + placebo) followed by M/T FDC (one tablet) during the open-label period. Patients and clinicians were asked to share their experience of pre-trial PAH medication, double-blind treatment, and open-label M/T FDC. Thematic analysis was conducted on blinded data. Results Patients preferred the M/T FDC tablet (open-label) over the four tablets during double-blind treatment. Patients were satisfied with M/T FDC, highlighting its positive impact on their psychological well-being, through reducing stress associated with managing multiple pills. All patients indicated that having a single, once-a-day pill for PAH was more convenient and associated with greater treatment adherence. Clinicians highlighted that their patients have a high daily pill burden for PAH and other comorbidities, and prefer treatments with an oral mode of administration that reduce the number of daily pills required. Clinicians felt that M/T FDC would be well received in clinical practice and potentially assist in implementing guideline-recommended combination treatment of PAH. Conclusions In this qualitative analysis, all 26 patients and 18 clinicians provided positive feedback on M/T FDC treatment, which was consistent across countries. Reducing the number of pills needed to treat PAH, through use of single-tablet M/T FDC, is highly valued by patients and endorsed by clinicians, who both felt the single-tablet combination therapy could have a positive effect on patients’ well-being and increase treatment adherence.

BACKGROUND: Sildenafil, approved for pulmonary arterial hypertension (PAH), has a recommended adult dose of 20 mg TID, with a previously approved 5-mg TID dose by the US Food and Drug Administration. Safety concerns arose because of common off-label use of higher doses, particularly after pediatric data linked higher doses to increased mortality. To assess this, the Food and Drug Administration mandated a study evaluating the effects of various sildenafil doses on mortality in adults with PAH. METHODS: This randomized, double-blind study compared sildenafil at doses of 5, 20, or 80 mg TID in adults with PAH. The primary objective was noninferiority of 80 mg of sildenafil versus 5 mg for all-cause mortality. Secondary end points included time to clinical worsening and change in 6-minute walk distance at 6 months. Interim analyses were planned at 50% and 75% of the anticipated mortality events. Safety and tolerability were assessed in the intention-to-treat population. RESULTS: The study was halted after the first interim analysis, demonstrating noninferiority for 80 mg of sildenafil versus 5 mg. Of 385 patients enrolled across all dose groups, 78 died. The primary analysis showed a hazard ratio of 0.51 (99.7% CI, 0.22–1.21; P P P =0.0201). No significant differences were found between 80 mg of sildenafil and 20 mg in mortality, clinical worsening, and 6-minute walk distance. Adverse event–related drug discontinuations were numerically higher with 80 mg of sildenafil. CONCLUSIONS: Sildenafil at 80 mg was noninferior to sildenafil at 5 mg when examining all-cause mortality in adults with PAH. Secondary efficacy end points favored 80 mg of sildenafil over 5 mg. On the basis of these findings, the Food and Drug Administration recently revoked the approval of 5 mg of sildenafil for adults with PAH, reinforced 20 mg TID as the recommended dose, and now allows dose titration up to 80 mg TID, if needed. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02060487.

Background: Combination therapy is recommended for the management of pulmonary arterial hypertension (PAH). The A DUE study showed that M/T FDC, a fixed dose combination (FDC) of the endothelin receptor antagonist (ERA) macitentan 10mg (M) and the phosphodiesterase type 5 inhibitor (PDE5i) tadalafil 40mg (T), led to a clinically relevant improvement in pulmonary vascular resistance (PVR) vs macitentan and tadalafil monotherapies in PAH patients. A clinically meaningful trend for improvement in 6-minute walk distance (6MWD) in favor of M/T FDC vs macitentan and tadalafil was observed. Purpose: Here we analysed the effect of M/T FDC in the subgroups of treatment-naïve and prior monotherapy patients. Methods: In A DUE 187 adult PAH patients in WHO functional class II / III were randomised 2:1:1 to M/T FDC, macitentan or tadalafil if treatment-naïve, 2:1 to M/T FDC or macitentan if on prior ERA, and 2:1 to M/T FDC or tadalafil if on prior PDE5i. The treatment effect of M/T FDC vs macitentan and M/T FDC vs tadalafil was calculated using ANCOVA models for PVR (geometric mean ratios [95% CL]) and for 6MWD (mean change [95% CL]) in treatment-naïve patients and in patients on prior monotherapy (ERA or PDE5i) at randomisation. Results: Treatment effects for M/T FDC versus macitentan and versus tadalafil on the change in PVR and 6MWD are reported in the table for each subgroup, along with those for the overall population. The safety profile of M/T FDC was in line with the safety profiles of macitentan and tadalafil. Conclusions: In A DUE, the effect of M/T FDC vs both monotherapies on PVR and 6MWD in treatment-naïve and prior ERA/PDE5i patients was consistent with that observed in the overall population.

Additional data on vasodilators and/or balloon pulmonary angioplasty (BPA) in patients with inoperable or persistent/recurrent CTEPH are important. The aim of our study was to evaluate safety and survival in severe CTEPH patients who received long-term subcutaneous (SC) treprostinil treatment in open label extension (OLE) of the randomized, double-blind, 24week CTREPH trial comparing high and low dose of SC treprostinil [Sadushi-Kolici R et al. Lancet Respir Med. 2019;Mar;7(3):239-48]. In OLE, dosing of SC treprostinil as well as any additional CTEPH therapy were at the investigators´ decision. The OLE was completed after marketing authorization of treprostinil in April 2020. 47 patients participated in the OLE with mean OLE treatment duration of approximately 3 years (1132.4 ± 755.7 days). 20 patients underwent BPA. 15 patients received additional PH specific medication. During OLE, 3 patients started riociguat (1 in addition to macitentan) and 2 patients switched from sildenafil to riociguat. Overall survival was 93%, 87%, 84% after one, two and three years, respectively when 14 deaths were observed, all related to the underlying disease.77 adverse events (AEs) related to treprostinil were experienced by 27 patients, most commonly infusion site pain (19.5%), other infusion site reactions (31.2%) and diarrhoea (18.2%). 4 serious AEs (SAEs) related to treprostinil resolved without sequel. 4 patients discontinued treprostinil due to related AEs (3 infusion site pain and 1 headache). The OLE results confirm that long-term SC treprostinil is safe and effective component of multimodal treatment for patients with severe CTEPH.