Many patients with pulmonary arterial hypertension are not receiving guideline-recommended combination therapy, survey suggests
Presenter: Lana Melendres-Groves, MD, Medical Director, Pulmonary Hypertension Program, University of New Mexico, Albuquerque, NM
Despite updated guidelines recommending combination therapy regardless of risk status, a recent survey of pulmonologists and cardiologists revealed that 46% of patients with pulmonary arterial hypertension (PAH) were being treated with monotherapy approaches.
A large proportion of patients with pulmonary arterial hypertension (PAH) are being treated with monotherapy, despite updated guidelines recommending combination therapy for all patients regardless of risk status, investigators reported at CHEST 2024.
In a survey of pulmonologists and cardiologists, nearly half of PAH patients were receiving monotherapy, according to the investigators, who presented their findings in a poster session at the meeting.
While presence of cardiopulmonary comorbidities would be one reason to avoid combination therapy, very few survey respondents cited this as the primary reason for selecting monotherapy, the investigators reported.
“The findings of this study help to highlight that many PAH patients may not be receiving an escalation in their therapeutic management when appropriate,” said study investigator Lana Melendres-Groves, MD, in an interview.
“Further attention during reevaluation of patients will improve consistent use of guideline-directed therapies in the real-world management of PAH,” Dr. Melendres-Groves continued.
This study underscores a key discrepancy between clinical practice and guidelines from the European Society of Cardiology (ESC) and the European Respiratory Society (ERS).
The 2022 update of the ERS/ESC guideline on the diagnosis and treatment of PAH includes the recommendation that—in the absence of cardiopulmonary comorbidities—all PAH patients should receive combination therapy, regardless of risk status.
The analysis conducted by Dr. Melendres-Groves and colleagues explores treatment approaches to PAH in a contemporary real-world US population. The data were obtained from a point-in-time survey completed by pulmonologists and cardiologists who provide treatment for patients with PAH.
The survey was limited to specialists in practice for at least 5 years who treated at least 10 PAH patients in the prior month. A total of 112 of these specialists, including 72 pulmonologists and 40 cardiologists, completed the survey between November 2023 and February 2024.
Respondents provided deidentified patient data for up to 7 consecutive adult PAH patients in functional class II, III, or IV. All patients were currently receiving PAH-specific medications, including phosphodiesterase type 5 (PDE-5) inhibitors, endothelin receptor antagonists (ERAs), soluble guanylate cyclase (sGC) stimulators, or prostacyclin pathway agents (PPAs), and were not currently enrolled in a clinical trial.
Survey respondents provided clinical information for a total of 768 patients with PAH. The mean patient age was 54 years, 53% were female, 62% were white, and 58% had idiopathic PAH, Dr. Melendres-Groves and co-authors reported in their poster.
Overall, 46% of patients were currently receiving monotherapy, the survey results revealed. Of the remaining patients, 42% were receiving dual combination therapy, and 12% were receiving triple combination therapy.
While cardiopulmonary comorbidities were present in many patients, these comorbidities were rarely cited as the explicit reason for selecting a monotherapy approach, the data show.
A total of 68% of the PAH patients had cardiopulmonary comorbidities in this sample, yet in less than 2% of patients, these comorbidities were selected as the primary reason for monotherapy, investigators reported.
Use of monotherapy did decrease with increasing severity of disease, with monotherapy selected in 52% of patients in functional class II versus 17% of those in functional class IV, the data further show.
More studies will be required to explain why the combination therapy guideline is not being followed, according to the study authors.
“In the real-world care of PAH, utilization of guidelines may be more nuanced,” Dr. Melendres-Groves said in the interview. “As such, further research is required to assess our patients’ needs and explore drivers and potential barriers to guideline-directed treatment.”
Disclosures:
Dr. Melendres-Groves reported disclosures related to United Therapeutics, Bayer Pharmaceuticals, Janssen Pharmaceuticals, and Merck Pharmaceuticals.
Suggested Reading:
Humbert M, Kovacs G, Hoeper MM, et al. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension [published correction appears in Eur Heart J. 2023 Apr 17; 44(15):1312]. Eur Heart J 2022; 43(38):3618–3731. doi: 10.1093/eurheartj/ehac237.