Anticoagulant Therapy Is Not Associated with Long Term Outcome in Patients with Pulmonary Arterial Hypertension (PAH): Insights from the GRIPHON Study

The burden of comorbidities in pulmonary arterial hypertension

Patients with comorbidities are often excluded from clinical trials, limiting the evidence base for pulmonary arterial hypertension (PAH)-specific therapies. This review aims to discuss the effect of comorbidities on the diagnosis and management of PAH. The comorbidities discussed in this review (systemic hypertension, obesity, sleep apnoea, clinical depression, obstructive airway disease, thyroid disease, diabetes, and ischaemic cardiovascular event) were chosen based on their prevalence in patients with idiopathic PAH in the REVEAL registry (Registry to EValuate Early and Long-term PAH disease management). Comorbidities can mask the symptoms of PAH, leading to delays in diagnosis and also difficulty evaluating disease progression and treatment effects. Due to the multifactorial pathophysiology of pulmonary hypertension (PH), the presence of comorbidities can lead to difficulties in distinguishing between Group 1 PH (PAH) and the other group classifications of PH. Many comorbidities contribute to the progression of PAH through increased pulmonary artery pressures and cardiac output, therefore treatment of the comorbidity may also reduce the severity of PAH. Similarly, the development of one comorbidity can be a risk factor for the development of other comorbidities. The management of comorbidities requires consideration of drug interactions, polypharmacy, adherence and evidence-based strategies. A multidisciplinary team should be involved in the management of patients with PAH and comorbidities, with appropriate referral to supportive services when necessary. The treatment goals and expectations of patients must be managed in the context of comorbidities.

Selexipag: A Review in Pulmonary Arterial Hypertension

Selexipag (Uptravi^®) is an orally active, first-in-class, selective prostacyclin IP receptor agonist. Selexipag was approved recently in the EU for the long-term treatment of pulmonary arterial hypertension (PAH) in adult patients with WHO functional class (FC) II or III as combination therapy in patients insufficiently controlled with an endothelin receptor antagonist and/or a phosphodiesterase type 5 inhibitor or as monotherapy in patients who are not candidates for these therapies, and in the USA for the treatment of PAH (WHO Group I) to delay disease progression and reduce the risk of hospitalization for PAH. Selexipag (200-1600 μg twice daily, as tolerated) significantly reduced the risk of the primary composite endpoint of all-cause death or a complication related to PAH (whichever happened first) versus placebo in patients with PAH (mainly WHO FC II or III) in the large, randomized, placebo-controlled GRIPHON study. The treatment effect was largely driven by significant reductions in disease progression and hospitalization for PAH. However, selexipag did not significantly reduce all-cause mortality. Additionally, the observed treatment effect was consistent in a broad range of prespecified subgroups, including treatment-naïve patients and those patients who were already receiving PAH-specific treatment at baseline. Exercise capacity was also improved with selexipag versus placebo. Selexipag was generally well tolerated, with an adverse event profile consistent with other therapies targeting the prostacyclin pathway. Thus, selexipag extends the treatment options available in patients with PAH.