1
|
Mihalek AD, Scott CD, Mazimba S. Evaluating Riociguat in the Treatment of Pulmonary Arterial Hypertension: A Real-World Perspective. Vasc Health Risk Manag 2022; 18:823-832. [PMID: 36299800 PMCID: PMC9590350 DOI: 10.2147/vhrm.s383572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 10/12/2022] [Indexed: 11/23/2022] Open
Abstract
Pulmonary hypertension (PH) is a broad term describing the mean pulmonary artery pressure, as measured by right heart catheterization, exceeds 20mmHg. Pulmonary arterial hypertension (PAH) exists when PH is accompanied by a normal wedge pressure and elevated pulmonary vascular resistance. PAH is typified by dysmorphic and dysfunctional pulmonary arterial vasculature. Attempting to restore the functionality of the pulmonary artery is a hallmark of care to the PAH patient. Riociguat is a powerful stimulator of soluble guanylate cyclase and increases blood flow through the pulmonary arteries by dilating vascular smooth muscle cells. This review examines the pharmacology of riociguat, the fundamental clinical trials applying it to PAH patients, practical aspects when selecting its use, and future directions for its utilization.
Collapse
Affiliation(s)
- Andrew D Mihalek
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia, Charlottesville, VA, USA,Correspondence: Andrew D Mihalek, University of Virginia Division of Pulmonary and Critical Care Medicine, 1215 Lee Street, Charlottesville, VA, 22903, Tel +1 (434) 243-1000, Fax +1 (434) 924-9720, Email
| | - Christopher D Scott
- Division of Thoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Sula Mazimba
- Division of Cardiovascular Medicine, Department of Medicine, University of Virginia, Charlottesville, VA, USA
| |
Collapse
|
2
|
Martynyuk TV, Shmalts AA, Gorbachevsky SV, Chazova IE. Optimization of specific therapy for pulmonary hypertension: the possibilities of riociguat. TERAPEVT ARKH 2021; 93:1117-1124. [DOI: 10.26442/00403660.2021.09.201014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 10/10/2021] [Indexed: 11/22/2022]
Abstract
Pulmonary hypertension (PH) is a severe and often rapidly progressive disease with fatal outcome. Endothelial dysfunction in PH is associated with decreased nitric oxide production. After reviewing the mechanisms of action and the evidence base for specific therapy with phosphodiesterase 5 inhibitors (PDE-5) and soluble guanylate cyclase stimulators, a reseach review on switching from PDE-5 to riociguat is conducted. A potential advantage of riociguat is its independence from endogenous nitric oxide and from the other (besides PDE-5) isoenzymes of phosphodiesterases. The favorable efficacy profile of sildenafil has been proven for the main forms of pulmonary arterial hypertension, of riociguat for the main forms of pulmonary arterial hypertension and chronic thromboembolic PH. The clinical efficacy of replacing PDE-5 with riociguat has been demonstrated in uncontrolled trials and in the randomized controlled study REPLACE. The possibility of therapy optimization by switching from IFDE-5 to riociguat is fixed in the Russian (class and level of evidence B-3) and Eurasian (class and level of evidence IIb-B) clinical guidelines, as well as in the materials of the Cologne Expert Consensus. An additional argument for switching is the lower cost as compared to combination therapy in the Russian Federation. According to the Russian and Eurasian guidelines for PH and the Russian instructions for the use of riociguat, the drug should be taken at least 24 hours after sildenafil discontinuation.
Collapse
|
3
|
Shostak NA, Klimenko AA, Demidova NA. [The place of riociguat in the treatment of patients with pulmonary arterial hypertension associated with systemic connective tissue diseases]. ACTA ACUST UNITED AC 2020; 60:92-101. [PMID: 33131480 DOI: 10.18087/cardio.2020.9.n1189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/14/2020] [Accepted: 08/05/2020] [Indexed: 11/18/2022]
Abstract
Pulmonary hypertension (PH) can develop in different systemic autoimmune rheumatic diseases (SARD), such as systemic scleroderma (SSD), systemic lupus erythematosus, rheumatoid arthritis, and mixed connective tissue disease In most cases, patients with SARD develop WHO group I PH (pulmonary arterial hypertension associated with systemic connective tissue diseases, PAH-SCTD). General prevalence of this pathology reaches 15 cases per million adults. Most cases of PAH-SCTD are induced by SSD. Survival of PAH-SCTD patients is generally lower than survival of patients with other forms of LAH. Treatment of any SARD, including in LAH, implies a complex approach using glucocorticoids, disease-modifying anti-rheumatic drugs (cyclophosphamide, methotrexate, azathioprine, and others), and genetically engineered biologics. Specific targeted therapy is indicated for most patients with PAH-SCTD. The representative of a new class (soluble guanylate cyclase (sGC) stimulators), riociguat, has been approved for the treatment of PAH. This drug has a unique double mechanism of action: (i) sGC sensibilization to endogenous nitric oxide (NO) by stabilizing the NO-sGC bond; and (ii) direct, NO-independent sGC stimulation. For patients with PAH-SCTD, riociguat is the major alternative to phosphodiesterase-5 inhibitors both as monotherapy and combination therapy.
Collapse
Affiliation(s)
- N A Shostak
- Pirogov Russian National Research Medical University (RNRMU), Moscow, Russia
| | - A A Klimenko
- Pirogov Russian National Research Medical University (RNRMU), Moscow, Russia
| | - N A Demidova
- Pirogov Russian National Research Medical University (RNRMU), Moscow, Russia
| |
Collapse
|
4
|
Almaaitah S, Highland KB, Tonelli AR. Management of Pulmonary Arterial Hypertension in Patients with Systemic Sclerosis. Integr Blood Press Control 2020; 13:15-29. [PMID: 32280271 PMCID: PMC7125406 DOI: 10.2147/ibpc.s232038] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 03/05/2020] [Indexed: 12/25/2022] Open
Abstract
Systemic sclerosis (SSc) is a rare and complex immune-mediated connective tissue disease characterized by multi-organ fibrosis and dysfunction. Systemic sclerosis-associated pulmonary arterial hypertension (SSc-PAH) is a leading cause of death in this population. Pulmonary arterial hypertension (PAH) can coexist with other forms of pulmonary hypertension in SSc, including pulmonary hypertension related to left heart disease, interstitial lung disease, chronic thromboembolism and pulmonary venous occlusive disease, which further complicates diagnosis and management. Available pulmonary arterial hypertension therapies target the nitric oxide, endothelin and prostacyclin pathways. These therapies have been studied in SSc-PAH in addition to idiopathic PAH, often with different treatment responses. In this article, we discuss the management as well as the treatment options for patients with SSc-PAH.
Collapse
Affiliation(s)
- Saja Almaaitah
- Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kristin B Highland
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Adriano R Tonelli
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
5
|
Kuroda K, Akagi S, Nakamura K, Sarashina T, Ejiri K, Ito H. Successful Transition From Phosphodiesterase-5 Inhibitors to Riociguat Without a Washout Period in Patients With Pulmonary Arterial Hypertension and Chronic Thromboembolic Pulmonary Hypertension: A Pilot Cohort Study. Heart Lung Circ 2020; 29:331-336. [DOI: 10.1016/j.hlc.2019.01.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 12/03/2018] [Accepted: 01/11/2019] [Indexed: 01/10/2023]
|
6
|
Abstract
Pulmonary arterial hypertension, categorized as group 1 pulmonary hypertension by the World Health Organization classification system, represents a major complication of systemic sclerosis resulting from pulmonary vascular involvement of the disease. The high mortality seen in systemic sclerosis-associated pulmonary arterial hypertension is likely due to the impairment of right ventricular systolic function and the coexistence of other non-group-1 pulmonary hypertension phenotypes that may negatively impact clinical response to pulmonary arterial hypertension-targeted therapy. This review highlights two areas of recent advances regarding the management of systemic sclerosis patients with pulmonary hypertension: the tolerability of pulmonary arterial hypertension-targeted therapy in the presence of mild to moderate interstitial lung disease and the potential clinical significance of the antifibrotic effect of soluble guanylate cyclase stimulators demonstrated in preclinical studies.
Collapse
Affiliation(s)
- Michael H Lee
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Colorado, USA
| | - Todd M Bull
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Colorado, USA
| |
Collapse
|
7
|
Koklin IS, Danilenko LM. Combined use of arginase II and tadalafil inhibitors for the correction of monocrotaline pulmonary hypertension. RESEARCH RESULTS IN PHARMACOLOGY 2019. [DOI: 10.3897/rrpharmacology.5.39522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Introduction: The concept of the regulatory role of endothelium in the pathogenesis of pulmonary hypertension (PH) is fundamental.
Research objective: To study the protective effects of the selective arginase II inhibitors L207-0525 and L327-0346 in combination with tadalafil in a monocrotaline model of pulmonary hypertension in rats.
Materials and methods: Monocrotaline-induced pulmonary hypertension was simulated in 10 animals by a subcutaneous injection of an alcohol-water solution of monocrotaline (MCT) in the dose of 60 mg/kg. Seven days after the injection of MCT, the administration of L207-0525 and L327-0346 in the doses of 1 mg/kg and 3 mg/kg was started. The compounds were administered intragastrically once a day for 21 days.
Results and discussion: It was found that L207-0525 and L327-0346 in the dose of 3 mg/kg and tadalafil in the dose of 1 mg/kg prevented the development of pulmonary hypertension, which was expressed in a statistically significant decrease in the coefficient of endothelial dysfunction (CED, prevention of an increase in systolic pressure in the right ventricle, as well as Fulton, RV/BW and WT indices. The greatest activity was shown by L207-0525 and L327-0346 in the dose of 3 mg/kg in combination with tadalafil in the dose of 0.1 mg/kg.
Conclusions: The received results suggest the dose-dependent protective activity of selective arginase II inhibitors L207-0525 and L327-0346 and the development of the additive effect of their combined use with low doses of PDE-5 inhibitor tadalafil in relation to the development of monocrotaline pulmonary hypertension.
Collapse
|
8
|
Benza RL, Corris PA, Ghofrani HA, Kanwar M, McLaughlin VV, Raina A, Simonneau G. EXPRESS: Switching to riociguat: A potential treatment strategy for the management of CTEPH and PAH. Pulm Circ 2019; 10:2045894019837849. [PMID: 30803329 PMCID: PMC7074518 DOI: 10.1177/2045894019837849] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 02/08/2019] [Indexed: 12/22/2022] Open
Abstract
Currently, five classes of drug are approved for the treatment of pulmonary arterial hypertension (PAH): phosphodiesterase 5 inhibitors (PDE5i); endothelin receptor antagonists; prostacyclin analogs; the IP receptor agonist selexipag; and the soluble guanylate cyclase (sGC) stimulator riociguat. For patients with inoperable or persistent/recurrent chronic thromboembolic pulmonary hypertension (CTEPH), riociguat is currently the only approved pharmacotherapy. Despite the development of evidence-based guidelines on appropriate use of specific drugs, in clinical practice patients are often prescribed PAH-targeted therapies off label or at inadequate doses. PDE5i are the most often prescribed class of drugs as initial therapy, either alone or in combination with other drug classes. However, a proportion of patients receiving PAH therapies do not reach or maintain treatment goals. As PDE5i and riociguat target different molecules in the nitric oxide-sGC-cyclic guanosine monophosphate (NO-sGC-cGMP) signaling pathway, for patients with PAH without an initial or sustained response to PDE5i, there is a biological rationale for switching to riociguat. However, robust data from randomized controlled trials on the safety and efficacy of switching are lacking, as is formal guidance for clinicians. Here we review studies of sequential combination therapy, and trial data and case studies that have investigated switching between PAH-approved therapies, particularly from PDE5i to riociguat in patients with PAH with an insufficient response to PDE5i, and in patients with CTEPH who were receiving off-label treatment. These studies summarize the current evidence and practical real-life experience on the concept of switching treatments.
Collapse
Affiliation(s)
- Raymond L. Benza
- Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Paul A. Corris
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Hossein-Ardeschir Ghofrani
- University of Giessen and Marburg Lung Centre, Giessen, Germany, member of the German Centre for Lung Research (DZL)
- Department of Medicine, Imperial College London, London, UK
| | - Manreet Kanwar
- Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA, USA
| | | | - Amresh Raina
- Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Gérald Simonneau
- Assistance Publique–Hôpitaux de Paris, Service de Pneumologie, Hôpital Bicêtre, Université Paris-Sud, Laboratoire d’Excellence en Recherche sur le Médicament et Innovation Thérapeutique, and INSERM Unité 999, Le Kremlin–Bicêtre, France
| |
Collapse
|
9
|
Ushkalova EA, Zyryanov SK, Zatolochina KE. Methods of Pharmacological Treatment of Chronic Thromboembolic Pulmonary Hypertension Current Approaches to the Patients Management. KARDIOLOGIYA 2018; 58:82-93. [PMID: 30625081 DOI: 10.18087/cardio.2018.11.10200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 11/24/2018] [Indexed: 11/18/2022]
Abstract
In this paper we have discussed epidemiology, pathogenesis, and approaches to treatment of chronic thromboembolic pulmonary hypertension (CTEPH). CTEPH is a unique potentially curable form of pulmonary hypertension. The gold standard of CTEPH treatment is pulmonary thromboendarterectomy. However, about 40% of patients with CTEPH are inoperable due to distal surgically inaccessible lesions of the pulmonary vasculature, severe hemodynamic impairments, or other contraindications. In addition, nearly half of patients have persistent or recurrent pulmonary hypertension following surgery. Current guidelines support the use of pharmacotherapy in these patients. In the article we have presented results of main clinical studies of targeted drugs therapy (endothelin receptor antagonists, prostanoids, phosphodiesterase type 5 inhibitors, soluble guanylate cyclase stimulators) of patients with CTEPH. The only drug that has demonstrated robust clinical efficacy in terms of improvment hemodynamic parameters, exercise capacity and patients' quality of life is the stimulator of the soluble guanylate cyclase riociguat. The efficacy and safety of riociguat have been investigated in short-term and long-term studies with follow-up up to 6 years. Results of these studies have constituted the basis forits approval by the regulatory authorities of more than 50 countries for the treatment of inoperable CTEPH and persistent or recurrent CTEPH after pulmonary thromboendarterectomy. In the European Union, USA and many other countries, riociguat is the only pharmacological agent approved for these indications.
Collapse
Affiliation(s)
- E A Ushkalova
- Peoples Friendship University of Russia (RUDN University).
| | | | | |
Collapse
|
10
|
Gall H, Vachiéry JL, Tanabe N, Halank M, Orozco-Levi M, Mielniczuk L, Chang M, Vogtländer K, Grünig E. Real-World Switching to Riociguat: Management and Practicalities in Patients with PAH and CTEPH. Lung 2018; 196:305-312. [PMID: 29470642 PMCID: PMC5942346 DOI: 10.1007/s00408-018-0100-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 02/16/2018] [Indexed: 12/22/2022]
Abstract
Purpose A proportion of patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) do not achieve treatment goals or experience side effects on their current therapy. In such cases, switching patients to a new drug while discontinuing the first may be a viable and appropriate treatment option. CAPTURE was designed to investigate how physicians manage the switching of patients to riociguat in real-world clinical practice. Observations from the study were used to assess whether recommendations in the riociguat prescribing information are reflected in clinical practice. Methods CAPTURE was an international, multicenter, uncontrolled, retrospective chart review that collected data from patients with PAH or inoperable or persistent/recurrent CTEPH who switched to riociguat from another pulmonary hypertension (PH)-targeted medical therapy. The primary objective of the study was to understand the procedure undertaken in real-world clinical practice for patients switching to riociguat. Results Of 127 patients screened, 125 were enrolled in CAPTURE. The majority of patients switched from a phosphodiesterase type 5 inhibitor (PDE5i) to riociguat and the most common reason for switching was lack of efficacy. Physicians were already using the recommended treatment-free period when switching patients to riociguat from sildenafil, but a slightly longer period than recommended for tadalafil. In line with the contraindication, the majority of patients did not receive riociguat and PDE5i therapy concomitantly. Physicians also followed the recommended dose-adjustment procedure for riociguat. Conclusion Switching to riociguat from another PH-targeted therapy may be feasible in real-world clinical practice in the context of the current recommendations. Electronic supplementary material The online version of this article (10.1007/s00408-018-0100-3) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Henning Gall
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Klinikstrasse 32, 35392, Giessen, Germany.
| | - Jean-Luc Vachiéry
- Département de Cardiologie, Cliniques Universitaires de Bruxelles, Hôpital Erasme, Brussels, Belgium
| | - Nobuhiro Tanabe
- Department of Respirology and Department of Advanced Medicine in Pulmonary Hypertension, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Michael Halank
- Medical Clinic 1/Pneumology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Mauricio Orozco-Levi
- Hospital Internacional de Colombia, Fundación Cardiovascular de Colombia, Santander, Colombia
| | | | | | | | - Ekkehard Grünig
- Center for Pulmonary Hypertension, Thorax Clinic at the University Hospital, Heidelberg, Germany
| |
Collapse
|