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Raghu G, Ghazipura M, Fleming TR, Aronson KI, Behr J, Brown KK, Flaherty KR, Kazerooni EA, Maher TM, Richeldi L, Lasky JA, Swigris JJ, Busch R, Garrard L, Ahn DH, Li J, Puthawala K, Rodal G, Seymour S, Weir N, Danoff SK, Ettinger N, Goldin J, Glassberg MK, Kawano-Dourado L, Khalil N, Lancaster L, Lynch DA, Mageto Y, Noth I, Shore JE, Wijsenbeek M, Brown R, Grogan D, Ivey D, Golinska P, Karimi-Shah B, Martinez FJ. Meaningful Endpoints for Idiopathic Pulmonary Fibrosis (IPF) Clinical Trials: Emphasis on 'Feels, Functions, Survives'. Report of a Collaborative Discussion in a Symposium with Direct Engagement from Representatives of Patients, Investigators, the National Institutes of Health, a Patient Advocacy Organization, and a Regulatory Agency. Am J Respir Crit Care Med 2024; 209:647-669. [PMID: 38174955 DOI: 10.1164/rccm.202312-2213so] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/02/2024] [Indexed: 01/05/2024] Open
Abstract
Background: Idiopathic pulmonary fibrosis (IPF) carries significant mortality and unpredictable progression, with limited therapeutic options. Designing trials with patient-meaningful endpoints, enhancing the reliability and interpretability of results, and streamlining the regulatory approval process are of critical importance to advancing clinical care in IPF. Methods: A landmark in-person symposium in June 2023 assembled 43 participants from the US and internationally, including patients with IPF, investigators, and regulatory representatives, to discuss the immediate future of IPF clinical trial endpoints. Patient advocates were central to discussions, which evaluated endpoints according to regulatory standards and the FDA's 'feels, functions, survives' criteria. Results: Three themes emerged: 1) consensus on endpoints mirroring the lived experiences of patients with IPF; 2) consideration of replacing forced vital capacity (FVC) as the primary endpoint, potentially by composite endpoints that include 'feels, functions, survives' measures or FVC as components; 3) support for simplified, user-friendly patient-reported outcomes (PROs) as either components of primary composite endpoints or key secondary endpoints, supplemented by functional tests as secondary endpoints and novel biomarkers as supportive measures (FDA Guidance for Industry (Multiple Endpoints in Clinical Trials) available at: https://www.fda.gov/media/162416/download). Conclusions: This report, detailing the proceedings of this pivotal symposium, suggests a potential turning point in designing future IPF clinical trials more attuned to outcomes meaningful to patients, and documents the collective agreement across multidisciplinary stakeholders on the importance of anchoring IPF trial endpoints on real patient experiences-namely, how they feel, function, and survive. There is considerable optimism that clinical care in IPF will progress through trials focused on patient-centric insights, ultimately guiding transformative treatment strategies to enhance patients' quality of life and survival.
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Affiliation(s)
- Ganesh Raghu
- Center for Interstitial Lung Diseases, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine
- Department of Laboratory Medicine and Pathology, and
| | - Marya Ghazipura
- ZS Associates, Global Health Economics and Outcomes Research, New York, New York
- Division of Epidemiology and
- Division of Biostatistics, Department of Population Health, New York University Langone Health, New York, New York
| | - Thomas R Fleming
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Kerri I Aronson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Jürgen Behr
- Department of Medicine V, LMU University Hospital, Ludwig-Maximilians-University Munich, Member of the German Center for Lung Research, Munich, Germany
| | | | - Kevin R Flaherty
- Division of Pulmonary and Critical Care, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ella A Kazerooni
- Division of Pulmonary and Critical Care, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Division of Cardiothoracic Radiology, Department of Radiology, University of Michigan Health System, Detroit, Michigan
| | - Toby M Maher
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Luca Richeldi
- Divisione di Medicina Polmonare, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Joseph A Lasky
- Department of Medicine, Tulane University, New Orleans, Louisiana
| | | | - Robert Busch
- Division of Pulmonology, Allergy, and Critical Care, Office of Immunology and Inflammation, and
| | - Lili Garrard
- Division of Biometrics III, Office of Biostatistics, Office of Translational Sciences, Center for Drug Evaluation and Research, and
| | - Dong-Hyun Ahn
- Division of Biometrics III, Office of Biostatistics, Office of Translational Sciences, Center for Drug Evaluation and Research, and
| | - Ji Li
- Division of Clinical Outcome Assessment, Office of Drug Evaluation Sciences, Office of New Drugs, and
| | - Khalid Puthawala
- Division of Pulmonology, Allergy, and Critical Care, Office of Immunology and Inflammation, and
| | - Gabriela Rodal
- Office of Product Evaluation and Quality, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Sally Seymour
- Division of Pulmonology, Allergy, and Critical Care, Office of Immunology and Inflammation, and
| | - Nargues Weir
- Office of Product Evaluation and Quality, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Sonye K Danoff
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Neil Ettinger
- Division of Pulmonary Medicine, St. Luke's Hospital, Chesterfield, Missouri
| | - Jonathan Goldin
- Department of Radiology, University of California, Los Angeles, Los Angeles, California
| | - Marilyn K Glassberg
- Department of Medicine, Stritch School of Medicine, Loyola Chicago, Chicago, Illinois
| | - Leticia Kawano-Dourado
- Hcor Research Institute - Hcor Hospital, São Paolo, Brazil
- Pulmonary Division, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil
| | - Nasreen Khalil
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lisa Lancaster
- Division of Pulmonary, Critical Care, and Sleep Medicine, Vanderbilt University, Nashville, Tennessee
| | - David A Lynch
- Department of Radiology, National Jewish Health, Denver, Colorado
| | - Yolanda Mageto
- Division of Pulmonary, Critical Care, and Sleep Medicine, Baylor University, Dallas, Texas
| | - Imre Noth
- Division of Pulmonary and Critical Care Medicine, University of Virginia, Charlottesville, Virginia
| | | | - Marlies Wijsenbeek
- Centre of Interstitial Lung Diseases, Erasmus MC, University Medical Centre, Rotterdam, the Netherlands
| | - Robert Brown
- Patient representative and patient living with IPF, Lovettsville, Virginia
| | - Daniel Grogan
- Patient representative and patient living with IPF, Charlottesville, Virginia; and
| | - Dorothy Ivey
- Patient representative and patient living with IPF, Richmond, Virginia
| | - Patrycja Golinska
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Banu Karimi-Shah
- Division of Pulmonology, Allergy, and Critical Care, Office of Immunology and Inflammation, and
| | - Fernando J Martinez
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York
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2
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Caccamo M, Harrell FE, Hemnes AR. Evolution and optimization of clinical trial endpoints and design in pulmonary arterial hypertension. Pulm Circ 2023; 13:e12271. [PMID: 37554146 PMCID: PMC10405062 DOI: 10.1002/pul2.12271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 07/20/2023] [Accepted: 07/25/2023] [Indexed: 08/10/2023] Open
Abstract
Selection of endpoints for clinical trials in pulmonary arterial hypertension (PAH) is challenging because of the small numbers of patients and the changing expectations of patients, clinicians, and regulators in this evolving therapy area. The most commonly used primary endpoint in PAH trials has been 6-min walk distance (6MWD), leading to the approval of several targeted therapies. However, single surrogate endpoints such as 6MWD or hemodynamic parameters may not correlate with clinical outcomes. Composite endpoints of clinical worsening have been developed to reflect patients' overall condition more accurately, although there is no standard definition of worsening. Recently there has been a shift to composite endpoints assessing clinical improvement, and risk scores developed from registry data are increasingly being used. Biomarkers are another area of interest, although brain natriuretic peptide and its N-terminal prohormone are the only markers used for risk assessment or as endpoints in PAH. A range of other genetic, metabolic, and immunologic markers is currently under investigation, along with conventional and novel imaging modalities. Patient-reported outcomes are an increasingly important part of evaluating new therapies, and several PAH-specific tools are now available. In the future, alternative statistical techniques and trial designs, such as patient enrichment strategies, will play a role in evaluating PAH-targeted therapies. In addition, modern sequencing techniques, imaging analyses, and high-dimensional statistical modeling/machine learning may reveal novel markers that can play a role in the diagnosis and monitoring of PAH.
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Affiliation(s)
- Marco Caccamo
- Division of CardiologyWVU Heart and Vascular InstituteMorgantownWest VirginiaUSA
| | - Frank E. Harrell
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Anna R. Hemnes
- Division of Allergy, Pulmonary, and Critical Care MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
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3
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Wang A, Chen M, Zhuang Q, Guan L, Xie W, Wang L, Huang W, Cheng Z, Yu S, Zhou H, Shen J. Time to clinical improvement: an appropriate surrogate endpoint for pulmonary arterial hypertension medication trials. Front Cardiovasc Med 2023; 10:1142721. [PMID: 37378404 PMCID: PMC10291317 DOI: 10.3389/fcvm.2023.1142721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 05/17/2023] [Indexed: 06/29/2023] Open
Abstract
Background Many retrospective studies suggest that risk improvement may be a suitable efficacy surrogate endpoint for pulmonary arterial hypertension (PAH) medication trials. This prospective multicenter study assessed the efficacy of domestic ambrisentan in Chinese PAH patients and observed risk improvement and time to clinical improvement (TTCI) under ambrisentan treatment. Methods Eligible patients with PAH were enrolled for a 24-week treatment with ambrisentan. The primary efficacy endpoint was 6-min walk distance (Δ6MWD). The exploratory endpoints were risk improvement and TTCI, defined as the time from initiation of treatment to the first occurrence of risk improvement. Results A total of 83 subjects were enrolled. After ambrisentan treatment, Δ6MWD was significantly increased at week 12 (42.2 m, P < 0.0001) and week 24 (53.4 m, P < 0.0001). Within 24 weeks, risk improvement was observed in 53 (64.6%) subjects (P < 0.0001), which is higher than WHO-FC (30.5%) and TAPSE/PASP (32.9%). Kaplan-Meier analysis of TTCI showed a median improvement time of 131 days and a cumulative improvement rate of 75.1%. Also, TTCI is consistent across different baseline risk status populations (log-rank P = 0.51). The naive group had more risk improvement (P = 0.043) and shorter TTCI (log-rank P = 0.008) than the add-on group, while Δ6MWD did not show significant differences between the two groups. Conclusions Domestic ambrisentan significantly improved the exercise capacity and risk status of Chinese PAH patients. TTCI has a relatively high positive event rate within 24-week treatment duration. Compared to Δ6MWD, TTCI is not affected by baseline risk status. Additionally, TTCI could identify better improvements in patients, which Δ6MWD does not detect. TTCI is an appropriate composite surrogate endpoint for PAH medication trials. Clinical Trial Registration NCT No. [ClinicalTrials.gov], identifier [NCT05437224].
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Affiliation(s)
- An Wang
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Mengqi Chen
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qi Zhuang
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Lihua Guan
- Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Weiping Xie
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Lan Wang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Wei Huang
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhaozhong Cheng
- Respiratory Department, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Shiyong Yu
- Department of Cardiology, The Second Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Hongmei Zhou
- Congenital Heart Disease Center, Wuhan Asia Heart Hospital, Wuhan University of Science and Technology, Wuhan, China
| | - Jieyan Shen
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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4
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The role of riociguat in combination therapies for pulmonary arterial hypertension. Respir Med 2023; 211:107196. [PMID: 36889521 DOI: 10.1016/j.rmed.2023.107196] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/28/2023] [Accepted: 03/05/2023] [Indexed: 03/08/2023]
Abstract
Effective clinical decision-making in initial treatment selection and switching or escalations of therapy for pulmonary arterial hypertension (PAH) depends on multiple factors including the patient's risk profile. Data from clinical trials suggest that switching from a phosphodiesterase-5 inhibitor (PDE5i) to the soluble guanylate cyclase stimulator riociguat may provide clinical benefit in patients not reaching treatment goals. In this review, we cover the clinical evidence for riociguat combination regimens for patients with PAH and discuss their evolving role in upfront combination therapy and switching from a PDE5i as an alternative to escalating therapy. Specifically, we review current evidence which suggests or provides a hypothesis for 1) the potential use of riociguat plus endothelin receptor antagonist combinations for upfront combination therapy in patients with PAH at intermediate to high risk of 1-year mortality and 2) the benefits of switching to riociguat from a PDE5i in patients who are not achieving treatment goals with PDE5i-based dual combination therapy and at intermediate risk.
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5
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Weatherald J, Boucly A, Peters A, Montani D, Prasad K, Psotka MA, Zannad F, Gomberg-Maitland M, McLaughlin V, Simonneau G, Humbert M. The evolving landscape of pulmonary arterial hypertension clinical trials. Lancet 2022; 400:1884-1898. [PMID: 36436527 DOI: 10.1016/s0140-6736(22)01601-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/12/2022] [Accepted: 08/16/2022] [Indexed: 11/26/2022]
Abstract
Although it is a rare disease, the number of available therapeutic options for treating pulmonary arterial hypertension has increased since the late 1990s, with multiple drugs developed that are shown to be effective in phase 3 randomised controlled trials. Despite considerable advancements in pulmonary arterial hypertension treatment, prognosis remains poor. Existing therapies target pulmonary endothelial dysfunction with vasodilation and anti-proliferative effects. Novel therapies that target proliferative vascular remodelling and affect important outcomes are urgently needed. There is need for additional innovations in clinical trial design so that all emerging candidate therapies can be rigorously studied. Pulmonary arterial hypertension trial design has shifted from short-term submaximal exercise capacity as a primary endpoint, to larger clinical event-driven trial outcomes. Event-driven pulmonary arterial hypertension trials could face feasibility and efficiency issues in the future because increasing sample sizes and longer follow-up durations are needed, which would be problematic in such a rare disease. Enrichment strategies, innovative and alternative trial designs, and novel trial endpoints are potential solutions that could improve the efficiency of future pulmonary arterial hypertension trials while maintaining robustness and clinically meaningful evidence.
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Affiliation(s)
- Jason Weatherald
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
| | - Athénaïs Boucly
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Anthony Peters
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC, USA
| | - David Montani
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Krishna Prasad
- Medicines and Healthcare products Regulatory Agency, London, UK
| | - Mitchell A Psotka
- Inova Heart and Vascular Institute, Falls Church, VA, USA; United States Food and Drug Administration, Silver Spring, MD, USA
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique, Cardiovascular and Renal Clinical Trialists, Université de Lorraine, Nancy, France
| | - Mardi Gomberg-Maitland
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Vallerie McLaughlin
- Department of Internal Medicine, Division of Cardiology, Frankel Cardiovascular Center, University of Michigan Medical School, Ann Arbor, MI , USA
| | - Gérald Simonneau
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.
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6
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Nathan SD, Fernandes P, Psotka M, Vitulo P, Piccari L, Antoniou K, Nikkho SM, Stockbridge N. Pulmonary hypertension in interstitial lung disease: Clinical trial design and endpoints: A consensus statement from the Pulmonary Vascular Research Institute's Innovative Drug Development Initiative-Group 3 Pulmonary Hypertension. Pulm Circ 2022; 12:e12178. [PMID: 36578976 PMCID: PMC9780699 DOI: 10.1002/pul2.12178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Pulmonary hypertension (PH) associated with interstitial lung disease (ILD) is an attractive target for clinical trials of PH medications. There are many factors that need to be considered to prime such studies for success. The patient phenotype most likely to respond to the intervention requires weighing the extent of the parenchymal lung disease against the severity of the hemodynamic impairment. The inclusion criteria should not be too restrictive, thus enabling recruitment. The trial should be of sufficient duration to meet the chosen endpoint which should reflect how the patient feels, functions, or survives. This paper summarizes prior studies in PH-ILD and provides a framework of the type of studies to be considered. Inclusion criteria, clinical trial endpoints, and pharmacovigilance in the context of PH-ILD trials are also addressed. Through lessons learnt from prior studies, suggestions and guidance for future clinical trials in PH-ILD are also provided.
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Affiliation(s)
- Steven D. Nathan
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular InstituteFalls ChurchVirginiaUSA
| | - Peter Fernandes
- Bellerophon Therapeutics Inc., Regulatory, Safety and Quality DepartmentWarrenNew JerseyUSA
| | - Mitchell Psotka
- Division of Cardiology and Nephrology, Food and Drug AdministrationSilver SpringMarylandUSA
| | - Patrizio Vitulo
- Department of Pulmonary Medicine, IRCCS Mediterranean Institute for Transplantation and Advanced Specialized, TherapiesPalermoSiciliaItaly
| | - Lucilla Piccari
- Hospital del Mar, Pulmonary Hypertension Unit, Department of Pulmonary MedicineBarcelonaCatalunya, ESSpain
| | - Katerina Antoniou
- University of Crete School of Medicine, Department of Thoracic MedicineHeraklionCreteGreece
| | | | - Norman Stockbridge
- US Food and Drug Administration, Division of Cardiology and NephrologySilver SpringMarylandUSA
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7
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Nikkho SM, Richter MJ, Shen E, Abman SH, Antoniou K, Chung J, Fernandes P, Hassoun P, Lazarus HM, Olschewski H, Piccari L, Psotka M, Saggar R, Shlobin OA, Stockbridge N, Vitulo P, Vizza CD, John Wort S, Nathan SD. CLINICAL SIGNIFICANCE OF PULMONARY HYPERTENSION IN INTERSTITIAL LUNG DISEASE A Consensus Statement from The Pulmonary Vascular Research Institute's Innovative Drug Development Initiative ‐ Group 3 Pulmonary Hypertension. Pulm Circ 2022; 12:e12127. [PMID: 36016668 PMCID: PMC9395696 DOI: 10.1002/pul2.12127] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/18/2022] [Accepted: 08/09/2022] [Indexed: 11/18/2022] Open
Abstract
Pulmonary hypertension (PH) has been linked to worse outcomes in chronic lung diseases. The presence of PH in the setting of underlying Interstitial Lung Disease (ILD) is strongly associated with decreased exercise and functional capacity, an increased risk of hospitalizations and death. Examining the scope of this issue and its impact on patients is the first step in trying to define a roadmap to facilitate and encourage future research in this area. The aim of our working group is to strengthen the communities understanding of PH due to lung diseases and to improve the care and quality of life of affected patients. This introductory statement provides a broad overview and lays the foundation for further in‐depth papers on specific topics pertaining to PH‐ILD.
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Affiliation(s)
| | - Manuel J. Richter
- Department of Internal Medicine Pulmonary Hypertension Division Universities of Giessen and Marburg Lung Center (UGMLC) Germany
| | - Eric Shen
- United Therapeutics Corporation, Global Medical Affairs Silver Spring MD USA
| | - Steven H. Abman
- University of Colorado ‐ Anschutz Medical Campus School of Medicine and Children's Hospital Aurora CO USA
| | - Katerina Antoniou
- University of Crete School of Medicine, Department of Thoracic Medicine Heraklion Crete Greece
| | - Jonathan Chung
- Department of Radiology The University of Chicago Medicine Chicago IL USA
| | - Peter Fernandes
- Bellerophon Therapeutics Inc, Regulatory Safety and Quality Department Warren NJ USA
| | - Paul Hassoun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine Johns Hopkins University Baltimore MD
| | | | - Horst Olschewski
- Division of Pulmonology, Department of Internal Medicine Medical University of Graz Graz Steiermark Austria
| | - Lucilla Piccari
- Department of Pulmonary Medicine Hospital del Mar, Pulmonary Hypertension Unit Barcelona Catalunya Spain
| | - Mitchell Psotka
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA; 2. Division of Cardiology and Nephrology Food and Drug Administration Silver Spring MD
| | - Rajan Saggar
- University of California Los Angeles David Geffen School of Medicine Lung & Heart‐Lung Transplant and Pulmonary Hypertension Programs Los Angeles CA USA
| | - Oksana A. Shlobin
- Inova Health System, Advanced Lung Disease and Transplant Program Falls Church VA USA
| | - Norman Stockbridge
- US Food and Drug Administration Division of Cardiology and Nephrology Silver Spring MD USA
| | - Patrizio Vitulo
- IRCCS Mediterranean Institute for Transplantation and Advanced Specialized Therapies, Department of Pulmonary Medicine Palermo Sicilia Italy
| | | | - S. John Wort
- National Pulmonary Hypertension Service at Royal Brompton Hospital London. UK. National Heart and Lung Institute, Imperial College London UK
| | - Steven D. Nathan
- Advanced Lung Disease and Transplant Program Inova Heart and Vascular Institute Falls Church Virginia
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8
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Rhodes CJ, Wharton J, Swietlik EM, Harbaum L, Girerd B, Coghlan JG, Lordan J, Church C, Pepke-Zaba J, Toshner M, Wort SJ, Kiely DG, Condliffe R, Lawrie A, Gräf S, Montani D, Boucly A, Sitbon O, Humbert M, Howard LS, Morrell NW, Wilkins MR. Using the Plasma Proteome for Risk Stratifying Patients with Pulmonary Arterial Hypertension. Am J Respir Crit Care Med 2022; 205:1102-1111. [PMID: 35081018 PMCID: PMC9851485 DOI: 10.1164/rccm.202105-1118oc] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Rationale: NT-proBNP (N-terminal pro-brain natriuretic peptide), a biomarker of cardiac origin, is used to risk stratify patients with pulmonary arterial hypertension (PAH). Its limitations include poor sensitivity to early vascular pathology. Other biomarkers of vascular or systemic origin may also be useful in the management of PAH. Objectives: Identify prognostic proteins in PAH that complement NT-proBNP and clinical risk scores. Methods: An aptamer-based assay (SomaScan version 4) targeting 4,152 proteins was used to measure plasma proteins in patients with idiopathic, heritable, or drug-induced PAH from the UK National Cohort of PAH (n = 357) and the French EFORT (Evaluation of Prognostic Factors and Therapeutic Targets in PAH) study (n = 79). Prognostic proteins were identified in discovery-replication analyses of UK samples. Proteins independent of 6-minute-walk distance and NT-proBNP entered least absolute shrinkage and selection operator modeling, and the best combination in a single score was evaluated against clinical targets in EFORT. Measurements and Main Results: Thirty-one proteins robustly informed prognosis independent of NT-proBNP and 6-minute-walk distance in the UK cohort. A weighted combination score of six proteins was validated at baseline (5-yr mortality; area under the curve [AUC], 0.73; 95% confidence interval [CI], 0.63-0.85) and follow-up in EFORT (AUC, 0.84; 95% CI, 0.75-0.94; P = 9.96 × 10-6). The protein score risk stratified patients independent of established clinical targets and risk equations. The addition of the six-protein model score to NT-proBNP improved prediction of 5-year outcomes from AUC 0.762 (0.702-0.821) to 0.818 (0.767-0.869) by receiver operating characteristic analysis (P = 0.00426 for difference in AUC) in the UK replication and French samples combined. Conclusions: The plasma proteome informs prognosis beyond established factors in PAH and may provide a more sensitive measure of therapeutic response.
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Affiliation(s)
- Christopher J Rhodes
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - John Wharton
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Emilia M Swietlik
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Lars Harbaum
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Barbara Girerd
- Université Paris-Saclay, AP-HP, INSERM UMR_S 999, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, Hôpital de Bicêtre, Le Kremlin Bicêtre, France
| | - J Gerry Coghlan
- Department of Cardiology, Royal Free Campus, University College London, London, United Kingdom
| | - James Lordan
- University of Newcastle upon Tyne, Newcastle upon Tyne, United Kingdom
| | - Colin Church
- University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, United Kingdom
| | - Mark Toshner
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Stephen J Wort
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - David G Kiely
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom.,Sheffield Pulmonary Vascular Unit, Royal Hallamshire Hospital, Sheffield, United Kingdom; and
| | - Robin Condliffe
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom.,Sheffield Pulmonary Vascular Unit, Royal Hallamshire Hospital, Sheffield, United Kingdom; and
| | - Allan Lawrie
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Stefan Gräf
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom.,BioResource for Translational Research, National Institute for Health Research Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - David Montani
- Université Paris-Saclay, AP-HP, INSERM UMR_S 999, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, Hôpital de Bicêtre, Le Kremlin Bicêtre, France
| | - Athénaïs Boucly
- Université Paris-Saclay, AP-HP, INSERM UMR_S 999, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, Hôpital de Bicêtre, Le Kremlin Bicêtre, France
| | - Olivier Sitbon
- Université Paris-Saclay, AP-HP, INSERM UMR_S 999, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, Hôpital de Bicêtre, Le Kremlin Bicêtre, France
| | - Marc Humbert
- Université Paris-Saclay, AP-HP, INSERM UMR_S 999, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, Hôpital de Bicêtre, Le Kremlin Bicêtre, France
| | - Luke S Howard
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Nicholas W Morrell
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Martin R Wilkins
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
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9
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Prognostic value of improvement endpoints in pulmonary arterial hypertension trials: A COMPERA analysis. J Heart Lung Transplant 2022; 41:971-981. [DOI: 10.1016/j.healun.2022.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/23/2022] [Accepted: 03/10/2022] [Indexed: 11/23/2022] Open
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10
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Tilea I, Petra DN, Serban RC, Gabor MR, Tilinca MC, Azamfirei L, Varga A. Short-Term Impact of Iron Deficiency in Different Subsets of Patients with Precapillary Pulmonary Hypertension from an Eastern European Pulmonary Hypertension Referral Center. Int J Gen Med 2021; 14:3355-3366. [PMID: 34285560 PMCID: PMC8285229 DOI: 10.2147/ijgm.s318343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 06/15/2021] [Indexed: 11/23/2022] Open
Abstract
Background Over the last few decades, interest in the role of iron status in pulmonary hypertension (PH) has grown considerably due to its potential impact on symptoms, exercise capacity (as assessed by the 6-minute walk distance [6MWD]), prognosis, and mortality. The aim of the present study was to identify iron deficiency (ID) prevalence in specific precapillary PH subgroups of Romanian patients and its short-term impact on 6MWD. Patients and Methods Complete datasets from 25 precapillary PH adults were examined and included in the analysis. Data were collected at baseline and after continuous follow-up of an average of 13.5 months. Enrolled patients were assigned to group 1 (pulmonary arterial hypertension) or subgroup 4.1 (chronic thromboembolic pulmonary hypertension), and individualized targeted therapy was prescribed. General characteristics, World Health Organization functional class, 6MWD, pulse oximetry, laboratory parameters, and echocardiographic and hemodynamic parameters were recorded. Ferritin values and transferrin saturation were used to assess ID. Results At baseline, 16 out of 25 patients were iron deficient. The univariate linear regression analysis did not show a statistically significant impact of ID on 6MWD (p=0.428). In multivariate regression analysis, possible predictors of 6MWD, including ID, were not statistically significant at baseline or after an average of 13.5 months follow-up (p=0.438, 0.361, respectively) and ID indicates a negative impact on 6MWD independent of applied corrections. Conclusion The results of this study demonstrate that 1.4.1 subgroup PAH patients have an increased prevalence of ID compared with other etiologies. ID has a negative impact on the functional status (assessed by 6MWD), in specific groups and subgroups of patients with precapillary PH, albeit not independently nor significant to other known predictors such as age, gender, oxygen saturation, and hemoglobin value. These data can be integrated with global research and are consistent with phenotypes of patients diagnosed with PH of different etiologies.
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Affiliation(s)
- Ioan Tilea
- Department of Internal Medicine, "George Emil Palade" University of Medicine, Pharmacy, Science and Technology of Targu Mures, Targu Mures, 540142, Romania.,Department of Cardiology II, County Emergency Clinical Hospital, Targu Mures, 540042, Romania
| | - Dorina Nastasia Petra
- Department of Family Medicine, "George Emil Palade" University of Medicine, Pharmacy, Science and Technology of Targu Mures, Targu Mures, 540142, Romania.,Department of Internal Medicine II, County Emergency Clinical Hospital, Targu Mures, 540042, Romania
| | - Razvan Constantin Serban
- Cardiac Catheterization Laboratory, The Emergency Institute for Cardiovascular Diseases and Transplantation, Targu Mures, 540136, Romania
| | - Manuela Rozalia Gabor
- Department of Economics and Law, "George Emil Palade" University of Medicine, Pharmacy, Science and Technology of Targu Mures, Targu Mures, 540142, Romania
| | - Mariana Cornelia Tilinca
- Department of Internal Medicine, "George Emil Palade" University of Medicine, Pharmacy, Science and Technology of Targu Mures, Targu Mures, 540142, Romania
| | - Leonard Azamfirei
- Department of Anesthesiology and Intensive Care, "George Emil Palade" University of Medicine, Pharmacy, Science and Technology of Targu Mures, Targu Mures, 540142, Romania.,Department of Anesthesiology and Intensive Care, County Emergency Clinical Hospital, Targu Mures, 540042, Romania
| | - Andreea Varga
- Department of Cardiology II, County Emergency Clinical Hospital, Targu Mures, 540042, Romania.,Department of Family Medicine, "George Emil Palade" University of Medicine, Pharmacy, Science and Technology of Targu Mures, Targu Mures, 540142, Romania
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11
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Benza RL, Kanwar MK, Raina A, Scott JV, Zhao CL, Selej M, Elliott CG, Farber HW. Development and Validation of an Abridged Version of the REVEAL 2.0 Risk Score Calculator, REVEAL Lite 2, for Use in Patients With Pulmonary Arterial Hypertension. Chest 2021. [PMID: 32882243 DOI: 10.1016/j.chest.2020.08.2069)] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Achievement of low-risk status is a treatment goal in pulmonary arterial hypertension (PAH). Risk assessment often is performed using multiparameter tools, such as the Registry to Evaluate Early and Long-Term PAH Disease Management (REVEAL) risk calculator. Risk calculators that assess fewer variables without compromising validity may expedite risk assessment in the routine clinic setting. We describe the development and validation of REVEAL Lite 2, an abridged version of REVEAL 2.0. RESEARCH QUESTION Can a simplified version of the REVEAL 2.0 risk assessment calculator for patients with PAH be developed and validated? STUDY DESIGN AND METHODS REVEAL Lite 2 includes six noninvasive variables-functional class (FC), vital signs (systolic BP [SBP] and heart rate), 6-min walk distance (6MWD), brain natriuretic peptide (BNP)/N-terminal prohormone of brain natriuretic peptide (NT-proBNP), and renal insufficiency (by estimated glomerular filtration rate [eGFR])-and was validated in a series of analyses (Kaplan-Meier, concordance index, Cox proportional hazard model, and multivariate analysis). RESULTS REVEAL Lite 2 approximates REVEAL 2.0 at discriminating low, intermediate, and high risk for 1-year mortality in patients in the REVEAL registry. The model indicated that the most highly predictive REVEAL Lite 2 parameter was BNP/NT-proBNP, followed by 6MWD and FC. Even if multiple, less predictive variables (heart rate, SBP, eGFR) were missing, REVEAL Lite 2 still discriminated among risk groups. INTERPRETATION REVEAL Lite 2, an abridged version of REVEAL 2.0, provides a simplified method of risk assessment that can be implemented routinely in daily clinical practice. REVEAL Lite 2 is a robust tool that provides discrimination among patients at low, intermediate, and high risk of 1-year mortality. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT00370214; URL: www.clinicaltrials.gov.
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Affiliation(s)
| | | | | | | | - Carol L Zhao
- Janssen Pharmaceuticals, Inc, South San Francisco, CA
| | - Mona Selej
- Janssen Pharmaceuticals, Inc, South San Francisco, CA
| | - C Greg Elliott
- Intermountain Medical Center and the University of Utah, Salt Lake City, UT
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12
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Nikkho S, Fernandes P, White RJ, Deng C(CQ, Farber HW, Corris PA. Clinical trial design in phase 2 and 3 trials for pulmonary hypertension. Pulm Circ 2020; 10:2045894020941491. [PMID: 33282181 PMCID: PMC7682228 DOI: 10.1177/2045894020941491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 06/17/2020] [Indexed: 11/15/2022] Open
Abstract
This article on clinical trial design incorporates the broad experience of members of the Pulmonary Vascular Research Institute's (PVRI) Innovative Drug Development Initiative (IDDI) as an open debate platform for academia, the pharmaceutical industry and regulatory experts surrounding the future design of clinical trials in pulmonary hypertension. It is increasingly clear that the design of phase 2 and 3 trials in pulmonary hypertension will have to diversify from the traditional randomised double-blind design, given the anticipated need to trial novel therapeutic approaches in the immediate future. This article reviews a wide range of differing approaches and places these into context within the field of pulmonary hypertension.
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Affiliation(s)
| | | | - R. James White
- University of Rochester Medical Center, Rochester, NY, USA
| | | | | | - Paul A Corris
- Translational and Clinical Science Institute, Newcastle University, Newcastle upon Tyne, UK
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13
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Development and Validation of an Abridged Version of the REVEAL 2.0 Risk Score Calculator, REVEAL Lite 2, for Use in Patients With Pulmonary Arterial Hypertension. Chest 2020; 159:337-346. [PMID: 32882243 PMCID: PMC7462639 DOI: 10.1016/j.chest.2020.08.2069] [Citation(s) in RCA: 121] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 08/12/2020] [Accepted: 08/16/2020] [Indexed: 12/04/2022] Open
Abstract
Background Achievement of low-risk status is a treatment goal in pulmonary arterial hypertension (PAH). Risk assessment often is performed using multiparameter tools, such as the Registry to Evaluate Early and Long-Term PAH Disease Management (REVEAL) risk calculator. Risk calculators that assess fewer variables without compromising validity may expedite risk assessment in the routine clinic setting. We describe the development and validation of REVEAL Lite 2, an abridged version of REVEAL 2.0. Research Question Can a simplified version of the REVEAL 2.0 risk assessment calculator for patients with PAH be developed and validated? Study Design and Methods REVEAL Lite 2 includes six noninvasive variables—functional class (FC), vital signs (systolic BP [SBP] and heart rate), 6-min walk distance (6MWD), brain natriuretic peptide (BNP)/N-terminal prohormone of brain natriuretic peptide (NT-proBNP), and renal insufficiency (by estimated glomerular filtration rate [eGFR])—and was validated in a series of analyses (Kaplan-Meier, concordance index, Cox proportional hazard model, and multivariate analysis). Results REVEAL Lite 2 approximates REVEAL 2.0 at discriminating low, intermediate, and high risk for 1-year mortality in patients in the REVEAL registry. The model indicated that the most highly predictive REVEAL Lite 2 parameter was BNP/NT-proBNP, followed by 6MWD and FC. Even if multiple, less predictive variables (heart rate, SBP, eGFR) were missing, REVEAL Lite 2 still discriminated among risk groups. Interpretation REVEAL Lite 2, an abridged version of REVEAL 2.0, provides a simplified method of risk assessment that can be implemented routinely in daily clinical practice. REVEAL Lite 2 is a robust tool that provides discrimination among patients at low, intermediate, and high risk of 1-year mortality. Trial Registry ClinicalTrials.gov; No.: NCT00370214; URL: www.clinicaltrials.gov;
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