Comparison of clinical and economic burden of pulmonary arterial hypertension patients with and without connective tissue disease treated with macitentan

Introduction

Patients with pulmonary arterial hypertension (PAH) and connective tissue disease (CTD) have a poorer prognosis than those diagnosed with other PAH etiologies.

Purpose

To compare the clinical and economic burden among PAH patients with and without CTD (PAH-CTD/PAH non-CTD) treated with macitentan.

Methods

This retrospective study used the Optum Clinformatics DataMart to identify PAH-CTD and PAH non-CTD patients aged ≥18 years and prescribed macitentan from 01JAN2015–30JUN2019. The index date was the date of the first macitentan claim. Patients had to have ≥12 months of continuous enrollment before index and were followed until earliest of macitentan discontinuation, health plan disenrollment, death, or study end. Patients in the PAH-CTD cohort had to have a claim for a CTD condition at any time during the 12-month baseline period. Patients with a baseline claim for any PAH medication, chronic thromboembolic pulmonary hypertension, prior atrial septostomy or lung transplant were excluded. Descriptive analysis comprised means, standard deviations, medians, and interquartile ranges for continuous variables and frequencies and percentages for categorical variables. Multivariable analyses (Cox proportional hazards and generalized linear models) adjusting for baseline characteristics were used to compare time to PAH-related and all-cause hospitalization, disease progression (death, lung transplant, atrial septostomy or addition of intravenous/subcutaneous prostanoids), and PAH- and all-cause related medical (inpatient and outpatient) costs between the two cohorts with PAH non-CTD as reference.

Results

The analysis included 203 PAH-CTD and 750 PAH non-CTD patients treated with macitentan. Versus PAH non-CTD, PAH-CTD patients were younger, had proportionately more females, and lower Charlson Comorbidity Index (CCI) scores (Table). The proportion of patients with a baseline hospitalization, length of stay and inpatient costs were similar across groups. There were no significant differences observed in time to PAH-related hospitalization (hazard ratio [HR]=0.99; p=0.910), all-cause hospitalization (HR=1.13; p=0.195), or disease progression (HR=1.00; p-value=0.973) for the PAH-CTD cohort (PAH non-CTD as reference). All-cause medical costs were similar between the cohorts ($3,836 per patient per month [PPPM] for PAH CTD vs $3,521 PPPM for PAH non-CTD, p=0.362). PAH-CTD patients incurred higher mean PAH-related medical costs vs PAH non-CTD ($2,806 PPPM vs $1,961 PPPM, p=0.047).

Conclusion

The study suggests that risk of all-cause and PAH-related hospitalization and disease progression did not differ for PAH-CTD and PAH non-CTD patients. Treatment with macitentan in the real world appears to confer similar clinical benefits in both PAH-CTD and PAH non-CTD groups. All-cause costs did not differ between the two cohorts but PAH-related costs were significantly higher in PAH-CTD patients suggesting an incremental burden associated with CTD.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Janssen Scientific Affairs, LLC

Persistence with macitentan versus other endothelin receptor antagonists in patients with pulmonary arterial hypertension: experience from a real-world data repository in the USA

Background

Pulmonary arterial hypertension (PAH) is a progressive and fatal disease and as such, it is imperative that patients remain on therapy to delay progression and maintain functional status. Previous research has demonstrated differences in overall survival in the real-world by endothelin receptor antagonists (ERA) treatments with a lower risk of death with macitentan than ambrisentan and bosentan. However, real-world data on persistence to ERAs are limited.

Purpose

To compare persistence to macitentan versus ambrisentan and bosentan) in patients with PAH.

Methods

This retrospective, non-interventional, observational study identified patients between 10/21/2013–3/31/2021 (study period) from the Decision Resources Group (DRG) Real World Data Repository. The repository links medical and prescription claims from commercial, Medicaid, and Medicare plans with electronic health records (EHRs) to provide longitudinal patient-level data representative of over 300 million patients in the US. Patients selected must have been dispensed an ERA prescription from 4/14/14–3/31/20 AND 1) either an inpatient diagnosis of pulmonary hypertension (PH), or 2) a right heart catheterization with any PH diagnosis, or 3) were taking a phosphodiesterase 5 inhibitor (PDE5i). The primary outcome was persistence defined by time from index to drug discontinuation (90-day gap after the end of the last prescription's days of supply). Descriptive analysis comprised means, standard deviations, medians, and interquartile ranges for continuous variables and frequencies and percentages for categorical variables. Three-sample proportion tests were conducted at baseline to detect differences between the three cohorts and identify potentially confounding variables. Hazard ratios (HR) for pairwise comparisons (macitentan vs ambrisentan; macitentan vs bosentan) were calculated using an inverse probability of treatment weighting (IPTW)-adjusted Cox proportional regression model, to adjust for potential confounders (see Table 1) of the probability of receiving a specific ERA. Data were analyzed by Kaplan-Meier method.

Results

A total of 4,526 patients were included, of whom 1,205 received macitentan, 2,592 received ambrisentan and 729 received bosentan. Study population characteristics were representative of a general PAH population (Table 1). Unadjusted Kaplan-Meier analysis showed that median persistence was shortest for ambrisentan (12.6 months) followed by bosentan (13.6 months) and greatest for macitentan (15.8 months; overall log-rank p-value: 0.061). Compared to macitentan, patients on other ERAs had a greater risk of discontinuation: ambrisentan (10%) and bosentan (18%) (Table 2).

Conclusions

Persistence to therapy was significantly greater for macitentan-treated patients than in those receiving ambrisentan or bosentan. Further research examining variability in key sub-groups as well as the impact of improved persistence on long-term outcomes is warranted.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Janssen Scientific Affairs, LLC