Safety of macitentan for the treatment of pulmonary hypertension: Real‐world experience from the OPsumit® USers Registry (OPUS) and OPsumit® Historical USers cohort (OrPHeUS)

Macitentan is an oral endothelin receptor antagonist for the management of pulmonary arterial hypertension (PAH). The OPsumit® USers Registry (OPUS) and the OPsumit® Historical USers cohort (OrPHeUS) medical chart review provide real‐world data for patients newly initiating macitentan. This study aims to describe the characteristics, safety profile, and clinical outcomes of PAH patients newly treated with macitentan in the combined OPUS/OrPHeUS data set. OPUS was a prospective, multicenter, long‐term, observational drug registry from April 2014 to June 2020. OrPHeUS was a retrospective, US, multicenter chart review: observation period October 2013 to March 2017. All analyses were descriptive. At registry closure in June 2020, the combined population consisted of 5654 patients, of whom 81.9% were diagnosed with PAH. For these 4626 patients, median duration of macitentan exposure observed was 14.5 (Q1 = 5.2, Q3 = 29.0) months; idiopathic PAH (54.8%) was the most common form of PAH; macitentan was initiated as monotherapy (37.9%), or as part of double (48.0%) or triple therapy (14.1%); discontinuation due to nonhepatic/hepatic adverse events occurred in 17.1%/0.3% of patients; 9.9% of patients experienced ≥1 hepatic adverse events; Kaplan–Meier estimates showed that at 1 year 59.9% (95% confidence interval: 58.3, 61.5) of patients were free from hospitalization and survival was 90.4% (89.3, 91.3). This analysis of real‐world data from the combined OPUS and OrPHeUS populations demonstrated that macitentan is well tolerated in a large, diverse population of PAH patients, with overall and hepatic safety profiles consistent with previous macitentan clinical trials.

Concomitant initiation of combination therapy with macitentan and tadalafil in pulmonary arterial hypertension (PAH) patients with comorbidities: real-world data from OPUS and OrPHeUS

Background

Guidelines for the management of pulmonary arterial hypertension (PAH) recommend early combination therapy of an endothelial receptor antagonist (ERA) and a phosphodiesterase type-5 inhibitor (PDE5i) [1]. There is, however, limited guidance about the management of PAH patients with comorbidities.

Purpose

To describe the demographics, clinical characteristics, safety, tolerability, and outcomes associated with initiation of the ERA macitentan and the PDE5i tadalafil in patients with comorbidities in the US OPsumit® USers (OPUS) and the OPsumit® Historical USers cohort (OrPHeUS) combined dataset.

Methods

This analysis reports data from the OPUS registry (Apr 2014–Jun 2020) and OrPHeUS medical chart review (Oct 2013–Mar 2017) on PAH patients initiating macitentan and tadalafil (M+T) combination therapy, in any order, as concomitant initiation (≤60 days apart, concomitant initiation group). The index date was defined as the start date of the second therapy (i.e., the start of combination therapy). Patients were further grouped by the number of comorbidities present prior to or at macitentan initiation: systemic hypertension, diabetes, renal insufficiency, BMI ≥30 kg/m2, other signs of right heart failure and atrial fibrillation. Results are presented descriptively alongside results for all PAH patients receiving M+T combination therapy (overall M+T group).

Results

Of the 1336 PAH patients that received M+T combination therapy, 431 (32%) were in the concomitant initiation group. In the concomitant initiation and overall M+T groups, respectively: 72% and 68% had ≥1 comorbidity, and the most common were systemic hypertension (47% and 47%), obesity (32% and 26%) and diabetes (23% and 22%). Patients were more likely to be older, male and have idiopathic/heritable PAH with increasing comorbidity burden (Table 1). Patients in the concomitant initiation group were more likely to be incident (median time from diagnosis: 1–2 months vs 9–24 months in the overall M+T group; Table 1). Most patients had ≥1 adverse event (AE); in both groups, patients with a high comorbidity burden (≥3) were more likely to have had an AE and to have discontinued treatment (Table 2). The incidence rate of first all-cause hospitalisation and mortality by comorbidity was comparable between the concomitant initiation and overall M+T groups.

Conclusions

In the real-world, concomitant initiation of M+T is used in PAH patients with comorbidities, usually shortly after diagnosis. Patient characteristics were similar for the concomitant initiation and overall M+T groups, with the exception of time from diagnosis. At index date, age, gender proportion, and PAH aetiology differed between the comorbidity groups. The safety profile of M+T combination therapy in the concomitant initiation group was consistent with that in the overall M+T group.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson & Johnson

Treatment with macitentan for pulmonary arterial hypertension (PAH) associated with congenital heart disease (CHD): real-world experience from the combined OPUS and OrPHeUS data sets

Introduction

Restrictive inclusion criteria can exclude some CHD-PAH patients from clinical trials. The OPsumit® USers (OPUS) Registry and the OPsumit® Historical USers (OrPHeUS) data sets provide real-world data in PAH patients newly started on macitentan, including patients with CHD-PAH regardless of defect type.

Purpose

To describe the characteristics, safety and clinical outcomes of CHD-PAH patients newly treated with macitentan.

Methods

OPUS is a prospective, US, multicentre, observational drug registry ongoing since April 2014. OrPHeUS was a retrospective, US, multicentre chart review; observation period Oct 2013–Mar 2017. This analysis reports information on CHD-PAH patients in the combined OPUS/OrPHeUS data set, descriptively compared with idiopathic/heritable PAH (I/HPAH) patients.

Results

As of Sept 2019, there were 4268 PAH patients with follow-up data, of whom 264 (6%) had CHD-PAH and 2396 (56%) had I/HPAH. For CHD-PAH and I/HPAH patients respectively at macitentan initiation: median age (Q1, Q3) was 48 (36, 62) and 65 (53, 73) years; 199 (75%) and 1748 (73%) were female; 67/114 (59%) and 802/1301 (62%) were WHO functional class III/IV; median (Q1, Q3) 6-minute walk distances were 350 (274, 420) and 289 (195, 375) m for the 82 and 840 patients with measurements; median (Q1, Q3) time from PAH diagnosis to macitentan initiation was 37.3 (4.5, 113.1) and 7.4 (1.4, 38.3) months; and 99 (38%) and 1056 (44%) initiated macitentan as monotherapy. The number of patients with ≥1 hepatic adverse event (HAE) was similar for CHD-PAH and I/HPAH (22 [8%] and 184 [8%]), as were the adverse event (AE) profiles (collected from OPUS only). Exposure, discontinuations, outcomes and most common AEs are shown in the table.

Conclusions

In general, compared with I/HPAH patients, CHD-PAH patients were younger and a greater proportion had prevalent disease than I/HPAH patients. Safety and outcomes were similar between the groups.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Actelion Pharmaceuticals Ltd

Effect of macitentan on left ventricular (LV) function in pulmonary arterial hypertension (PAH): results from REPAIR

Introduction

PAH impacts right ventricular (RV) structure and function but also leads to changes in the LV due to RV/LV interaction and underfilling. REPAIR, the first PAH study to use a primary endpoint assessed by cardiac MRI (cMRI), reported that RV stroke volume (RVSV) increased by 12 mL and pulmonary vascular resistance (PVR) decreased by 38% from baseline (BL) to Week 26 with macitentan.

Purpose

To assess the effect of macitentan on LV function in patients with PAH.

Methods

REPAIR (NCT02310672) was a 52-week, multicentre, open-label, single-arm, phase 4 study assessing the effect of macitentan primarily on RV structure and function, determined by cMRI and right heart catheterisation. Macitentan 10 mg was initiated in treatment-naïve patients, in patients receiving stable background phosphodiesterase type-5 inhibitor (PDE5i) at BL, or in initial combination with PDE5i. Exploratory LV endpoints were assessed by cMRI at Weeks 26 and 52. Safety was assessed up to end of study treatment +30 days in all patients who received ≥1 dose of macitentan (N=87). Patients with BL and Week 26 assessments for both PVR and RVSV were included in the modified Full Analysis Set (mFAS; N=71).

Results

In the mFAS, 57 (80%) patients were female. At BL, median age was 45 years; median (Q1, Q3) six-minute walk distance was 395 (323, 483) m; 48%/51% of patients were WHO functional class II/III; 59% had idiopathic PAH. Compared to BL, at Weeks 26 and 52 there were significant changes in LV cMRI parameters (table). The most common AEs were peripheral oedema (22%), headache (21%) and dizziness (14%).

Conclusions

Macitentan led to improvements in LV mass, volume and function, including clinically-relevant increases in LV stroke volume, at both 26 and 52 weeks in patients with PAH. Safety was consistent with other macitentan clinical trial data.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Actelion Pharmaceuticals Ltd

Combination therapy with macitentan and phosphodiesterase type-5 inhibitor (PDE5i) in pulmonary arterial hypertension (PAH): real-world data from OPUS and OrPHeUS

Introduction

Guidelines for the management of PAH recommend combination therapy for most patients, yet real-world data on treatment patterns in PAH are limited.

Purpose

To describe the characteristics, safety and clinical outcomes of PAH patients newly treated with double combination therapy with macitentan and PDE5i in the OPsumit® USers (OPUS) Registry and the OPsumit® Historical USers cohort study (OrPHeUS) combined dataset.

Methods

OPUS is a prospective, US, multicentre, observational drug registry (NCT02126943) ongoing since April 2014. OrPHeUS was a retrospective, US, multicentre chart review (NCT03197688); Oct 2013–Mar 2017. This cohort included patients initiating combination therapy with macitentan and a PDE5i (in any order) ≤60 days apart. Baseline was defined as the start date of the second therapy (i.e., start of combination therapy). Patient characteristics at baseline, changes in 6-minute walk distance (6MWD) and WHO functional class (FC) from baseline to follow-up, safety and outcomes are described.

Results

Of the 4428 OPUS/OrPHeUS PAH patients initiating macitentan, 2490 received this in combination with a PDE5i; of these patients, 740 (29.7%) initiated macitentan and a PDE5i concurrently (≤60 days apart). Data on disease duration was recorded in 729 patients at baseline; of these, 588 (80.7%) patients were incident (≤6 months since diagnosis) and 141 (19.3%) were prevalent (>6 months since diagnosis); median time from diagnosis to start of combination therapy of was 1.4 (Q1=0.6, Q3=3.6) months. At baseline, median age was 60 (Q1=49, Q3=70) years and 73.6% of patients were female. Mean baseline 6MWD was 264.5 (SD=119.8) m, recorded in 240 (32.4%) patients. WHO FC was recorded at baseline for 347 (46.9%) patients; 263 (75.8%) were in FC III/IV. Median combination therapy exposure was 10.2 (Q1=3.4, Q3=21.8) months, with 58.8% of patients ongoing at data cut. Changes from baseline to follow up in FC and 6MWD are shown in the figure. There was ≥1 adverse event (AE) reported in 455 (61.5%) patients and ≥1 hepatic AE (HAE) in 76 (10.3%) patients. In total, 232 (31.4%) patients discontinued macitentan; 122 (16.5%) due to AEs, 4 (0.5%) due to HAEs, 98 (13.2%) not due to an AE/HAE, and 8 (1.1%) for unknown reasons. Of the 305 patients who discontinued combination therapy, 137 (18.5%) discontinued macitentan only, 73 (9.9%) discontinued PDE5i only, and 95 (12.8%) discontinued both drugs at the same time. Kaplan-Meier estimates (95% CI) showed that 60.7% (56.4, 64.8) of patients were free from hospitalisation and 88.7% (85.7, 91.1) were alive at 12 months.

Conclusions

In this real-world setting, less than one third of patients treated with macitentan received initial oral combination therapy, despite current expert consensus favouring such therapeutic approaches. Patients initiating macitentan+PDE5i ≤60 days apart had improved 6MWD and WHO FC from baseline to follow-up.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Actelion Pharmaceuticals Ltd

P3674Patient characteristics and treatment patterns in the multicentre, retrospective chart review of first-time Opsumit (macitentan) users in the United States (OrPHeUS)

Introduction

The OPsumit® Historical USers cohort (OrPHeUS) is a multicentre, US, retrospective medical chart review conducted to supplement the OPsumit® USers (OPUS) Registry to fulfil the FDA request to characterise the safety of macitentan in clinical practice.

Purpose

To describe patient characteristics, treatment patterns, hepatic safety and survival in patients with pulmonary hypertension (PH) newly treated with macitentan.

Methods

OrPHeUS (NCT03197688) aimed to include 2200 new users of macitentan, between October 2013 and March 2017, who were not enrolled in OPUS. Here we present patients with follow-up data, including characteristics and treatment patterns at macitentan initiation, hepatic adverse events (HAEs) identified using preferred terms in chart entries and pharmacovigilance reporting, hospitalisations and survival.

Results

OrPHeUS included 2982 patients newly treated with macitentan and with follow-up data; the reason for macitentan prescription was pulmonary arterial hypertension (PAH) in 2362 (79.3%) patients, other PH aetiologies in 612 (20.6%) patients and 8 patients with other/unknown reasons. At macitentan initiation, the median (Q1, Q3) age of the patients was 62 (51, 72) years and 73.9% were female. WHO functional class (FC) was documented in 654 (21.9%) patients, 35.6% of patients were in FC I/II and 64.4% in FC III/IV; median (Q1, Q3) 6-minute walk distance, documented in 411 (13.8%) patients, was 293 (200, 383) metres. At macitentan initiation, 41.5% (n=1239) of patients were not receiving PAH therapy, 46.3% (n=1382) were already receiving one PAH therapy and 11.9% (n=356) were already receiving two PAH therapies. The median (Q1, Q3) exposure to macitentan was 14.9 (5.6, 27.1) months; 57% and 43% of patients had exposures of >12 and >18 months. During the exposure period, 933 (31.3%) patients discontinued treatment, including 474 (15.9%) patients who discontinued due to an adverse event (AE), 6 (0.2%) due to a HAE, 449 (15.1%) for reasons other than an AE/HAE, and 4 (0.1%) for unknown reasons. There were 275 (9.2%) patients who experienced ≥1 HAE (incidence rate [IR]: 0.07 [95% CI, 0.06, 0.08] per 1 person-year); alanine aminotransferase (ALT) or aspartate aminotransferase (AST) ≥3x upper limit of normal (ULN) were experienced by 113 (3.8%) patients (IR: 0.028 [95% CI, 0.023, 0.033] per 1 person-year); ALT/AST ≥x3 ULN and bilirubin ≥2x ULN was experienced by 33 (1.1%) patients (IR: 0.008 [95% CI, 0.006, 0.011] per 1 person-year). There were 1148 (38.5%) patients who experienced at least one hospitalisation (IR: 0.36 [95% CI, 0.34, 0.39] per 1 person-year). The 12-month Kaplan-Meier survival estimate was 92% (95% CI, 91, 93).

Conclusion

OrPHeUS provides additional real-world evidence in patients newly treated with macitentan, confirming the hepatic safety profile of macitentan.

Acknowledgement/Funding

Actelion Pharmaceuticals Ltd

P4673Macitentan in chronic thromboembolic pulmonary hypertension (CTEPH): combined data from OPUS and OrPHeUS real-world data sets

Introduction

The OPsumit® USers Registry (OPUS) provides real-world data in patients (pts) with pulmonary hypertension newly started on macitentan. The OPsumit® Historical USers cohort (OrPHeUS) study was conducted to supplement OPUS to fulfil the FDA request to characterise the safety of macitentan in clinical practice. Both studies included pts with CTEPH.

Purpose

To describe the characteristics and safety outcomes of CTEPH pts newly treated with macitentan.

Methods

OPUS is a prospective, US, multicentre, long-term, observational drug registry (NCT02126943) ongoing since Apr 2014. OrPHeUS was a retrospective, US, multicentre medical chart review (NCT03197688); data collected Oct 2013-Mar 2017. This subgroup analysis describes CTEPH patient characteristics at macitentan initiation, hospitalisations, survival and liver function tests (LFTs) in the combined OPUS/OrPHeUS data set. LFTs are also provided for the OPUS/OrPHeUS pulmonary arterial hypertension (PAH) population.

Results

As of Oct 2018, OPUS/OrPHeUS included 144 CTEPH pts with follow-up data. At macitentan initiation, median (Q1, Q3) age was 66 (56, 73) years; of the 53 pts with a WHO functional class (FC) assessment, 35.8%, 49.1% and 15.1% were in FC II, III and IV, respectively. Median (Q1, Q3) time from CTEPH diagnosis was 18.6 (7.4, 56.4) months (n=141). At macitentan initiation, 32.6% of pts had no PAH therapy, 63.9% were receiving one and 3.5% were receiving two PAH therapies. Median (Q1, Q3) exposure to macitentan was 15.9 (4.3, 30.4) months. There were 43 (29.9%) CTEPH pts who discontinued treatment; 23 due to an adverse event (AE), 0 due to a hepatic AE (HAE) and 20 not due to an AE/HAE. There were 58 (40.3%) CTEPH pts who experienced ≥1 hospitalisation and 9 (6.3%) pts died. LFTs are presented in the table.

LFTs CTEPH follow-up pts PAH follow-up pts (N=144) (N=4072) ALT or AST ≥3x ULN   Pts with ≥1 event, n (%) 1 (0.7) 132 (3.2)   Incidence rate per 1 person-year (95% CI) 0.005 (0.001, 0.035) 0.024 (0.020, 0.029) ALT or AST ≥3x ULN and total bilirubin ≥2x ULN   Pts with ≥1 event, n (%) 1 (0.7) 27 (0.7)   Incidence rate per 1 person-year (95% CI) 0.005 (0.001, 0.035) 0.005 (0.003, 0.007) ALT: alanine aminotransferase; AST: aspartate aminotransferase; CI: confidence interval; ULN: upper limit of normal.

Conclusions

Analysis of OPUS/OrPHeUS data provides further insight into real-world use of macitentan in CTEPH pts. The observed hepatic safety profile in CTEPH pts is in line with that of PAH pts.

Acknowledgement/Funding

Actelion Pharmaceuticals Ltd

4973Efficacy and safety of selexipag in pulmonary arterial hypertension (PAH) patients with and without significant cardiovascular (CV) comorbidities

Introduction

Many PAH patients today have a number of CV comorbidities, yet data on the efficacy and safety of therapies in such patients remain scarce. Most recent PAH clinical trials also include patients with comorbidities.

Purpose

To assess the long-term efficacy and safety of the oral, selective IP prostacyclin receptor agonist, selexipag, in PAH patients with and without significant CV comorbidities using post hoc analysis of GRIPHON data.

Methods

GRIPHON enrolled 1156 PAH patients randomised 1:1 to placebo:selexipag. The present analysis includes patients with right heart catheterisation within 1 year of randomisation who were categorised as with or without CV comorbidities. Patients with CV comorbidities were defined as having ≥3 of the following: body mass index (BMI) >30 kg/m2, history of essential hypertension, diabetes mellitus, or historical evidence of significant coronary artery disease; if PAWP/LVEDP was >12 but <15 mmHg, pulmonary vascular resistance (PVR) had to be >500 dyn.sec/cm5; if PAWP/LVEDP was <12, then PVR had to be >300 dyn.sec/cm5. Selexipag effect on time to first morbidity/mortality (M/M) event up to end of treatment was assessed for both subgroups. Baseline (BL) adjusted treatment hazard ratios with 95% CIs were calculated using Cox models. Model building involved stepwise backward elimination of BL covariates.

Results

752 PAH patients could be categorised based on these criteria (99 with CV comorbidities, 653 without). At BL, patients with CV comorbidities were older (median [range] 60 [28–80] vs 46 [18–78] yrs), had higher BMI (mean [SD] 33.3 [7.23] vs 26.0 [5.64] kg/m2) and lower 6-minute walk distance (mean [SD] 319 [95.7] vs 354 [79.3] m) vs those without. A greater proportion were from Western Europe/Australia/North America (60.6% vs 38.9%) and in WHO functional class III (69.7% vs 49.9%). At BL, 82.8% of patients with CV comorbidities were receiving PAH therapies vs 75.7% of those without. As expected, at BL a higher proportion of patients with CV comorbidities (vs without) had previous/concomitant cardiac disease (62.6% vs 43.0%), metabolism/nutrition disorders (75.8% vs 31.2%), respiratory/thoracic/mediastinal disorders (59.6% vs 37.5%) and vascular disorders (76.8% vs 37.4%). Selexipag reduced the risk of M/M events vs placebo in both subgroups (Figure), with no evidence of an inconsistent treatment effect (interaction p-value=0.1544). Adverse events leading to treatment discontinuation were reported in 35.4% (25.9% selexipag, 46.7% placebo) of patients with CV comorbidities and 35.0% (32.0% selexipag, 38.0% placebo) of those without. Common prostacyclin associated side effects observed with selexipag (headache, diarrhoea, nausea) were reported at a similar incidence in both subgroups.

Conclusions

Selexipag had a beneficial effect on long-term outcome in PAH patients both with and without CV comorbidities. Safety in both groups was consistent with the known profile of selexipag.

Acknowledgement/Funding

Actelion Pharmaceuticals Ltd

Complications associated with thoracentesis. A prospective, randomized study comparing three different methods

To determine what role the technique plays in complications associated with thoracentesis performed by physicians in training, we undertook a prospective study of thoracentesis in the medical service at our institution in which the sampling method was randomized among needle, needle with catheter, and needle with direct sonographic guidance. Fifty-two spontaneously breathing, cooperative patients with free-flowing effusions obliterating more than half of the hemidiaphragm on an upright, posteroanterior chest roentgenogram were randomized. When we analyzed those complications that were potentially life-threatening (eg, pneumothorax) and/or placed patients at increased risk for further morbidity (eg, pneumothorax, dry tap, inadequate tap), the sonography-guided method was associated with significantly fewer serious complications (0 of 19) than the needle-catheter (9 of 18) or needle-only methods (5 of 15). The sonography-guided method was associated with fewer pneumothoraces (0 of 19) than the needle-catheter (7 of 18) or needle-only methods (3 of 15). The difference between needle-catheter and needle-only methods was not significant. From our results, we conclude that the method by which thoracentesis was performed significantly influenced the spectrum and frequency of complications, and the sonography-guided method was the safest.