An HCPLive roundtable of pulmonologists from UCLA, Cedars-Sinai, and community practices discussed optimizing pulmonary arterial hypertension management.
Key points:
Treatment sequencing: Upfront dual oral combination therapy (ERA + PDE5 inhibitor) remains standard for non-high-risk patients, though sotatercept hasn’t formally displaced it despite growing clinical interest. An Italian study cited at the roundtable found about a third of treatment-naive patients failed to achieve a meaningful PVR reduction at 6 months on dual therapy, raising questions about whether the current approach is sufficient. Risk stratification tools (REVEAL 2.0, COMPERA, ESC/ERS models) were seen as useful but imperfect, especially since most don’t incorporate echo-based RV parameters.
Sotatercept’s real-world profile: Erythrocytosis was the most discussed side effect — modest on average, with hemoglobin cutoffs varying by institution (20 g/dL at UCLA, 22 g/dL at Cedars-Sinai). More notably, multiple panelists independently observed iron depletion after starting the drug, a signal not yet well documented in peer-reviewed literature, prompting UCLA to add routine iron monitoring. Some patients showed dramatic improvement in RV function on echo after starting sotatercept.
Access barriers: Insurance prior authorization was named the biggest systemic obstacle, particularly for Opsynvi (macitentan/tadalafil), with near-automatic denials described as destabilizing for practices — especially smaller ones without dedicated administrative support. The panel noted AI-generated appeal letters and discount pharmacy options (GoodRx, Cost Plus Drugs) as practical workarounds, while flagging at least one case where a patient died awaiting tadalafil approval, and another where a sotatercept patient lost access despite responding well, after both insurance and manufacturer assistance were denied.
Read more at this link on HCP Live