An article published in the Polish Heart Journal on December 23, 2024, titled “Emerging therapies and new directions in the treatment of pulmonary arterial hypertension” points out that the integration of novel therapeutic protocols into everyday medical practice faces various obstacles, particularly when considering regional differences in implementation.
The paper draws insights from medical experts across eight nations in Central and Eastern Europe: Croatia, Czech Republic, Latvia, Lithuania, Poland, Romania, Slovakia, and Slovenia. These healthcare systems underwent significant restructuring in the early 1990s following major political shifts, and this transition continues to influence their capacity to embrace new treatment approaches, especially given financial constraints.
The paper therefore aims to outline current treatment guidelines, emphasize crucial elements that can enhance patient outcomes, and examine the practical challenges of implementing these recommendations from a regional perspective.
The key changes in the pulmonary arterial hypertension treatment algorithm from the 2024 World Symposium on Pulmonary Hypertension are summarised in the paper as follows:
Major Algorithm Changes:
- Risk Categories: Simplified from three (high, intermediate, low) to two categories (high and non-high)
- Follow-up Timeline: Shortened from 3-6 months to 3-4 months after treatment initiation
- Sotatercept: Added as a second-line therapeutic option
- Maximal Medical Therapy: Now includes four drugs (adding sotatercept to the previous three-drug combination)
- Comorbidities Approach: Eliminated separate pathway for patients with cardiopulmonary comorbidities in favor of individualized treatment
Treatment Specifics:
- Preferred initial treatment for non-high risk patients remains tadalafil with macitentan or ambrisentan
- New consideration: possible escalation of sildenafil dosage to 80mg TID (with careful monitoring)
- Treatment for comorbid patients now based on:
- Balance between PVR severity and comorbidity burden
- Individualized approach with careful monitoring
- PDE5i preferred over ERA in patients with low PVR and high comorbidity burden
The authors say that these changes have been endorsed by US and Belgian pulmonary hypertension experts, with some modifications.
With regard to the Central-Eastern European perspective on pulmonary arterial hypertension treatment the authors highlight the following key factors:
Historical Context:
- PAH-specific therapies were only included in reimbursement schemes in early 21st century
- Implementation of advanced diagnostics and treatments lagged behind Western Europe by up to 20 years in some cases
Current Situation:
- PAH prevalence and incidence rates are similar to Western countries
- Oral treatments are widely available across the region
- Subcutaneous/intravenous treprostinil is accessible in all countries
- Major gaps remain:
- Epoprostenol is largely unavailable
- Sotatercept is not available in most countries
Call for Action:
- Urgent need for wider access to newly approved treatments
- Strong advocacy for sotatercept availability due to:
- Proven efficacy and safety profile
- Potential life-saving benefits for patients not responding to current therapies
- Overall limited cost burden due to low disease prevalence
- Importance for patients who don’t respond to or cannot tolerate maximum vasodilatory therapy
Read the full article (open access) at this link on the Polish Heart Journal
Citation
Emerging therapies and new directions in the treatment of pulmonary arterial hypertension, Grzegorz Kopeć, Andris Skride, Egle Ereminiene, Iveta Simkova, Roxana Enache, Miroslav Samarzija, Barbara Salobir, Pavel Jansa, Polish Heart Journal, December 23, 2024, https://journals.viamedica.pl/polish_heart_journal/article/view/104053/80720
