This “How I Do It” article addresses a practical question now facing pulmonary arterial hypertension (PAH) clinicians: as sotatercept gets added to background combination treatment, some patients on prostacyclin therapy show sustained improvement — raising the question of whether their prostacyclin dose can be safely reduced. The challenge is that standard monitoring tools (functional class, 6-minute walk distance, biomarkers, composite risk scores) often aren’t precise enough to guide that decision, especially in higher-functioning patients.
The authors review emerging evidence on prostacyclin de-escalation in carefully selected sotatercept-treated patients, covering safety considerations and patient selection, and propose using cardiopulmonary exercise testing (CPET) as an added tool — a stress-based way to assess cardiopulmonary reserve and right ventricle-pulmonary vascular coupling that conventional monitoring misses. They lay out a structured framework combining cardiopulmonary exercise testing with standard assessments, illustrated through a clinical case, to support more individualized, shared decision-making around de-escalation in the sotatercept era.
Citation
Tasevac B, Cirulis MM, Dodson MW, Hegewald MJ, Elliott CG, Graham JD. How I Do It: De-escalation of Prostacyclin-Based Therapy in Patients Treated With Sotatercept. Chest. 2026 Jun 24:S0012-3692(26)00912-8. doi: 10.1016/j.chest.2026.06.021. Epub ahead of print. PMID: 42341978. DOI: 10.1016/j.chest.2026.06.021