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Abstract Number: 875

Treatment-Related Outcomes in Connective Tissue Disease-Associated Pulmonary Arterial Hypertension: A Pooled Analysis of 12 Randomized Controlled Trials

Rennie L. Rhee1, Nicole B. Gabler2, Amy Praestgaard2, Peter A. Merkel3 and Steven M. Kawut4, 1Rheumatology, University of Pennsylvania, Philadelphia, PA, 2Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, 3University of Pennsylvania, Philadelphia, PA, 4Pulmonary and Critical Care, University of Pennsylvania, Philadelphia, PA

Meeting: 2014 ACR/ARHP Annual Meeting

Keywords: clinical trials, Connective tissue diseases, meta-analysis, pulmonary complications and treatment

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Session Information

Session Title: Systemic Sclerosis, Fibrosing Syndromes and Raynaud's - Clinical Aspects and Therapeutics I: Systemic Sclerosis, Advances in Therapy

Session Type: Abstract Submissions (ACR)

Background/Purpose: Recent studies have shown that therapies for pulmonary arterial hypertension (PAH) improve exercise capacity, but subgroup analyses suggest that these therapies may be less effective in patients with connective tissue disease (CTD-PAH). The aim of this study was to compare the effect of treatment on the change in six minute walk distance (D6MWD) and clinical events in CTD-PAH vs idiopathic PAH (IPAH).

Methods: A pooled analysis was performed on patient-level data from 12 Phase III randomized placebo-controlled trials of advanced therapies for PAH that were submitted to the FDA for approval.  Outcomes for this analysis included D6MWD from baseline to 12 weeks, the occurrence of clinical worsening (defined as first occurrence of death, hospitalization for PAH, addition of other PAH medications, lung transplant, atrial septostomy, or worsening exercise capacity and/or functional class), and all-cause mortality.  Missing 6MWD at 12 weeks was multiply imputed.  A robust generalized estimating equation within a linear or logistic regression model was utilized using an exchangeable correlation structure and clustering on study trial.  Effect modification of treatment assignment (drug vs placebo) by diagnosis (CTD-PAH vs IPAH) was assessed.  All regression models were adjusted for age, sex, race, drug class, baseline 6MWD, functional class, and baseline hemodynamics (right atrial pressure, pulmonary vascular resistance, and cardiac index).

Results: The study sample included 2,736 participants: 824 had CTD-PAH and 1,912 had IPAH.  Patients with CTD-PAH were significantly older, more often female, and had a lower baseline 6MWD compared to patients with IPAH (Table 1).  There was a significant interaction between treatment assignment and diagnosis in terms of the D6MWD, such that the treatment-related improvement in D6MWD was significantly less in CTD-PAH than in IPAH (difference-in-difference -11.3 meters, [95% CI -20.0, -2.6], p for interaction = 0.011).  There was also greater treatment-associated reduction in clinical worsening and mortality in IPAH than in CTD-PAH (Table 2).

Conclusion: In clinical trials, treatment for PAH was less effective in CTD-PAH compared to IPAH in terms of increasing 6MWD, preventing clinical worsening, and possibly reducing the risk of death.  The differential treatment response in CTD-PAH and IPAH supports the need for stratified analysis in future trials and suggests that a different pathophysiological process may exist in the two phenotypes of disease.

 

Table 1: Characteristics of Study Participants

 

CTD-PAH

(n = 824)

IPAH

(n = 1,912)

p-value

Age, years

54 ± 14

47 ± 16

< 0.001

Female sex, No. (%)

735 (89)

1,402 (73)

< 0.001

Race, No (%)

      White

      Black

      Other

480 (58)

33 (4)

311 (38)

1,155 (60)

54 (3)

703 (37)

0.210

WHO functional class, No (%)

      I-II

      III-IV

374 (45)

450 (55)

847 (44)

1,065 (56)

0.599

Baseline hemodynamics

      Right atrial pressure, mmHg

      Mean pulmonary arterial pressure, mmHg

      Cardiac index, L/min/m2

      Pulmonary capillary wedge pressure, mmHg

      Pulmonary vascular resistance, Woods units

7.9 ± 4.9

45 ± 12

2.5 ± 0.8

9 ± 3

9.8 ± 6.0

9.2 ± 5.7

55 ± 15

2.3 ± 0.8

9 ± 4

12.9 ± 7.5

< 0.001

< 0.001

< 0.001

0.993

< 0.001

Baseline 6-minute walk distance, meters

338 ± 89

351 ± 86

< 0.001

Drug Class, No. (%)

      Endothelin receptor antagonists

      Phosphodiesterase-5 inhibitors

      Prostacyclin analogue

      Soluble guanylate cyclase stimulator

507 (62%)

90 (11%)

117 (14%)

110 (13%)

1,071 (56%)

211 (11%)

349 (18%)

281 (15%)

0.025

Data are presented as mean ± standard deviation unless otherwise indicated.

 

 

Table 2: Risk of Clinical Worsening and Death Stratified by Diagnosis

Outcome

Diagnosis

OR

95% CI

p-value

p for interaction

Clinical Worsening

CTD-PAH

0.80

0.63-1.03

0.081

0.011

IPAH

0.51

0.40-0.65

<0.001

Death

CTD-PAH

1.73

0.75-4.00

0.198

0.115

IPAH

0.66

0.27-1.60

0.356

 


Disclosure:

R. L. Rhee,
None;

N. B. Gabler,
None;

A. Praestgaard,
None;

P. A. Merkel,

Genentech and Biogen IDEC Inc.,

2,

Bristol-Myers Squibb,

2,

GlaxoSmithKline,

2,

Actelion Pharmaceuticals US,

2,

Actelion Pharmaceuticals US,

5,

Sanofi-Aventis Pharmaceutical,

5,

Chemocentryx,

5;

S. M. Kawut,
None.

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