Pulmonary Hypertension - PHA Online University

Combination Therapy in Pulmonary Artery HypertensionNicholas W. Morrell, MA, MD, FRCPProfessor of Cardiopulmonary Medicine/Honorary Consultant,University of Cambridge School of Clinical MedicineAddress for correspondence: University of Cambridge School of ClinicalMedicine Box 157, Addenbrooke's Hospital, Hills Road, Cambridge CB22QQ, United Kingdom; e-mail: nwm23@cam.ac.uk.In her excellent article Iona Preston 1 systematically evaluatesthe current status of combination therapy in the treatment ofpatients with pulmonary artery hypertension (PAH) in theUnited States. The United Kingdom recently published itsown consensus statement on the management of PAH in clinicalpractice, which included the current use of combinationtherapy. 2Despite the current lack of definitive clinical trial data,combination therapy remains an attractive option for the clinicianfaced with a patient who is getting worse or a patient whois failing to improve on monotherapy. In the UK, the mostcommon way to combine therapies is to add a second drugwhen the patient is not improving or getting worse on optimaldoses of single therapy. Despite the concerns over pharmacologicalinteractions, the most common combination in the UKis the addition of an endothelin receptor antagonist (ETRA) tosildenafil or vice versa, which accounts for 65% of combinationtherapy prescriptions.In rapidly deteriorating patients, a parenteral prostanoidmay be added to the original oral therapy. The combination ofa prostanoid with sildenafil accounts for 23% of combinationprescriptions in the UK. Combined use of a prostanoid andETRA accounts for the remaining 12% of prescriptions. It is ofsome concern that the funding arrangements in the UK aremaking it harder to prescribe combination therapy in theabsence of definitive trial data and a favourable cost-benefitanalysis. Thus it is recommended that where combination therapyis being considered that all patients should be entered intoa clinical trial where possible. When it is not possible toinclude patients in clinical trials, we recommend that at thevery least the patient’s response to treatment is carefully monitoredand that data are submitted to national databases foraudit purposes.References1. Preston IR. Combination therapies in pulmonary arterial hypertension.Adv Pulmonary Hypertens. 2008;7:235-242.2. National Pulmonary Hypertension Centres of the UK and Ireland.Consensus statement on the management of pulmonary hypertension inclinical practice in the UK and Ireland. Thorax. 2008;63:1-41.PHA has just completed fundingfor the first year’s budget for our newMedical Education FundThis new two million dollar Fund will supportfour new PHA programs:Thirty-City Medical Education TourTo present information on the diagnosis and management of PAH to physicians and otherhealth professionals located in areas that lack recognized experts or centers for PAH.Preceptorship ProgramTo facilitate direct education and training of medical professionals, particularlycardiologists, pulmonologists and rheumatologists, by experienced pulmonary hypertensionspecialists in clinical settings.PHA Online UniversityTo create a clear, focused website for medical education in pulmonary hypertension,segmented by levels of expertise and medical interestMedical Education for Patients Regional SessionsTo present information on the mechanisms, diagnosis and treatment of PAH to patientsand family members in regional face-to-face settingsMade possible by unrestricted educational grants from our sponsors:Platinum: Actelion Gold: Gilead and Pfizer Silver: United TheraputicsWatch for more details and schedules in coming issues.