CHEST Provides PAH Adult Treatment Guideline Updates

The American College of Chest Physicians (CHEST) has announced updates to the organization’s evidence-based guidelines on treating pulmonary arterial hypertension (PAH).

In this newest guideline, Therapy for Pulmonary Arterial Hypertension in Adults: Update of the CHEST Guideline and Expert Panel Report, 78 evidence-based recommendations from a CHEST panel of experts detail updated guidance for therapies in patients with PAH. The guideline improves on the standards set in the organization’s most recently-published recommendations from 2014, guidelines committee co-chair Deporah Jo Levine, MD, said.

“In addition, an evidence-based and consensus-driven treatment algorithm was created to guide the clinician through an organized approach to management,” Levine said in a statement.

The panel conducted an update to its systematic review on the clinical questions and criteria that shaped prior PAH guidelines. Based on the results, they have created 2 new recommendations pertaining to the pharmacologic therapy for PAH.

The recommendations are as follows:

• Treatmentnaïve patients with PAH who are considered World Health Organization (WHO) functional class 2 and 3 are advised to be treated with initial combination therapy with ambrisentan and tadalfil, to improve six-minute walking distance (6MWD).
• Stale or symptomatic patients with PAH on background therapy with ambrisentan are advised to be treated with ambirsentan and tadalafil to improve 6MWD.

According to the guideline authors, PAH is associated with a poor prognosis in patients not promptly diagnosed and treated with appropriate measures. Perhaps in response to its severe effect, there have been 14 different therapies developed and approved for PAH in the past few decades.

“Therapeutic options for the patient with PAH continue to expand through basic discovery, translational science, and clinical trials,” authors wrote. “Optimal use of new treatment options require prompt evaluation at an expert center, utilization of current evidence-based guidelines, and collaborative care using sound clinical judgement.”

In an interview with MD Magazine® while at the 2018 CHEST Annual Meeting in San Antonio, TX, last October, Gary Palmer, MD, MBA, Vice President of Medical Affairs for Actelion Pharmaceuticals and Victor Tapson, MD, Director of the Venous Thromboembolism & Pulmonary Vascular Disease Research Program at the Cedars-Sinai Medical Center, described the advancement of PAH therapies they’ve seen firsthand in the past 3 decades.

With each added therapy, the pair said, came a stronger embrace of dual therapy regimen for patients at risk of deadly symptoms.

“Even though patients may seem stable and do OK, we want to get them to a place where they're doing well,” Tapson said. “We tend to be, in a nutshell, using drugs upfront and adding a second or third drug more commonly nowadays than we used to, because we have them available.”

The guideline, “Therapy for Pulmonary Arterial Hypertension in Adults 2018,” were published online in the CHEST Journal.