Key result
Upfront macitentan and PDE5i linked to ~39% lower mortality vs PDE5i alone in PAH.
Why the study?
Upfront combination therapy with an ERA and PDE5i is guideline-recommended for low- or intermediate-risk PAH, but time to all-cause mortality had not been directly compared between macitentan plus PDE5i and each monotherapy.
Does upfront combination therapy with macitentan and a PDE5i reduce all-cause mortality in adults with newly diagnosed pulmonary arterial hypertension compared to monotherapy?
Observational (n=2,201)
Yes
Does upfront combination therapy with macitentan and a PDE5i reduce all-cause mortality in adults with newly diagnosed pulmonary arterial hypertension compared to monotherapy?
Upfront combination therapy with macitentan and a PDE5i is associated with a significant survival benefit compared to either monotherapy in patients with newly diagnosed pulmonary arterial hypertension.
Answers are grounded in this paper and cite their sources.
Upfront macitentan+PDE5i improves survival in new PAH; reinforces guideline recommendations for ERA+PDE5i combination.
INTRODUCTION: Upfront combination therapy with endothelin receptor antagonist (ERA) and phosphodiesterase-5 inhibitor (PDE5i) is guideline-recommended for low- or intermediate-risk pulmonary arterial hypertension (PAH). This study compared time to all-cause mortality for macitentan+PDE5i combination and each monotherapy. METHODS: Long-term patient-level data (planned follow-up ≥1 year) were pooled from four clinical trials and three observational registries. All-cause mortality data were available from adults with incident PAH initiated on macitentan 10 mg or PDE5i monotherapy, or macitentan+PDE5i. Propensity-score (PS) methods balanced key demographic and disease characteristics across cohorts. Hazard ratios (HRs) were computed from a Cox-regression model that included PS-calculated weights. Weighted Kaplan-Meier estimates with 95% confidence intervals (CI) were computed 6-monthly. RESULTS: 2201 patients were included: 754 received macitentan+PDE5i (421 tadalafil, 324 sildenafil, 9 other), 654 macitentan, and 793 PDE5i (301 tadalafil, 490 sildenafil, 2 other). After weighting, characteristics were similar across cohorts. Upfront macitentan+PDE5i was associated with a 39% risk reduction of all-cause mortality versus PDE5i (HR 0.61 [95% CI 0.46-0.82]) and 32% versus macitentan (HR 0.68 [95% CI 0.37-0.95]). Reduction in all-cause mortality was 49% for macitentan+tadalafil vs tadalafil (HR 0.51 [95% CI 0.30-0.85]), 43% for macitentan+tadalafil vs macitentan (HR 0.57 [95% CI 0.37-0.88]), 31% for macitentan+sildenafil vs sildenafil (HR 0.69 [95% CI 0.45-1.0]) and 26% for macitentan+sildenafil vs macitentan (HR 0.74 [95% CI 0.46-1.17]). CONCLUSION: This large, pooled analysis suggests an observed statistical association indicating a potential survival benefit for early macitentan+PDE5i versus either monotherapy in newly diagnosed PAH.
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McLaughlin et al. (2025) conducted an observational in newly diagnosed pulmonary arterial hypertension (n=2,201). macitentan + PDE5i vs. macitentan monotherapy or PDE5i monotherapy was evaluated on all-cause mortality (HR 0.61, 95% CI 0.46-0.82). Upfront macitentan+PDE5i reduced all-cause mortality by 39% versus PDE5i (HR 0.61; 95% CI 0.46-0.82) and 32% versus macitentan (HR 0.68; 95% CI 0.37-0.95) in newly diagnosed PAH.
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