Rahaghi Franck F, Balasubramanian Vijay P, Bourge Robert C, Burger Charles D, Chakinala Murali M, Eggert Michael S, Elwing Jean M, Feldman Jeremy, King Christopher, Klinger James R, Mathai Stephen C, McConnell John Wesley, Palevsky Harold I, Restrepo-Jaramillo Ricardo, Safdar Zeenat, Sager Jeffrey S, Sood Namita, Sulica Roxana, White R James, Hill Nicholas S
Advanced Lung Disease Clinic Cleveland Clinic Florida Weston Florida USA.
UCSF Fresno Fresno California USA.
Pulm Circ. 2022 Apr 7;12(2):e12055. doi: 10.1002/pul2.12055. eCollection 2022 Apr.
Dual combination therapy with a phosphodiesterase-5 inhibitor (PDE5i) and endothelin receptor antagonist is recommended for most patients with intermediate-risk pulmonary arterial hypertension (PAH). The RESPITE and REPLACE studies suggest that switching from a PDE5i to a soluble guanylate cyclase (sGC) activator may provide clinical improvement in this situation. The optimal approach to escalation or transition of therapy in this or other scenarios is not well defined. We developed an expert consensus statement on the transition to sGC and other treatment escalations and transitions in PAH using a modified Delphi process. The Delphi process used a panel of 20 physicians with expertise in PAH. Panelists answered three questionnaires on the management of treatment escalations and transitions in PAH. The initial questionnaire included open-ended questions. Later questionnaires consolidated the responses into statements that panelists rated on a Likert scale from -5 () to +5 () to determine consensus. The Delphi process produced several consensus recommendations. Escalation should be considered for patients who are at high risk or not achieving treatment goals, by adding an agent from a new class, switching from oral to parenteral prostacyclins, or increasing the dose. Switching to a new class or within a class should be considered if tolerability or other considerations unrelated to efficacy are affecting adherence. Switching from a PDE5i to an SGC activator may benefit patients with intermediate risk who are not improving on their present therapy. These consensus-based recommendations may be helpful to clinicians and beneficial for patients when evidence-based guidance is unavailable.
对于大多数中度风险的肺动脉高压（PAH）患者，推荐使用磷酸二酯酶-5抑制剂（PDE5i）和内皮素受体拮抗剂进行联合治疗。RESPITE和REPLACE研究表明，在这种情况下，从PDE5i转换为可溶性鸟苷酸环化酶（sGC）激活剂可能会带来临床改善。在这种或其他情况下，治疗升级或转换的最佳方法尚未明确界定。我们使用改良的德尔菲法制定了一份关于PAH患者向sGC转换及其他治疗升级和转换的专家共识声明。德尔菲法采用了由20名PAH领域专家组成的小组。小组成员回答了三份关于PAH治疗升级和转换管理的问卷。初始问卷包含开放式问题。后续问卷将回答整合为陈述，小组成员根据从-5（）到+5（）的李克特量表对陈述进行评分以确定共识。德尔菲法产生了若干共识性建议。对于高危患者或未达到治疗目标的患者，应考虑升级治疗，可通过添加新类别的药物、从口服前列环素转换为肠外前列环素或增加剂量来实现。如果耐受性或其他与疗效无关的因素影响依从性，则应考虑转换为新类别或在同一类别内进行转换。从PDE5i转换为sGC激活剂可能使目前治疗效果不佳的中度风险患者受益。当缺乏循证指南时，这些基于共识的建议可能对临床医生有所帮助且对患者有益。
