Advanced Therapies for Pharmacological Treatment of ...€¦ · Combination therapy with Letairis (ambrisentan) and Adcirca (Tadalafil) for the treatment of pulmonary arterial hypertension

Medical Policy

MP 5.01.509 Advanced Therapies for Pharmacological Treatment of Pulmonary Hypertension

DISCLAIMER/INSTRUCTIONS FOR USE

Medical Policy provides general guidance for applying Blue Cross of Idaho benefit plans (for purposes of Medical Policy, the terms “benefit plan” and “member contract” are used interchangeably). Coverage decisions must reference the member specific benefit plan document. The terms of the member specific benefit plan document may be different than the standard benefit plan upon which this Medical Policy is based. If there is a conflict between a member specific benefit plan and the Blue Cross of Idaho’s standard benefit plan, the member specific benefit plan supersedes this Medical Policy. Any person applying this Medical Policy must identify member eligibility, the member specific benefit plan, and any related policies or guidelines prior to applying this Medical Policy. Blue Cross of Idaho Medical Policies are designed for informational purposes only and are not an authorization, explanation of benefits or a contract. Receipt of benefits is subject to satisfaction of all terms and conditions of the member specific benefit plan coverage. Blue Cross of Idaho reserves the sole discretionary right to modify all its Policies and Guidelines at any time. This Medical Policy does not constitute medical advice.

POLICY

PULMONARY ARTERIAL HYPERTENSION

The following therapies may be considered medically necessary for the treatment of pulmonary arterial hypertension (PAH/WHO Group 1):

• epoprostenol sodium (e.g., Flolan®) continuous intravenous infusion;

• treprostinil sodium (Remodulin®) continuous SC infusion, intravenous infusion; (Tyvaso®) inhalation via nebulizer; or (Orenitram®) oral;

• iloprost (Ventavis®) inhalation via nebulizer;

• bosentan (Tracleer®) oral;

• ambrisentan (Letairis®) oral;

• sildenafil citrate (e.g., Revatio®) oral;

• tadalafil (Adcirca®) oral;

• vardenafil (Levitra®) oral;

• riociguat (Adempas®) oral;

• macitentan (Opsumit®) oral.

• selexipag (Uptravi®)

Combination therapy with Letairis (ambrisentan) and Adcirca (Tadalafil) for the treatment of pulmonary arterial hypertension (PAH/WHO Group 1) may be considered medically necessary.

Combination therapy (other than Letairis and Adcirca) for the treatment of pulmonary arterial

BCBSA Ref. Policy: 5.01.09 Last Review: 10/24/2019 Effective Date: 01/30/2020 Section: Prescription Drug

Related Policies None

https://providers.bcidaho.com/medical-management/medical-policies/pd/mp_501509.page

Original Policy Date: January 1998 Page: 2


hypertension (PAH/ WHO Group 1) may be considered medically necessary when all of the following conditions are met (see Policy Guidelines section):

• Patients have failed to demonstrate an adequate response to a single medication;

• Medications are from different therapeutic classes;

• Each medication may be considered medically necessary for the treatment of PAH (see above statement).

Combination therapy with tadalafil and ambrisentan as first-line treatment may be considered medically necessary in the treatment of treatment naive PAH patients who have WHO Functional Class Groups II and III disease.

Combination therapy as first-line treatment is considered investigational for any other combination therapy besides Letairis (ambristentan) and Adcirca (Tadalifil).

Use of other advanced therapies for the pharmacologic treatment of pulmonary arterial hypertension (PAH/WHO group 1) that are not approved by the U.S. Food and Drug Administration for this indication, including but not limited to imatinib, simvastatin, and atorvastatin, is considered investigational.

PULMONARY HYPERTENSION

The use of epoprostenol, treprostinil, iloprost, bosentan, ambrisentan, macitentan, sildenafil, tadalafil, and vardenafil, is considered investigational for the treatment of non-PAH PH conditions (WHO Groups 2-5), including but not limited to:

• Pulmonary hypertension associated with left heart diseases;

• Pulmonary hypertension associated with lung diseases and/ or hypoxemia (including chronic obstructive pulmonary disease);

• Pulmonary hypertension due to chronic thrombotic and/or embolic disease;

• Miscellaneous group (i.e., sarcoidosis, histiocytosis X and lymphangiomatosis)

CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION

The use of riociguat (Adempas®) for the treatment of chronic thromboembolic pulmonary hypertension (CTEPH/WHO Group 4) may be considered medically necessary in the following conditions:

• Persistent pulmonary hypertension after surgical thrombectomy; or

• Inoperable CTEPH.

The use of riociguat or PAH-specific medications to reduce pulmonary vascular resistance before surgery in patients with CTEPH who are considered candidates for pulmonary endarterectomy is considered investigational.

The use of riociguat is considered investigational for the treatment of WHO Groups 2, 3, and 5 pulmonary hypertension, including but not limited to:

• Pulmonary hypertension associated with left heart diseases;

• Pulmonary hypertension associated with lung diseases and/ or hypoxemia (including chronic obstructive pulmonary disease);

• Miscellaneous group (i.e., sarcoidosis, histiocytosis X and lymphangiomatosis)

POLICY GUIDELINES

Treatment with epoprostenol requires 3 steps: initial dose-ranging, catheter insertion and portable pump attachment, and catheter and pump maintenance.

• An initial dose-ranging study is typically performed as an inpatient. The pulmonary capillary wedge pressure is monitored, and the drug infusion rate is increased until dose-limiting



pharmacologic effect such as nausea, vomiting, or headache is elicited. Some practitioners may consider the initial dose-ranging study optional.

• Insertion of central venous catheter and attachment to portable infusion pump. Because rebound pulmonary hypertension may recur if the drug is abruptly withdrawn, the drug labeling advises that all patients have access to a backup infusion pump and intravenous infusion set.

• For ongoing maintenance of portable infusion pump and treatment of complications related to the pump, complications include catheter thrombosis, sepsis, and pump malfunction. In clinical trials, a cold pouch and frozen gel packs were used to facilitate extended use at ambient temperatures.

Treatment with iloprost requires the use of a specialized dispensing device.

Oral treprostinil should only be prescribed by a physician with expertise in treating pulmonary arterial hypertension, including administration of infused prostanoids.

For combination treatment, riociguat should not be combined with a phosphodiesterase type 5 inhibitor (sildenafil, tadalafil, vardenafil).

BENEFIT APPLICATION

BLUECARD/NATIONAL ACCOUNT ISSUES

While epoprostenol would generally be considered under medical benefits, the use of bosentan, ambrisentan, macitentan, iloprost, treprostinil, sildenafil, and riociguat may be considered under pharmacy benefits, as determined by each individual Plan.

Benefit or contract language describing the “least costly alternative” may apply to the choice of therapy among epoprostenol, bosentan, ambrisentan, macitentan, iloprost, or treprostinil. A generic formulation of epoprostenol is available.

Patients treated with infusion pumps may require a backup pump. However, the cost of a backup pump may be included in the home infusion therapy charges or in the HCPCS code (see Codes section).

Sildenafil citrate is available as Revatio and Viagra. Benefit or contract language describing the “least costly alternative” may apply to this choice. Pricing differences may exist between alternatives. Revatio is available as a 10- and 20-mg tablet. Viagra is available in 25-, 50-, and 100-mg tablets. Generic sildenafil is available.

Tadalafil is available as Cialis and Adcirca. Benefit or contract language describing the "least costly alternative" may apply to this choice. Pricing differences may exist between alternatives. Cialis is available as 2.5-, 5-, 10-, and 20-mg tablets. Adcirca is available as a 20-mg tablet. The recommended initial daily dose of Adcirca is 40 mg once a day (two 20-mg tablets).

BACKGROUND

PHARMACOLOGIC THERAPIES FOR PULMONARY HYPERTENSION

This evidence review addresses advanced pharmacologic therapies for pulmonary hypertension (PH). Advanced pharmacologic therapies are newer specialty pharmacy drugs specifically intended to impact the natural history of PH, rather than supportive medications that treat disease manifestations. These newer specialty pharmacy drugs have been approved by the U.S. Food and Drug Administration (FDA) only for a subset of classes of PH (World Health Organization [WHO] groups 1 and 4, discussed below); as a result, BCBSA only addresses classes of PH for which advanced pharmacologic therapies are approved.



Pulmonary Hypertension

Classification

The 2013 WHO classification of PH, which is based on the consensus of an international group of experts at the Fifth World Symposium on Pulmonary Hypertension, is the most widely used system used in clinical care and research.1 There are 5 WHO categories of PH:

• Group 1: Pulmonary arterial hypertension (PAH)

• Group 2: PH due to left heart disease

• Group 3: PH due to chronic lung disease and/or hypoxemia

• Group 4: PH due to chronic thromboembolic disease (chronic thromboembolic pulmonary hypertension [CTEPH])

• Group 5: PH due to mixed or uncertain causes.

For each category, there are numerous subcategories indicating more specific disease etiologies. For example, in WHO group 1, the most common subcategory is idiopathic PAH, which is a disorder of unknown etiology categorized by abnormal proliferation of blood vessels in the pulmonary arterial system. Other classification systems, such as those developed by the American College of Cardiology Foundation and American Heart Association, are very similar but have differences in the subcategories of group 1.

Disease Description

PH is defined as increased arterial pressure in the lung vasculature.2 Increased pulmonary pressure can be caused by primary abnormalities in the pulmonary vascular system; it can also be caused by other abnormalities in the cardiac or pulmonary organs, which may lead to secondary elevations in pulmonary arterial pressure. A definitive diagnosis of PH is usually made following measurement of pulmonary arterial pressure by right heart catheterization. A pulmonary arterial pressure of at least 25 mm Hg confirms the diagnosis.3

Clinical symptoms of PH are related to right-sided heart failure and impaired oxygen delivery by the lungs. Warning signs are nonspecific but often present as a constellation of symptoms including dyspnea on exertion, fatigue, weakness, and syncope.3 High pulmonary pressures lead to increased work of the right ventricle. This chronic hemodynamic overload leads to low cardiac output and progressive right ventricular dilatation. In advanced disease, signs of right-sided heart failure occur (eg, abdominal distension, hepatic congestion, pedal edema). Without treatment, the disease is progressive and eventually fatal; however, the natural history and rapidity of progression is variable. Premature death most commonly results from complications of right heart failure.

There are also differences in the pathophysiology, clinical manifestations, and natural history of each PH category. Only categories relevant to this evidence review (WHO groups 1 and 4) are discussed herein.

The World Health Organization (WHO) further classifies patients with pulmonary hypertension based on functional ability: Class I: No limitations with ordinary physical activity Class II: Ordinary physical activity results in symptoms. Comfortable at rest. Class III: Less than ordinary physical activity results in symptoms. Comfortable at rest. Class IV: Inability to perform any physical activity without symptoms. Symptoms present at rest.

Treatment

Conventional therapies considered in all patients with PH regardless of etiology include medications to treat heart failure (diuretics, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers,



digoxin), oxygen therapy, and exercise. Lung transplantation and combined heart-lung transplantation have been performed in patients refractory to medical management. There are also specific therapies for each WHO group. For example, anticoagulation is a treatment option in WHO groups 1 and 4, and both anticoagulation and surgical thrombectomy are treatment options for appropriate patients in group 4.7

Advanced Pharmacologic Therapies

Advanced pharmacologic therapies for PH are defined as newer specialty pharmacy drugs specifically intended to impact the natural history of PH, rather than treat disease manifestations (see Table 1 for specific agents). These specialty drugs can be administered as single agents or in various combinations. Advanced pharmacologic therapies are FDA-approved for treatment of PH groups 1 and 4; therefore, these classes are discussed further.

WHO Group 1(PAH)

Table 1 lists the classes of medications with FDA approvals for treatment of PAH.

Table 1. Approved Medication Classes for Treating Pulmonary Arterial Hypertension

Class Definition

Prostacyclin analogues Prostacyclin is an endogenously produced vasodilator. Analogues of prostacyclin mimic the vasodilatory action of endogenous prostacyclin.

Prostacyclin receptor agonists The approved drug in this class, selexipag, and its active metabolite are selective for the IP receptor and thus differ from other prostanoid receptors

Endothelin receptor antagonists Endothelin 1 is a potent vasoconstrictor and is found in increased concentrations in the lungs of patients with familial hypercholesterolemia. Endothelin receptor antagonists block the action of endothelin, thus resulting in vasoconstriction.

PDE inhibitors PDE inhibitors are cyclic guanosine monophosphate inhibitors. Cyclic guanosine monophosphate inhibition results in reduced breakdown and longer duration of nitric oxide, which is a potent vasodilator.

Soluble guanylate cyclase stimulator

Riociguat is a first-in-class oral soluble guanylate cyclase stimulator

IP: prostacyclin receptor, also known as the prostaglandin I2 receptor or IP; PDE: phosphodiesterase.

WHO Group 4(CTEPH)

The single medication currently FDA-approved for treatment of CTEPH is riociguat. Riociguat stimulates soluble guanylate cyclase, both directly and indirectly, by increasing sensitivity of the enzyme to nitric oxide. Thus, riociguat may be effective for conditions in which endogenous nitric oxide (a vasodilator) is depleted.8

REGULATORY STATUS

Table 2 summarizes advanced therapies for treatment of PAH (WHO group 1) and CTEPH (WHO group 4) and their current regulatory status (see Appendix Tables 1 and 2 for functional classes).

Table 2. Regulatory Status of Advanced Treatments of PAH and CTEPH

Codes used: NA



Drug (Brand) Name Manufacturer

FDA Approval Date

Routes of Administration Dose Range

FDA-Approved Indications

Prostacyclin analogue (ie, prostanoids) Epoprostenol sodium (Flolan®) GlaxoSmithKline FDA approved 1995

• Continuous IV infusion via central venous catheter using an ambulatory infusion pump

• 1-20 ng/kg/min

• Treatment of PAH (WHO group 1) to improve exercise capacity. Studies establishing effectiveness included predominantly (97%) patients with NYHA class III-IV symptoms and etiologies of idiopathic or heritable PAH (49%) or PAH associated with CTD (51%).

Treprostinil sodium (Remodulin®) United Therapeutics FDA approved 2002

• Continuous SC infusion

• IV infusion (if SC infusion not tolerated)

• 0.625-1.25 ng/kg/min

• Treatment of PAH (WHO group 1) to diminish symptoms associated with exercise. Studies establishing effectiveness included patients with NYHA class II-IV symptoms and etiologies of idiopathic or heritable PAH (58%), PAH associated with congenital systemic-to-pulmonary shunts (23%), or PAH associated with CTD (19%)

• Patients who require transition from epoprostenol sodium (Flolan), to reduce rate of clinical deterioration

Treprostinil (Tyvaso®) United Therapeutics FDA approved 2009

• Inhalation via nebulizer; specific to 1 pulmonary drug delivery system

• 18-54 μg, 4 times daily

• Treatment of PAH (WHO group 1) to improve exercise ability. Studies establishing effectiveness included predominately patients with NYHA class III symptoms and etiologies of idiopathic or heritable PAH (56%) or PAH associated with CTD (33%)

Treprostinil (Orenitram®) United Therapeutics FDA approved 2013

• Oral • Maximum dose

as tolerated: 3.4-21 mg twice dailya

• Treatment of PAH (WHO group 1) to improve exercise capacity. Study establishing effectiveness included predominately patients with WHO functional class II-III symptoms and etiologies of idiopathic or heritable PAH (75%) or PAH associated with CTD (19%).

Iloprost (Ventavis®) Actelion Pharmaceuticals FDA approved 2004

• Inhalation via nebulizer using a specific pulmonary drug delivery system

• 2.5-5 μg, 6-9 times daily

• Treatment of PAH (WHO group 1) to improve a composite end point consisting of exercise tolerance, symptoms (NYHA class), and lack of deterioration. Studies establishing effectiveness predominately included patients with NYHA class III-IV symptoms and etiologies of idiopathic



or heritable PAH (65%) or PAH associated with CTD (23%).

Beraprost NOT APPROVED IN U.S. AND E.U. Failed reviews Approved in Japan for PAH

• Oral • No FDA-approved indications

Prostacyclin receptor agonists Selexipag (Uptravi®) Actelion Pharmaceuticals FDA approved 2015

• Oral • Starting dose 200

μg twice daily. Increase by 200 μg twice weekly to maximum tolerated dose up to 1600 μg twice daily.

• Treatment of PAH (WHO group 1) to delay disease progression and reduce risk of hospitalization for PAH. Study establishing effectiveness had long-term follow-up and included patients with WHO functional class II-III symptoms.

Endothelin receptor antagonists Bosentan (Tracleer®) Actelion Pharmaceuticals FDA approved 2001

• Oral • 62.5-125 mg

twice daily

• Treatment of PAH (WHO group 1) to improve exercise ability and decrease clinical worsening. Studies establishing effectiveness predominantly included patients with NYHA class II-IV symptoms and etiologies of idiopathic or heritable PAH (60%), PAH associated with CTD (21%), and PAH associated with congenital heart disease with left-to-right shunts (18%).

Ambrisentan (Letairis®) Gilead Sciences FDA approved 2007

• Oral • 5-10 mg daily

• Treatment of PAH (WHO group 1) to improve exercise ability and delay clinical worsening and in combination with tadalafil to reduce the risks of disease progression and hospitalization for worsening PAH, and to improve exercise ability. Studies establishing effectiveness predominantly included patients with NYHA class II-III symptoms and etiologies of idiopathic or heritable PAH (60%) or PAH associated with CTD (34%).

Macitentan (Opsumit®) Actelion Pharmaceuticals FDA approved 2013

• Oral • 10 mg daily

• Treatment of PAH (WHO group 1) to delay disease progression (defined as death, initiation of IV or SC prostanoids, or clinical worsening of PAH [decreased 6-minute walk distance, worsened PAH



symptoms, need for additional PAH treatment]). Macitentan also reduced hospitalization for PAH.

Phosphodiesterase inhibitors Sildenafil citrate (Revatio®) Pfizer Labs FDA approved 2005

• Oral • 20 mg 3 times

daily

• Treatment of PAH (WHO group 1) in adults to improve exercise ability and delay clinical worsening. Studies establishing effectiveness were short-term (12-16 wk) and included predominately patients with NYHA class II-III symptoms. Etiologies were idiopathic (71%) or associated with CTD (25%).

• 2012: FDA recommended Revatio not be prescribed to children (ages 1-17 y) for PAH. (Product not approved for treatment of PAH in children.)

Tadalafil (Adcirca®) Eli Lilly FDA approved 2009

• Oral • 40 mg once daily

• Treatment of PAH (WHO group 1) to improve exercise ability. Studies establishing effectiveness predominately included patients with NYHA class II-III symptoms and etiologies of idiopathic or heritable PAH (61%) or PAH associated with CTD (23%).

Vardenafil (Levitra®) FDA approved 2003

• Oral • No FDA-approved indications for PAH or CTEPH

Soluble guanylate cyclase stimulator Riociguat (Adempas®) Bayer HealthCare FDA approved 2013

• Oral • 0.5-2.5 mg 3

times daily

• Treatment of adults with PAH (WHO group 1) to improve exercise capacity and WHO functional class

• Treatment of adults with persistent or recurrent CTEPH (WHO group 4) after surgical treatment or inoperable CTEPH to improve exercise capacity and WHO functional class

Tyrosine kinase inhibitors Imatinib (Gleevec®) FDA approved 2001


Statins Simvastatin FDA approved 1991


Atorvastatin FDA approved 1999


CTD: connective tissue disease; CTEPH: chronic thromboembolic pulmonary hypertension; FDA: U.S. Food and Drug Administration; PAH: pulmonary arterial hypertension; NYHA: New York Heart Association; SC: subcutaneous; WHO: World Health Organization.



a Mean dose in a controlled clinical trial at 12 wk was 3.4 mg twice daily. Maximum doses studied were 12 mg twice daily in a 12-wk blinded study and 21 mg twice daily in an open-label long-term study.

RATIONALE

This evidence review was created in January 1998 and has been updated regularly with searches of the MEDLINE database. The most recent literature update was performed through August 5, 2019.

Evidence reviews assess the clinical evidence to determine whether the use of a technology improves the net health outcome. Broadly defined, health outcomes are length of life, quality of life, and ability to function-including benefits and harms. Every clinical condition has specific outcomes that are important to patients and to managing the course of that condition. Validated outcome measures are necessary to ascertain whether a condition improves or worsens; and whether the magnitude of that change is clinically significant. The net health outcome is a balance of benefits and harms.

To assess whether the evidence is sufficient to draw conclusions about the net health outcome of a technology, 2 domains are examined: the relevance and the quality and credibility. To be relevant, studies must represent one or more intended clinical use of the technology in the intended population and compare an effective and appropriate alternative at a comparable intensity. For some conditions, the alternative will be supportive care or surveillance. The quality and credibility of the evidence depend on study design and conduct, minimizing bias and confounding that can generate incorrect findings. The randomized controlled trial (RCT) is preferred to assess efficacy; however, in some circumstances, nonrandomized studies may be adequate. RCTs are rarely large enough or long enough to capture less common adverse events and long-term effects. Other types of studies can be used for these purposes and to assess generalizability to broader clinical populations and settings of clinical practice.

Pulmonary Arterial Hypertension Monotherapy Using Tyrosine Kinase Inhibitors or Statins

Clinical Context and Therapy Purpose

The purpose of monotherapy using tyrosine kinase inhibitors (TKIs) or statins is to provide a treatment option that is an alternative to or an improvement on existing therapies in patients with pulmonary arterial hypertension (PAH).

The question addressed in this evidence review is: Does use of monotherapy with TKIs or statins improve the net health outcome in individuals who have PAH?

The following PICO were used to select literature to inform this review.

Patients

The relevant population of interest is individuals with PAH. PAH is characterized pathophysiologically by abnormal proliferation of pulmonary artery smooth muscle cells in the arteries.2, This causes a decrease in the size of the pulmonary artery lumen, decreased reactivity of the vascular bed, increased pulmonary vascular resistance, and elevated pressure in the pulmonary circulation. Idiopathic PAH is the most common type of PAH and is more prevalent in women than in men. It often affects women in the third or fourth decade, resulting in a very high burden of illness for young, otherwise healthy patients. Median 1-year survival has been estimated to be 85%, and median 5-year survival has been estimated to be 57%.6,

Interventions

The therapy being considered is monotherapy using TKIs or statins, the administration of which is actively managed by pulmonologists or cardiologists in an outpatient setting.

https://www.evidencepositioningsystem.com/_w_2aa1086aef33aa4b626873a76052503fb3f8f8b231cc5bbc/BCBSA/html/_w_2aa1086aef33aa4b626873a76052503fb3f8f8b231cc5bbc/#reference-2




TKIs and statins were not developed as PAH-specific therapy and are not approved by the U.S. Food and Drug Administration (FDA) for treatment of PAH.

Comparators

The following therapies are currently being used to treat PAH: conventional therapy and different PAH-specific drugs, the administration of which is actively managed by pulmonologists or cardiologists in an outpatient setting.

Outcomes

The general outcomes of interest are overall survival, functional outcomes (such as 6-minute walking distance), hospitalizations, and treatment-related morbidity. Follow-up ranges from months to years to monitor outcomes.

Study Selection Criteria

Methodologically credible studies were selected using the following principles: • To assess efficacy outcomes, comparative controlled prospective trials were sought, with a

preference for RCTs; • In the absence of such trials, comparative observational studies were sought, with

a preference for prospective studies. • To assess longer term outcomes and adverse events, single-arm studies that capture longer

periods of follow-up and/or larger populations were sought. • Studies with duplicative or overlapping populations were excluded.

Tyrosine Kinase Inhibitors

No RCTs were identified that evaluated imatinib as monotherapy for patients with PAH. The safety of imatinib in patients with PAH was assessed by Frost et al (2015) in a long-term extension of an RCT of imatinib as add-on third-line therapy.7, A total of 144 patients entered the extension study (66 patients had been on imatinib for 24 weeks, 78 patients were switching to imatinib from placebo). One hundred thirty-five (94%) of 144 patients discontinued the extension study, and about one-third of the patients discontinued because of adverse events. When the study was terminated (due to high dropout rate), the mean exposure to imatinib was 931 days in the group who took imatinib in the original RCT, and 590 days in the ex-placebo group. Seventeen (12%) of the 144 patients died during the study or within 30 days of leaving it. Serious adverse events (other than death) occurred in 40 (60.6%) patients in the group originally taking imatinib, and 53 (67.9%) in the ex-placebo group. The trialists concluded that imatinib should not be used off-label for treatment of PAH.

Statins

Anand et al (2016) published a systematic review of placebo-controlled RCTs evaluating statins for treating PAH.8, Reviewers identified 4 RCTs, of which two evaluated simvastatin, one assessed atorvastatin, and one evaluated rosuvastatin. The total sample size was 387; 1 study had 220 patients, and the others had fewer than 100 patients each. The primary outcomes of the review were mortality and change in 6-minute walk distance (6MWD) from baseline to follow-up. A pooled analysis of data from 3 trials did not find a significant benefit of stains on mortality (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.32 to 1.74; I2=0%). Similarly, a pooled analysis of 3 trials did not find a significant benefit of statins on the 6MWD (weighted mean difference [WMD], -9.27 meters; 95% CI, -27.7 to 9.2 meters; I2=1.7%).





The largest trial assessed in the Anand systematic review was published by Zeng et al (2012).9, This was a 6-month, double-blind, placebo-controlled randomized trial of 220 Chinese patients with PAH (83%) or chronic thromboembolic pulmonary hypertension (CTEPH; 6%) in World Health Organization (WHO) functional class II or III. Patients received atorvastatin 10 mg orally daily or matching placebo in addition to supportive care (diuretics, digoxin, warfarin). After 6 months, the mean difference in 6MWD (atorvastatin - placebo) was 2.5 meters (95% CI, -33 to 38 meters). There was no statistically significant difference between treatment groups in the proportion of patients who improved or deteriorated in WHO functional class or in hemodynamic parameters (right atrial pressure, pulmonary artery pressure, cardiac index, pulmonary vascular resistance [PVR], or mixed venous oxygen saturation). There were 9 (8%) deaths in the atorvastatin group and 11 (10%) deaths in the placebo group (P=0.31). The trialists concluded: “Atorvastatin 10 mg daily has no beneficial effect on the natural history of PAH or CTEPH over 6 months.”

Section Summary: Pulmonary Arterial Hypertension Monotherapy Using Tyrosine Kinase Inhibitors or Statins

There are no RCTs evaluating the efficacy of TKIs for PAH and 4 RCTs on statins for PAH. A meta-analysis of RCTs evaluating statins for PAH did not report significantly better outcomes (ie, mortality, 6MWD) with the study medication than with placebo. For imatinib, a TKI, there are no placebo-controlled studies evaluating efficacy. However, a 2016 safety study identified a high rate of adverse effects in patients who took imatinib.

PAH Therapy Treated with Add-On Combination Therapies


The purpose of add-on combination therapy using 2 drug classes FDA-approved for treatment of PAH is to provide a treatment option that is an alternative to or an improvement on existing therapies in patients with PAH and inadequate response to monotherapy.

The question addressed in this evidence review is: Does add-on combination therapy, using 2 drug classes FDA-approved for treatment of PAH, improve the net health outcome in individuals who have PAH and inadequate response to monotherapy?

The following PICOs were used to select literature to inform this review.

Patients

The relevant population of interest is individuals with PAH and inadequate response to monotherapy. (See indication 1 above for more information on patients with PAH.)

Interventions

The therapy being considered is add-on combination therapy using 2 drug classes FDA-approved for treatment of PAH, the administration of which is actively managed by pulmonologists or cardiologists in an outpatient setting.

Comparators

The following therapies are currently being used to treat PAH: different PAH-specific drugs or drug combinations, which are actively managed by pulmonologists or cardiologists in an outpatient setting.

Outcomes

The general outcomes of interest are overall survival, functional outcomes, hospitalizations, and treatment-related morbidity. Follow-up of months to years is of interest to monitor outcomes.









Systematic Reviews

Meta-analyses have considered various combinations of medications; all of the individual trials included in the meta-analyses used medications from different classes. In addition, all trials used combination therapy as add-on treatment for patients with an inadequate response to a single medication. (Several trials in the Lajoie et al [2016]10, meta-analysis included a combination of patients on baseline therapy and treatment-naive patients.) Key recent meta-analyses are described in Table 3.

Table 3. Key Meta-Analyses of RCTs Assessing Add-On Combination Therapy vs Monotherapy

Study No. of Studies

Study Eligibility No. of Studies

Summary of Results (95% CI)

Lajoie et al (2016)10,

17 • RCTs of PAH-specific combination therapy vs monotherapy in adults

• ≥12 wk in duration

16 15 8

All-cause mortality: • RR=0.88 (0.74 to

1.05) Clinical worseninga:

• RR=0.65 (0.56 to 0.76)

Hospitalization: • RR=0.71 (0.53 to

0.96) McCrory et al (2013)11, (AHRQ)

5 • RCTs of PAH-specific combination therapy vs monotherapy

3 3

All-cause mortality: • OR=0.37 (0.04 to

3.32) 6MWD (m):

• MD=23.9 (8.0 to 39.9)

Hospitalization: • OR=0.64 (0.31 to

1.36) Fox et al (2011)12, 6 • RCTs of PAH-

specific combination therapy vs monotherapy

• ≥12 wk in duration

4 4 4

All-cause mortality: • RR=0.42 (0.08 to

2.26) Clinical worseninga:

• RR=0.42 (0.17 to 1.04)

6MWD (m): • MD=25.2 (13.3.

to 38.2)







AHRQ: Agency for Healthcare Research and Quality; CI: confidence interval; MD: mean difference; OR: odds ratio; PAH: pulmonary arterial hypertension; RCT: randomized controlled trial; RR: relative risk; 6MWD: 6-minute walk distance.

aClinical worsening: Composite outcome defined differently across studies but generally included death, admission to hospital due to worsening PAH, lung transplantation, symptom progression, and treatment escalation.

These meta-analyses of add-on combination therapy had mixed findings but generally found improvements in some outcomes compared with a single medication. The most recent and comprehensive meta-analysis found significantly lower rates of hospitalizations and less clinical worsening with the addition of a second class of medications compared with a single medication. Several meta-analyses found significantly greater exercise capacity, as measured by 6MWD with add-on combination therapy; however, the additional distance walked may not be clinically significant. The 2013 Agency for Healthcare Research and Quality comparative effectiveness review by McCrory et al (2013) indicated that 33 meters isgenerally considered the minimally important difference in distance walked in 6MWD.11, None of the meta-analyses found significantly less all-cause mortality with add-on combination therapy.

Randomized Controlled Trials

RCTs have evaluated various medication combinations for treating PAH. These combinations include, but are not limited to prostacyclin analogues and endothelin receptor antagonists,13,14,15, phosphodiesterase (PDE) inhibitors and endothelin receptor antagonists,16,17, and prostacyclin analogues and PDE inhibitors.13,18, An RCT evaluating riociguat plus sildenafil (PDE type 5 [PDE5] inhibitors) concluded that this combination is contraindicated.19,

Section Summary: Therapy Using Add-On Combination Therapies

Numerous RCTs of different combinations of medication and meta-analyses of RCTs have been conducted. In all RCTs included in the 2016 meta-analysis, the combination therapy involved drugs from different classes, although the specific combination of riociguat and PDE5 inhibitors is contraindicated. The 2016 meta-analysis is the most recent and comprehensive. It included 17 RCTs of add-on combination therapy vs monotherapy, with at least 12 weeks of follow-up; while mortality rates did not differ significantly between the 2 groups, the meta-analysis reported significantly lower rates of clinical worsening and hospitalizations for the group receiving combination therapy.

PAH Therapy Using Initial Combination Therapies


The purpose of initial combination therapy using 2 drug classes FDA-approved for treatment of PAH is to provide a treatment option that is an alternative to or an improvement on existing therapies in patients with PAH.

The question addressed in this evidence review is: Does initial combination therapy, using 2 drug classes FDA-approved for treatment of PAH, improve the net health outcome in individuals who have PAH?


Patients

The relevant population of interest is individuals with PAH (See indication 1 for more information on patients with PAH.)












Interventions

The therapy being considered is initial combination therapy using 2 drug classes FDA-approved for treatment of PAH, the administration of which is actively managed by pulmonologists or cardiologists in an outpatient clinical setting.

Comparators

The following therapeutic strategy is currently being used to treat PAH: initial monotherapy, followed by combination therapy if monotherapy fails, actively managed by pulmonologists or cardiologists in an outpatient clinical setting.

Outcomes

The general outcomes of interest are overall survival, functional outcomes hospitalizations, and treatment-related morbidity. Follow-up from months to years is of interest to monitor outcomes.

Study Selection Criteria • Methodologically credible studies were selected using the following principles: • To assess efficacy outcomes, comparative controlled prospective trials were sought, with a

preference for RCTs; • In the absence of such trials, comparative observational studies were sought, with a preference

for prospective studies. • To assess longer term outcomes and adverse events, single-arm studies that capture longer


Randomized Controlled Trials

Two RCTs specifically evaluating initial combination therapy in patients with PAH were identified.

The Ambrisentan and Tadalafil in Patients with Pulmonary Arterial Hypertension (AMBITION) trial, reported by Galie et al (2015) randomized patients to initial treatment with ambrisentan (an endothelin receptor antagonist), tadalafil (a PDE inhibitor), or a combination of these 2 medications.20, A total of 610 adults aged 18 to 75 years with WHO functional class II or III symptoms of WHO group 1 PAH underwent randomization, but the entry criteria changed during the trial. The primary end point was the first event of clinical failure in a time-to-event analysis. Clinical failure was a composite end point including death, hospitalization for worsening PAH, disease progression, and unsatisfactory long-term clinical response. Mean duration of trial participation in the 500 patients included in the primary analysis set was 609 days. In these patients, the primary end point of clinical failure occurred in 46 (18%) of 253 patients in the combination therapy group, in 43 (34%) of 126 in the ambrisentan group, and in 34 (28%) of 121 in the tadalafil group. The clinical failure rate was significantly lower in the combined treatment group than in the ambrisentan group (P<0.001) or the tadalafil group (P=0.005). Serious adverse events among patients in the primary analysis set occurred in 92 (36%) patients in the combined treatment group, 45 (36%) patients in the ambrisentan group, and 50 (41%) patients in the tadalafil group (no significant difference among groups).

The Bosentan Randomized trial of Endothelin Antagonist Therapy for PAH (BREATH-2) trial, reported by Humbert et al (2004) compared epoprostenol alone with the combination of epoprostenol plus bosentan.21, The trial was multicenter, double-blind, and placebo-controlled. It included 33 patients with PAH who were scheduled to begin treatment with epoprostenol. After 2 days of epoprostenol therapy, patients were randomized to add bosentan (n=22) or placebo (n=11). The double-blind treatment duration was 16 weeks, and the primary efficacy outcome was change in total pulmonary resistance.





Five (15%) of 33 patients did not complete the trial. At 16 weeks, mean change in total pulmonary resistance did not differ significantly between groups (-36.3 dyns-1cm5 ± 4.3% in the combination treatment group vs -22.6 dyns-1cm5 ± 4.3% in the epoprostenol plus placebo group, P=0.08). Secondary outcomes also did not differ significantly between groups. For example, the median 6MWD increased 68 meters in the combination treatment group and 74 meters in the epoprostenol plus placebo group. Moreover, the modified New York Heart Association functional class improved for 59% (13 of 22) of patients in the combination treatment group and 45% (5 of 11) of patients in the epoprostenol plus placebo group, a difference that was not statistically significant.

Tables 4-7 summarize the characteristics, results, and limitations of the AMBITION and BREATHE-2 trials.

Table 4. Key Characteristics of the AMBITION and BREATHE-2 Trials

Trial Countries Sites Dates Participants Interventions Active Comparator

Galiè et al (2015); AMBITION20,

EU, US, Australia, Japan

14 2010-2014

Patients aged 18-75 y; weight ≥40 kg; WHO FC II or III symptoms of PAH; diagnosis of idiopathic PAH, hereditary PAH, or PAH associated with connective tissue disease, drugs or toxins, HIV (stable), or repaired congenital heart defects; not previously treated (N=605a).

10 mg ambrisentan + 40 mg tadalafil, once daily (n=253)

• 10 mg ambrisentan + placebo, once daily, (n=126) OR

• 40 mg tadalafil + placebo, once daily, (n=121)

Humbert et al (2004); BREATHE-221,

EU, US 7 NR Patients with severe PAH in modified NYHA FC III or IV scheduled for epoprostenol therapy within 2 weeks of screening; PAH either primary or associated with connective tissue disease; (N=33).

Epoprostenol up to 14±2 ng•kg-1min-

1 + bosentan up to 125 mg twice daily (n=20)

Epoprostenol up to 14±2 ng•kg-

1min-1 + placebo (n=10)

FC: functional class; NR: not reported; NYHA: New York Heart Association; PAH: pulmonary arterial hypertension; RCT: randomized controlled trial; WHO: World Health Organization; y: year(s).

a Modified intention-to-treat population.

Table 5. Key Results of the AMBITION and BREATHE-2 Trials

Study Change in 6MWD, median (IQR)

Change in FC,a no. (%) First Event of Clinical Failure,b no. (%)

Change in TPR, dyn•s-1cm5 ± SEM

Better Worse NC

AMBITION





(2015)20, Combo group

48.98 m (4.63 to 85.75 m)

94 (37)

12 (5) 146 (58)

46 (18)

Pooled mono group

23.80 m (-12.25 to 64.53 m)

81 (33)

16 (7) 147 (60)

77 (31)

HR

0.50

(95% CI)

(0.35 to 0.72)

P value <0.001

<0.001

BREATHE-2 (2004)21,

Combo group

68 m (-) 13 (59)

- -

-36.3±4.3

Mono group

74 m (-) 5 (45) - -

-22.6±6.2

P value

0.08 CI: confidence interval; Combo: combination; HR: hazard ratio; IQR: interquartile range; Mono: monotherapy; NC: no change; NNT: number needed to treat; OR: odds ratio; RCT: randomized controlled trial; RR: relative risk; SEM: standard error of the mean. a Classes in the two systems have similar characteristics. b Defined as death, hospitalization or worsening pulmonary arterial hypertension, disease progression, or unsatisfactory long-term clinical response.

The purpose of the limitations tables (see Tables 6 and 7) is to display notable limitations identified in each study. This information is synthesized as a summary of the body of evidence following each table and provides the conclusions on the sufficiency of evidence supporting the position statement.

Table 6. Relevance Limitations of the AMBITION and BREATHE-2 Trials

Study Populationa Interventionb Comparatorc Outcomesd Follow-Upe

AMBITION (2015)20,

4. Initial eligibility criteria amended 6 mo into study to amend exclusion criteria

- - 5. clinically significant difference not prespecified

-

BREATHE-2 (2004)21,

4. small study population - - - -

The evidence limitations stated in this table are those notable in the current review; this is not a comprehensive limitations assessment. Mo: month(s). a Population key: 1. Intended use population unclear; 2. Clinical context is unclear; 3. Study population is unclear; 4. Study population not representative of intended use. b Intervention key: 1. Not clearly defined; 2. Version used unclear; 3. Delivery not similar intensity as comparator; 4. Not the intervention of interest. c Comparator key: 1. Not clearly defined; 2. Not standard or optimal; 3. Delivery not similar intensity as intervention; 4. Not delivered effectively. d Outcomes key: 1. Key health outcomes not addressed; 2. Physiologic measures, not validated surrogates; 3. No CONSORT reporting of harms; 4. Not establish and validated measurements; 5. Clinical significant difference not prespecified; 6. Clinical significant difference not supported.







e Follow-Up key: 1. Not sufficient duration for benefit; 2. Not sufficient duration for harms.

Table 7.Study Design and Conduct Limitations of the AMBITION and BREATHE-2 Trials

Study Allocationa Blindingb Selective Reportingc

Follow-Upd

Powere Statisticalf

AMBITION (2015)20,

- - - - - 3. Confidence intervals not reported

BREATHE-2 (2004)21,

3. allocation concealment unclear

- 1. not registered

- 3. underpowered

3. Confidence intervals not reported

The evidence limitations stated in this table are those notable in the current review; this is not a comprehensive gaps assessment.

a Allocation key: 1. Participants not randomly allocated; 2. Allocation not concealed; 3. Allocation concealment unclear; 4. Inadequate control for selection bias. b Blinding key: 1. Not blinded to treatment assignment; 2. Not blinded outcome assessment; 3. Outcome assessed by treating physician. c Selective Reporting key: 1. Not registered; 2. Evidence of selective reporting; 3.Evidence of selective publication. d Follow-Up key: 1. High loss to follow-up or missing data; 2. Inadequate handling of missing data; 3. High number of crossovers; 4. Inadequate handling of crossovers; 5. Inappropriate exclusions; 6. Not intent to treat analysis (per protocol for noninferiority trials). e Power key: 1. Power calculations not reported; 2. Power not calculated for primary outcome; 3. Power not based on clinically important difference. f Statistical key: 1. Intervention is not appropriate for outcome type: (a) continuous; (b) binary; (c) time to event; 2. Intervention is not appropriate for multiple observations per patient; 3. Confidence intervals and/or p values not reported; 4. Comparative treatment effects not calculated.

Section Summary: PAH Therapy Using Initial Combination Therapies

Two RCTs have compared 6 months of initial combination therapy vs monotherapy for PAH. In the AMBITION trial, among patients in the primary analysis set, there was a significantly lower rate of clinical failure at 6 months in the group receiving both ambrisentan plus tadalafil than in the monotherapy groups. Rates of adverse events were similar across groups. Data interpretation of this study is difficult because the trialists changed enrollment criteria during the trial and used a complex composite outcome with multiple components. The other RCT did not find significant differences in outcomes between a group receiving initial combined therapy with bosentan and epoprostenol and a group receiving monotherapy at 16 weeks; this study had a small sample size and might have been underpowered for secondary outcomes. Both trials lacked a clinically relevant comparison between initial combination therapy and initial monotherapy followed by combination therapy for patients with an inadequate response.

Inoperable CTEPH Monotherapy


The purpose of soluble guanylate cyclase stimulator (eg, riociguat) is to provide a treatment option that is an alternative to or an improvement on existing therapies in patients with inoperable CTEPH or pulmonary hypertension (PH) after surgery.





The question addressed in this evidence review is: Does use of a soluble guanylate cyclase stimulator improve the net health outcome in individuals with inoperable CTEPH or PH after surgery?


Patients

The relevant populations of interest are individuals with inoperable CTEPH or PH after surgery. CTEPH primarily occurs after acute or chronic pulmonary embolism. Progressive pulmonary vascular remodeling (thrombi organization, fibrous stenosis, microvascular changes) obstructs pulmonary arteries, leading to PH and right heart failure.2,22, Estimated CTEPH incidence among patients who survive an acute pulmonary embolism ranges from 0.6% to 3.8%.2,23, However, many patients have no clinical history of pulmonary embolism, and CTEPH is likely underdiagnosed. The severity and prognosis are variable, depending on the extent of lung damage caused by prior thromboembolism and the degree to which future episodes can be prevented.

Interventions

The therapy being considered is a soluble guanylate cyclase stimulator (eg, riociguat), which is administered and actively managed by pulmonologists or cardiologists in an outpatient clinical setting.

Comparators

The following therapy is currently being used to treat inoperable CTEPHor PH after surgery: standard of care, which is actively managed by pulmonologists or cardiologists in an inpatient and outpatient clinical setting.

Outcomes

The general outcomes of interest are overall survival, functional outcomes, hospitalizations (see Table 3 for a description of the 6-Minute Walk Test), hospitalizations, and treatment-related morbidity. Follow-up over years is of interest to monitor outcomes.






Riociguat

The pivotal CHEST-1 trial, published by Ghofrani et al (2013), assessed the efficacy and safety of riociguat to treat CTEPH.24, CHEST-1 was a double-blind RCT in 261 adults who had inoperable CTEPH (n=188 [72%]) or persistent PH after pulmonary endarterectomy (n=73 [28%]). Patients receiving PAH medications were excluded. Patients were randomized to receive placebo or riociguat 3 times daily, and doses were titrated to 0.5 to 2.5 mg. Doses were optimized during the first 8 weeks, and the optimized dose was continued for 8 additional weeks. The primary efficacy outcome was change in 6MWD at 16 weeks.








Two hundred forty-two (93%) patients from both groups completed the trial; 77% of completers in the riociguat group continued at the maximum dose to week 16. Mean change in 6MWD, the primary efficacy outcome, was +39 meters in the riociguat group and -6 meters in the placebo group (least-squares mean difference, 46 meters; 95% CI, 25 to 67 meters; P<0.001). Results were consistent across multiple sensitivity analyses and predefined subgroups (eg, baseline WHO functional class). Adverse events that occurred more commonly in the riociguat group (vs placebo) included headache (25% vs 14%), dizziness (23% vs 12%), stomach upset (18% vs 8%), vomiting (10% vs 3%), diarrhea (10% vs 5%), and hypotension (9% vs 3%), respectively. The most common serious adverse events were right ventricular failure (3% in each group), syncope (2% riociguat vs 3% placebo), and hemoptysis (2% riociguat). One patient died due to acute renal failure attributed to riociguat.

Additional data on secondary outcomes from CHEST-1 were published by Kim et al (2017).25, Study findings generally favored the riociguat group. At week 16, compared with baseline, PVR significantly decreased in the riociguat group (-29%) compared with the placebo group (+3%). There were also significantly improved outcomes in the riociguat group vs placebo for other hemodynamic outcomes (eg, systemic vascular resistance, mean pulmonary arterial pressure, diastolic pulmonary artery pressure, cardiac output, mixed venous oxygen saturation, mean arterial pressure, diastolic pressure gradient; P<0.001 for each).

CHEST-2 (2015) was an extension study that included patients in CHEST-1 who did not withdraw due to clinical worsening. All patients in CHEST-2 received open-label riociguat. Simonneau et al (2015) published results of an interim analysis in which most patients had received one or more years of treatment, were published by Simonneau et al (2015).26, A total of 243 patients entered CHEST-2, and at the data cutoff for the analysis, 179 (76%) had received more than 1 year of treatment. The estimated overall survival rate at 1 year was 97% (95% CI, 93% to 98%). In an analysis assuming that all patients who dropped out of the study had died, the estimated 1-year survival rate was 93% (95% CI, 88% to 96%). The rate of clinical worsening-free survival at 1 year was 88% (95% CI, 83% to 92%). Adverse events occurred in 228 (96%) patients, most commonly nasopharyngitis (23%), dizziness (19%), and peripheral edema (18%). Serious adverse events occurred in 100 (42%) patients. Thirteen patient deaths occurred during CHEST-2, none of which was considered drug-related by the investigators.

Treprostinil

Sadushi-Kolici et al (2019) conducted a 24-week, double-blind RCT assessing the efficacy and safety of treprostinil, a prostacyclin analogue, for the treatment of inoperable CTEPH.27, One hundred five patients were enrolled in the study, 53 randomly assigned to receive high-dose subcutaneous treprostinil (target dose approximately 30 ng/kg/min at wk 12) and 52 assigned to receive a low dose (target dose approximately 3 ng/kg/min at wk 12). The primary end point was 6MWD at week 24. At week 24, the marginal mean 6MWD in the high-dose group improved by 44.98 m (95% CI, 27.52 to 62.45 m), and the low-dose group improved by 4.29 m (95% CI, -13.34 to 21.92 m); treatment effect was 40.69 m (95% CI, 15.86 to 65.53 m; P=0.0016). Patients in both groups (high-dose group n=9 [17%]; low-dose group n=10 [19%]) experienced serious adverse events, but the most common adverse events reported were infusion site pain and other infusion site reactions.

Section Summary: Inoperable CTEPH Monotherapy

There is only 1 FDA-approved medication for this indication: riociguat. One RCT and its extension study have been published. The double-blind RCT found that functional outcomes at 16 weeks improved significantly more in the group receiving riociguat. Both groups had a high proportion of adverse events, and 1 death was attributed to riociguat. In the extension study, the estimated 1-year survival rate was 97%. Thirteen deaths occurred, none of which was attributed to study medication.






Perioperative CTEPH Therapy


The purpose of perioperative prostacyclin analogues, endothelin receptor antagonists, and riociguat is to provide a treatment option that is an alternative to or an improvement on existing therapies in patients with operable CTEPH.

For patients with CTEPH who are eligible for pulmonary endarterectomy, preoperative elevation of PVR (>1100 Wood units) can increase operative mortality rates to 6% to 10%.28,

The question addressed in this evidence review is: Does the use of perioperative prostacyclin analogues, endothelin receptor antagonists, or riociguat improve the net health outcome in individuals who have CTEPH?


Patients

The relevant population of interest is individuals with operable CTEPH.(See previous indication for more information on patients with CTEPH.)

Interventions

The therapies being considered are perioperative prostacyclin analogues, endothelin receptor antagonists, and riociguat, which are administered and actively managed by pulmonologists or cardiologists in a surgical setting on an inpatient or outpatient basis.

Comparators

The following therapy is currently being used to treat operable CTEPH: pulmonary endarterectomy alone, which is performed in a surgical setting on an inpatient or outpatient basis.

Outcomes

The general outcomes of interest are overall survival, functional outcomes, hospitalizations, and treatment-related morbidity. Follow-up of weeks to months is of interest to monitor outcomes.






Prostacyclin Analogues (Prostanoids)

Epoprostenol

One nonrandomized comparative study was identified. Nagaya et al (2003) reported retrospectively on 33 patients with CTEPH who underwent pulmonary endarterectomy.28, Twelve patients with preoperative PVR greater than 1200 Wood units received preoperative epoprostenol for a mean of 6 weeks. There were statistically significant reductions in PVR before and after surgery in both groups and





no statistically significant difference in PVR between groups at 1 month after surgery (mean PVR, 300 Wood units in both groups). The only patient who died within 30 days postsurgery was in the epoprostenol group (overall mortality rate, 3.0%; 8.3% in the epoprostenol group vs 0% in the comparator group).

Iloprost

Kramm et al (2003) reported on the effect of inhaled iloprost in the perioperative period.29, Ten patients with mean PVR of 972 Woods units received inhaled iloprost at 3 time points: immediately before surgery, on admission to the intensive care unit after surgery, and at 12 or more hours postsurgery. Preoperative inhalation did not affect PVR. After surgery, PVR decreased 10% and 22% after each postoperative dose compared with placebo (saline) inhalation at the same time points; however, all postoperative measurements (pre- and posttreatment) were less than 360 Wood units. One patient died 17 days after surgery due to persistent PH (10% mortality rate).

Endothelin Receptor Antagonists

Bosentan

Reesink et al (2010) reported on the results from a single-blind RCT of 26 patients with CTEPH who were eligible for pulmonary endarterectomy.30, Mean baseline total pulmonary resistance was approximately 1000 Wood units. Fourteen patients received bosentan for 16 weeks before surgery; 1 patient developed liver enzyme elevations 6 times the upper limit of normal and was excluded from efficacy analyses. Eleven patients in the bosentan group and 10 patients in the no-bosentan group underwent pulmonary endarterectomy. Mortality rates within 30 days of surgery were 9% and 30%, respectively.

Soluble Guanylate Cyclase Stimulators

Riociguat

No trials evaluating riociguat for preoperative therapy were identified.

Section Summary: Perioperative CTEPH Treatment

The few studies identified, all with small numbers of patients and limited comparative data, do not provide sufficient evidence to determine whether mortality and PVR are improved with any of these medications. High-quality RCTs are needed to determine whether perioperative treatment with advanced medications improves outcomes for this population.

Summary of Evidence

Pulmonary Arterial Hypertension

For individuals with PAH who receive monotherapy using tyrosine kinase inhibitors or statins, the evidence includes no randomized controlled trials (RCTs) on tyrosine kinase inhibitors and 4 RCTs and a meta-analysis on statins. Relevant outcomes are overall survival, functional outcomes, hospitalizations, and treatment-related morbidity. A meta-analysis of RCTs evaluating statins for PAH did not find significantly better outcomes (ie, mortality, 6-minute walk distance) with study medication than with placebo. For imatinib (a tyrosine kinase inhibitor), there are no placebo-controlled studies evaluating efficacy. However, a 2016 safety study identified a high rate of adverse events in patients who took imatinib. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have PAH and inadequate response to monotherapy who receive add-on combination therapy using 2 drug classes FDA-approved for treatment of PAH, the evidence includes RCTs and meta-analyses. Relevant outcomes are overall survival, functional outcomes, hospitalizations,





and treatment-related morbidity. The most recent and comprehensive meta-analysis of RCTs was published in 2016. It included 17 RCTs comparing add-on combination therapy with monotherapy with at least 12 weeks of follow-up. The meta-analysis found significantly lower rates of clinical worsening and hospitalizations with add-on combination therapy, but mortality rates did not differ significantly between groups. In all RCTs selected for the 2016 meta-analysis, the combination therapy involved different drug combinations from different classes, although the specific combination of riociguat and phosphodiesterase type 5 inhibitors is contraindicated. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals who have PAH who receive initial combination therapy using 2 drug classes FDA-approved for treatment of PAH, the evidence includes 2 RCTs. Relevant outcomes are overall survival, functional outcomes, hospitalizations, and treatment-related morbidity. In the first study (AMBITION trial), among patients in the primary analysis set, there was a significantly lower rate of clinical failure at 6 months in the combination therapy group than in the monotherapy group. Clinical failure was defined as a complex composite endpoint that included death, hospitalizations, functional improvement and other measures of disease progression. Study limitations include change in enrollment criteria during the trial and use of a complex composite outcome with multiple components. The other RCT did not find significant differences in outcomes between a group receiving initial combination therapy and the group receiving monotherapy at 16 weeks; this study had a small sample size and might have been underpowered to assess secondary outcomes. Multiple reviews of the AMBITION trial with an emphasis on functional improvement (6MWT) have led to guideline recommendations for making ambristentan plus tadalafil and appropriate initial treatment option. The evidence is sufficient to determine the effects of the technology on health outcomes.

Chronic Thromboembolic Pulmonary Hypertension

For individuals who have inoperable CTEPH or PH after surgery who receive a soluble guanylate cyclase stimulator (eg, riociguat), the evidence includes 1 RCT. Relevant outcomes are overall survival, functional outcomes, hospitalizations, and treatment-related morbidity. The double-blind RCT found that functional outcomes at 16 weeks improved significantly more in the group receiving riociguat than placebo. Both groups had a high proportion of adverse events, and 1 death was attributed to riociguat. In an extension study, the estimated 1-year survival rate was 97%. Thirteen deaths occurred, none of which was attributed to study medication. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals who have operable CTEPH who receive perioperative prostacyclin analogues, endothelin receptor antagonists, or riociguat, the evidence includes 1 small RCT on bosentan, retrospective noncomparative studies on epoprostenol and iloprost, and no trials on riociguat. Relevant outcomes are overall survival, functional outcomes, hospitalizations, and treatment-related morbidity. The few studies identified, all with small numbers of patients and limited comparative data, do not provide sufficient evidence to determine whether mortality and pulmonary vascular resistance are reduced with any of these medications. The evidence is insufficient to determine the effects of the technology on health outcomes.

SUPPLEMENTAL INFORMATION

Clinical Input From Physician Specialty Societies and Academic Medical Centers

While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process, through the provision of appropriate reviewers, input



received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted.

2014 Input

In response to requests, input was received from 4 academic medical centers (5 reviewers) and 1 professional pharmacy society while this policy was under review in 2014. Input focused on:

• The use of riociguat and pulmonary arterial hypertension-specific medications to reduce pulmonary vascular resistance preoperatively in patients with chronic thromboembolic pulmonary hypertension who are candidates for pulmonary endarterectomy. There was consensus among reviewers that riociguat is investigational in this setting and that pulmonary arterial hypertension-specific medications are investigational in this setting.

• The use of riociguat in patients with chronic thromboembolic pulmonary hypertension who are candidates for pulmonary endarterectomy but prefer medical treatment. Results were mixed on this question.

2011 Input

In response to requests, input was received from 4 academic medical centers while this policy was under review in 2011. Input focused on combination therapy. Two academic medical centers disagreed with the 2010 policy statement that combination therapy is considered investigational (other than when changing from 1 medication to another). The other 2 centers had mixed input; both thought there were situations when combination therapy is medically necessary.

Practice Guidelines and Position Statements

Pulmonary Arterial Hypertension

American College of Cardiology Foundation et al

In 2009, the American College of Cardiology Foundation and American Heart Association released an expert consensus document on pulmonary hypertension (PH) developed with 3 other medical associations.2, This evidenced-based treatment algorithm stated that “in general, patients with poor prognostic indexes should be initiated on parenteral therapy, while patients with class II or early II symptoms commonly commence therapy with either endothelin receptor antagonists or PDE5 [phosphodiesterase type 5] inhibitors.” The consensus report also cautioned “against widespread treatment of non-PAH PH” until patient benefit has been proven in clinical trials. On the topic of combination therapy, the authors encouraged enrollment into randomized controlled trials evaluating combination therapy.

American College of Chest Physicians

In 2019, the American College of Chest Physicians (ACCP) updated their guidelines on pharmacologic therapy for PAH in adults.31, Relevant new recommendations include:

• For patients with PAH who are treatment naive with WHO functional class (FC) II or class III symptoms, “an initial combination therapy with ambrisentan and tadalafil to improve 6MWD” is suggested (a weak recommendation with moderate quality evidence).

• “For stable or symptomatic PAH patients on background therapy with ambrisentan,” a weak recommendation with low-quality evidence is made for the addition of tadalafil to improve 6MWD.

• To delay time to clinical worsening in PAH patients with WHO FC II symptoms, the guidelines recommend bosentan, macitentan, or riociguat (all ungraded consensus-based statements).





• To improve 6MWD for patients with WHO FC III symptoms, the guidelines recommend bosentan (strong recommendation, moderate quality evidence), ambrisentan (strong recommendation, low quality evidence), sildenafil (strong recommendation, low-quality evidence), or riociguat (ungraded consensus-based statement).

• To delay time to clinical worsening in PAH patients with WHO FC III symptoms, the guidelines recommend macitentan, tadalafil, or riociguat (all ungraded consensus-based statements).

• For patients with PAH who are treatment-naive, have WHO functional class II or class III symptoms, and “who are not candidates for CCB therapy or who have failed CCD therapy,” monotherapy with an “approved endothelin receptor antagonist (ETRA), phosphodiesterase-5 (PDE-5) inhibitor, or … riociguat."

• For patients with PAH in WHO functional class III “who have evidence of rapid progression of their disease, or … poor clinical prognosis despite treatment with one or two classes of oral agents,” consideration of the “addition of a parenteral or inhaled prostanoid” is recommended.

• For patients with PAH who are treatment-naive and have WHO functional class IV symptoms, initial “monotherapy with a parental prostanoid agent” is recommended. If patients “are unable or do not desire to manage parenteral prostanoid therapy,” combination treatment with “an inhaled prostanoid” and “an ETRA” is recommended.

In 2013, the ACCP and American Heart Association released a joint policy statement, The Choosing Wisely Top Five List in Adult Pulmonary Medicine.32, The list includes a recommendation to not routinely offer advanced vasoactive agents approved only for the management of PAH to patients with disease resulting from left heart disease or hypoxemic lung disease (group II or III PH).

American Thoracic Society

The American Thoracic Society (ATC), in their 2013 practice guideline on diagnosis, risk stratification, and management of PAH of sickle cell disease (SCD), strongly recommends against PAH-specific therapy “[f]or all patients with SCD with elevated TRV [tricuspid regurgitant velocity] alone or elevated NT-pro-BNP [N-terminal pro-brain natriuretic peptide] alone, and for patients with SCD with RHC [right heart catheterization]-confirmed PH with elevated pulmonary artery wedge pressure and low pulmonary vascular resistance.33,

“However, for select patients with SCD with RHC-confirmed PH who have elevated pulmonary vascular resistance and normal pulmonary capillary wedge pressure, [the guidelines] make a weak recommendation for either prostacyclin agonist or endothelin receptor antagonist therapy and a strong recommendation against phosphodiesterase-5 inhibitor therapy.”

In an official statement on pulmonary hypertension phenotypes, the ATC (2014) asserts that “[r]apid advances in mechanistic understanding of PH, improved imaging methods and new modalities, and the emergence of innovative biomarkers…offer an opportunity to define PH phenotypes more precisely on the basis of pathobiology, which is crucial in such a heterogenous syndrome34,….Accurate phenotyping of PH can be used in research studies to increase homogeneity of study cohorts.

“In addition, once the ability of the phenotypes to predict outcomes has been validated, phenotyping may also be useful for determining prognosis and guiding treatment.” Defining phenotypes will enable testing “whether selective targeting of care” will afford the opportunity to use “the wide array of medications so that patients can live longer and more satisfying lives.”

Chronic Thromboembolic Pulmonary Hypertension

American College of Cardiology Foundation and American Heart Association






The 2009 American College of Cardiology Foundation and American Heart Association expert consensus document on PH, recommended pulmonary endarterectomy for eligible patients with chronic thromboembolic pulmonary hypertension (CTEPH).2,

The panel noted that pharmacotherapy with PAH-specific medications may benefit CTEPH patients who are ineligible for pulmonary endarterectomy due to significant distal disease or comorbidity; patients who have persistent PH due to residual distal disease after pulmonary endarterectomy; and patients eligible for pulmonary endarterectomy who are considered high risk due to poor functional status or hemodynamics and may benefit from presurgical treatment with intravenous epoprostenol.

The panel recommended that PAH-specific medications be used for CTEPH patients only when “appropriate secondary preventive measures, including anticoagulation, have been instituted” and “the patient’s symptoms suggest that PAH-specific therapy may yield clinical benefit.”

American Heart Association

An American Heart Association (AHA) scientific statement (2011) makes the following recommendations for medical therapy and pulmonary endarterectomy in patients with CTEPH35,:

1. Patients with CTEPH should be promptly evaluated for pulmonary endarterectomy, even with mild symptoms.

2. Patients with CTEPH “should receive indefinite therapeutic anticoagulation in the absence of contraindications.”

3. “PAH (WHO Group I)-specific medical therapy may be considered for patients with CTEPH who are not surgical candidates…or who have residual pulmonary hypertension after operation not amenable to repeat pulmonary endarterectomy….

4. “PAH (WHO Group I)-specific medical therapy should not be used in lieu of pulmonary endarterectomy or delay evaluation for pulmonary endarterectomy for patients with…CTEPH who are or may be surgical candidates.”

U.S. Preventive Services Task Force Recommendations

Not applicable.

Medicare National Coverage

There is no national coverage determination. In the absence of a national coverage determination, coverage decisions are left to the discretion of local Medicare carriers.

Ongoing and Unpublished Clinical Trials

Some currently unpublished trials that might influence this review are listed in Table 8.

Table 8. Summary of Key Trials

NCT No. Trial Name Planned Enrollment

Completion Date

Ongoing

Pulmonary arterial hypertension

NCT02634203 Riociguat Versus Balloon Pulmonary Angioplasty in Non-operable Chronic thromboEmbolic Pulmonary Hypertension (RACE)

124 Sep 2019

NCT03273257 A Phase 2, Randomised, Double- 80 Jul 2020





Blind, Placebo-Controlled, Multicentre, Prospective Study to Assess Efficacy of Riociguat in Patients With Operable CTEPH Prior to Pulmonary Endarterectomy With High Preoperative Pulmonary Vascular Resistance

Chronic thromboembolic pulmonary hypertension

NCT01416636a A Double Blind Controlled Clinical Study to Investigate the Efficacy and Tolerability of Subcutaneous Treprostinil Sodium in Patients With Severe Non-operable Chronic Thromboembolic Pulmonary Hypertension (CTEPH)

100 Dec 2020

Unpublished

Pulmonary arterial hypertension

NCT01560624a A Phase III, International, Multi-Center, Randomized, Double-Blind, Placebo-Controlled, Clinical Worsening Study of UT-15C in Subjects With Pulmonary Arterial Hypertension Receiving Background Oral Monotherapy

696 Jun 2018 (completed)

NCT01908699a A Multicenter, Double-blind, Randomized, Placebo-controlled, Phase 3 Study to Assess the Efficacy and Safety of Oral BPS-314d-MR added-on to Treprostinil, Inhaled (Tyvaso®) in Subjects With Pulmonary Arterial Hypertension

240 February 2019

NCT: national clinical trial.

a Denotes industry-sponsored or cosponsored trial.

ESSENTIAL HEALTH BENEFITS

The Affordable Care Act (ACA) requires fully insured non-grandfathered individual and small group benefit plans to provide coverage for ten categories of Essential Health Benefits (“EHBs”), whether the benefit plans are offered through an Exchange or not. States can define EHBs for their respective state.

States vary on how they define the term small group. In Idaho, a small group employer is defined as an employer with at least two but no more than fifty eligible employees on the first day of the plan or contract year, the majority of whom are employed in Idaho. Large group employers, whether they are self-funded or fully insured, are not required to offer EHBs, but may voluntary offer them.



The Affordable Care Act requires any benefit plan offering EHBs to remove all dollar limits for EHBs.

REFERENCES

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3. Galie N, Hoeper MM, Humbert M, et al. Guidelines for the diagnosis and treatment of pulmonary hypertension: the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT). Eur Heart J. Oct 2009;30(20):2493-2537. PMID 19713419.

4. Galie N, Humbert M, Vachiery JL, et al. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). Eur Respir J. Oct 2015;46(4):903-975. PMID 26318161.

5. Archer SL. Riociguat for pulmonary hypertension -- a glass half full. N Engl J Med. 2013;369(4):386-388. PMID 23883383.

6. Benza RL, Miller DP, Barst RJ, et al. An evaluation of long-term survival from time of diagnosis in pulmonary arterial hypertension from the REVEAL Registry. Chest. Aug 2012;142(2):448-456. PMID 22281797.

7. Frost AE, Barst RJ, Hoeper MM, et al. Long-term safety and efficacy of imatinib in pulmonary arterial hypertension. J Heart Lung Transplant. Nov 2015;34(11):1366-1375. PMID 26210752.

8. Anand V, Garg S, Duval S, et al. A systematic review and meta-analysis of trials using statins in pulmonary arterial hypertension. Pulm Circ. Sep 2016;6(3):295-301. PMID 27683606.

9. Zeng WJ, Xiong CM, Zhao L, et al. Atorvastatin in pulmonary arterial hypertension (APATH) study. Eur Respir J. Jul 2012;40(1):67-74. PMID 22362846.

10. Lajoie AC, Lauziere G, Lega JC, et al. Combination therapy versus monotherapy for pulmonary arterial hypertension: a meta-analysis. Lancet Respir Med. Apr 2016;4(4):291-305. PMID 26935844.

11. McCrory DC, Coeytaux RR, Schmit KM, et al. Pulmonary Arterial Hypertension: Screening, Management, and Treatment. Rockville MD: Agency for Healthcare Research and Quality; 2013.

12. Fox BD, Shimony A, Langleben D. Meta-analysis of monotherapy versus combination therapy for pulmonary arterial hypertension. Am J Cardiol. Oct 15 2011;108(8):1177-1182. PMID 21864815.

13. McLaughlin VV, Benza RL, Rubin LJ, et al. Addition of inhaled treprostinil to oral therapy for pulmonary arterial hypertension: a randomized controlled clinical trial. J Am Coll Cardiol. May 4 2010;55(18):1915-1922. PMID 20430262.

14. McLaughlin VV, Oudiz RJ, Frost A, et al. Randomized study of adding inhaled iloprost to existing bosentan in pulmonary arterial hypertension. Am J Respir Crit Care Med. Dec 1 2006;174(11):1257-1263. PMID 16946127.



15. Hoeper MM, Leuchte H, Halank M, et al. Combining inhaled iloprost with bosentan in patients with idiopathic pulmonary arterial hypertension. Eur Respir J. Oct 2006;28(4):691-694. PMID 17012628.

16. Vizza CD, Jansa P, Teal S, et al. Sildenafil dosed concomitantly with bosentan for adult pulmonary arterial hypertension in a randomized controlled trial. BMC Cardiovasc Disord. Sep 6 2017;17(1):239. PMID 28874133.

17. McLaughlin V, Channick RN, Ghofrani HA, et al. Bosentan added to sildenafil therapy in patients with pulmonary arterial hypertension. Eur Respir J. Aug 2015;46(2):405-413. PMID 26113687.

18. Simonneau G, Rubin LJ, Galie N, et al. Addition of sildenafil to long-term intravenous epoprostenol therapy in patients with pulmonary arterial hypertension: a randomized trial. Ann Intern Med. Oct 21 2008;149(8):521-530. PMID 18936500.

19. Galie N, Muller K, Scalise AV, et al. PATENT PLUS: a blinded, randomised and extension study of riociguat plus sildenafil in pulmonary arterial hypertension. Eur Respir J. May 2015;45(5):1314-1322. PMID 25657022.

20. Galie N, Barbera JA, Frost AE, et al. Initial use of ambrisentan plus tadalafil in pulmonary arterial hypertension. N Engl J Med. Aug 27 2015;373(9):834-844. PMID 26308684.

21. Humbert M, Barst RJ, Robbins IM, et al. Combination of bosentan with epoprostenol in pulmonary arterial hypertension: BREATHE-2. Eur Respir J. Sep 2004;24(3):353-359. PMID 15358690.

22. Hoeper MM, Mayer E, Simonneau G, et al. Chronic thromboembolic pulmonary hypertension. Circulation. Apr 25 2006;113(16):2011-2020. PMID 16636189.

23. Fedullo P, Kerr KM, Kim NH, et al. Chronic thromboembolic pulmonary hypertension. Am J Respir Crit Care Med. Jun 15 2011;183(12):1605-1613. PMID 21330453.

24. Ghofrani HA, D'Armini AM, Grimminger F, et al. Riociguat for the treatment of chronic thromboembolic pulmonary hypertension. N Engl J Med. Jul 25 2013;369(4):319-329. PMID 23883377.

25. Kim NH, D'Armini AM, Grimminger F, et al. Haemodynamic effects of riociguat in inoperable/recurrent chronic thromboembolic pulmonary hypertension. Heart. Apr 2017;103(8):599-606. PMID 28011757.

26. Simonneau G, D'Armini AM, Ghofrani HA, et al. Riociguat for the treatment of chronic thromboembolic pulmonary hypertension: a long-term extension study (CHEST-2). Eur Respir J. May 2015;45(5):1293-1302. PMID 25395036.

27. Sadushi-Kolici R, Jansa P, Kpoec G, et al. Subcutaneous treprostinil for the treatment of several non-operable chronic thromboembolic pulmonary hypertension (CTREPH): a double-blind, phase 3, randomized controlled trial. Lancet Respir Med. 2019;7:239-248. PMID: 30477763.

28. Nagaya N, Sasaki N, Ando M, et al. Prostacyclin therapy before pulmonary thromboendarterectomy in patients with chronic thromboembolic pulmonary hypertension. Chest. Feb 2003;123(2):338-343. PMID 12576349.

29. Kramm T, Eberle B, Krummenauer F, et al. Inhaled iloprost in patients with chronic thromboembolic pulmonary hypertension: effects before and after pulmonary thromboendarterectomy. Ann Thorac Surg. Sep 2003;76(3):711-718. PMID 12963183.

30. Reesink HJ, Surie S, Kloek JJ, et al. Bosentan as a bridge to pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension. J Thorac Cardiovasc Surg. Jan 2010;139(1):85-91. PMID 19660388.

31. Klinger JR, Elliot CG, Levine DJ, et al. Therapy for pulmonary arterial hypertension in adults: update of the CHEST guideline and expert panel report. Chest. March 2019;155(3):565-586. PMID: 30660783.



32. Wiener RS, Ouellette DR, Diamond E, et al. An official American Thoracic Society/American College of Chest Physicians policy statement. Chest. 2014;145(6):1383-1391. PMID:24889436.

33. Klings ES, Machado RF, Barst RJ, et al. An official American Thoracic Society clinical practice guideline: diagnosis, risk stratification, and management of pulmonary hypertension of sick cell disease. Am J Respir Crit Care Med. March 15, 2014;189(6):727-740. PMID: 24628312.

34. Dweik RA, Rounds S, Erzurum SC, et al. An official American Thoracic Society statement: pulmonary hypertension phenotypes. Am J Respir Crit Care Med. February 1, 2014;189(3):345-355. PMID: 24484330.

35. Jaff MR, McMurtry MS, Archer SL, et al. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension. Circulation. 2011 Apr 26;123(16):1788-1830. PMID: 21422387.

CODES

Codes Number Description

CPT 93503 Insertion and placement of flow-directed catheter (eg, Swan-Ganz) for monitoring purposes (ie, as part of dose- ranging study)

HCPCS J1325 Injection, epoprostenol, 0.5 mg J3285 Injection, treprostinil, 1 mg K0455 Infusion pump used for uninterrupted parenteral administration of medication (eg,

epoprostenol or treprostinil) K0730 Controlled dose inhalation drug delivery system Q4074 Iloprost, inhalation solution, FDA-approved final product, noncompounded,

administered through DME, up to 20 mcg S0088 Imatinib, 100 mg S0090 Sildenafil citrate, 25 mg S0155 Sterile dilutant for epoprostenol, 50 ml S9347 Home infusion therapy, uninterrupted, long-term, controlled rate intravenous or

subcutaneous infusion therapy (eg, epoprostenol); administrative services, professional pharmacy services, care coordination, all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

ICD-10-CM

I27.0 Primary pulmonary hypertension

I27.20 -I27.29

Other secondary pulmonary hypertension code range

I27.89 Other specified pulmonary heart diseases I27.9 Pulmonary heart disease, unspecified

ICD-10-PCS

ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.

3E013GC, 3E033GC

Administration, physiological systems and anatomical regions, introduction, percutaneous, other therapeutic substance, code by body part (subcutaneous tissue or peripheral vein)

Type of service

Drug therapy

Place of service

Inpatient, home



POLICY HISTORY

Date Action Description

03/13/14 Replace policy Policy updated with input from clinical reviewers. The investigational policy statement on preoperative reduction of pulmonary vascular resistance in patients with CTEPH who are candidates for pulmonary endarterectomy modified to include riociguat. PAH classification and references 2, 14, and 42 updated.

03/12/15 Replace policy Policy updated with literature review through February 2, 2015; references 11, 32-35, 49, 63-66, and 74 added; reference 36 updated. Oral treprostinil (Orenitram®) added to medically necessary policy statement.

10/28/15 Replace policy Added policy statement "Combination therapy with Letairis (ambrisentan) and Adcirca (Tadalafil) for the treatment of pulmonary arterial hypertension (PAH/WHO Group 1) may be considered medically necessary

05/19/16 Replace policy Policy updated with literature review through March 22, 2016; references 7, 15, 27-28, 30, 36, 38-39, 41, 43, and 49 added. Oral selexipag (e.g., Uptravi®) added to medically necessary policy statement.

06/16/16 Replace policy Policy statement on single agents approved by FDA for treatment of PAH/WHO group 1 and related material in other sections of the policy removed. The policy no longer addresses single agents approved by FDA for treatment of PAH/WHO group 1.

06/22/17 Replace policy Blue Cross of Idaho policy annual review; no change to policy statement. 12/27/17 Replace policy Blue Cross of Idaho adopted changes as noted, policy statement remains

unchanged. Policy updated with literature review through August 24, 2017; references 10, 22, and 24 added.

04/30/18 Update only Medical policy renumbered from 5.01.09 to 5.01.509. 10/18/18 Replace policy Blue Cross of Idaho adopted changes as noted, effective 10/18/2018.

Policy updated with literature review through August 23, 2018; reference 15 added. Policy statements unchanged.

10/24/19 Update policy Blue Cross of Idaho adopted changes as noted, effective 01/30/2020. Policy updated with literature review through August 5, 2019, references added. Policy statement added that Combination therapy with tadalafil and ambrisentan as first-line treatment may be considered medically necessary in the treatment of treatment naive PAH patients with WHO Functional Class Groups II and III. Other policy statements unchanged.

APPENDIX

Appendix Table 1. New York Heart Association Functional Classification

Class Definition

I Patients with no limitation of activities; they suffer no symptoms from ordinary activities II Patients with slight, mild limitation of activity; they are comfortable with rest or mild exertion III Patients with marked limitation of activity; they are comfortable only at rest IV Patients who should be at complete rest, confined to bed or chair; any physical activity brings

on discomfort and symptoms occur at rest



Appendix Table 2. WHO Functional Classification for Pulmonary Arterial Hypertension

Class Definition

I No limitation of clinical activity; ordinary physical activity does not cause dyspnea or fatigue II Slight limitation in physical activity; ordinary physical activity produces dyspnea, fatigue, chest

pain, or near-syncope; no symptoms at rest III Marked limitation of physical activity; less than ordinary physical activity produces dyspnea,

fatigue, chest pain, or near-syncope; no symptoms at rest IV Unable to perform any physical activity without symptoms; dyspnea and/or fatigue present at

rest; discomfort increased by any physical activity

WHO: World Health Organization.