Exploring Providers' Behaviors, Attitudes, and Preferences on the Treatment of Pulmonary Arterial Hypertension With Endothelin Receptor Antagonist (ERA) + Phosphodiesterase-5 Inhibitors (PDE5i)

Abstract

This study aims to understand healthcare providers' (HCPs) decision to adopt double combination therapy with ERA + PDE5i for pulmonary arterial hypertension (PAH), and to explore whether a single tablet combination therapy (STCT) might increase adoption practices. 195 US HCPs completed a survey evaluating their PAH treatment preferences. HCPs' willingness to use double combination ERA + PDE5i was assessed using a discrete choice experiment (DCE). The sample predominantly included physicians (73.3%) from centers of excellence (63.1%), with a mean of 117.4 PAH patients treated in the past year. Key factors influencing ERA + PDE5i adoption in the DCE were the patient's current treatment (17.9), PAH etiology (16.2), existing comorbidities (14.1), and history of side effects (12.7), with higher scores indicating stronger preference. HCPs were more likely to select ERA + PDE5i for patients currently on PDE5i monotherapy, with idiopathic PAH, and without comorbidities or a history of side effects. Regarding STCT, most HCPs reported that it would allow them to initiate ERA + PDE5i sooner (76.4%) and improve patient compliance (82.6%). However, concerns regarding cost/insurance issues (63.6%) and a history of side effects (50.8%) were identified as limitations to adopting STCT. Patients' current therapy, the cause of PAH, comorbidities, and side effects are key factors influencing whether US providers are willing to treat them with ERA + PDE5i. Providers perceive that STCT may help HCPs initiate ERA + PDE5i sooner, improve compliance, and simplify initiation of upfront double therapy and delivery of triple therapy. Addressing cost and insurance barriers will be critical to realizing these potential benefits.

Keywords: ERA; PDE5i; combination therapy; pulmonary arterial hypertension; treatment preferences.

Figure 1

Relative importance of each attribute. Note: Relative importance estimates are preference weights on a scale from 0 to 100, with higher values indicating stronger preferences. Risk status based on REVEAL 2.0 criteria; Symptom progression within the last 3 months; Hospitalization within the last 6 months. PAH, pulmonary arterial hypertension; WHO, World Health Organization.

Figure 2

Attribute‐level preference weights. Note: Each respondent completed a series of choice tasks, in which they reviewed three profiles of hypothetical PAH patients and selected the profile that would be most optimally treated with a double combination of ERA + PDE5i. Each patient profile presented a randomized combination of these attributes. Preference weights are used to evaluate within‐attribute patterns, with higher values indicating stronger preferences. * Risk status based on REVEAL 2.0 criteria; Symptom progression within the last 3 months; Hospitalization within the last 6 months. ERA, endothelin receptor antagonist; PAH, pulmonary arterial hypertension; PDE5i, phosphodiesterase‐5 inhibitors; SGC, soluble guanylate cyclase; WHO, World Health Organization.

Figure 3

Blinded choice of PAH therapies. Note: HCPs were asked to choose one of four specific PAH ERA + PDE5i combo therapy options that was most appropriate for the patient profile that had previously been presented. Treatment profiles were based on existing PAH double combination therapies; all therapies were presented in a blinded fashion (e.g., “Treatment A”). Results reflect the proportion of treatment choice trials in which HCPs selected each therapy as the optimal choice for managing PAH. STCT, single tablet combination therapy.

Figure 4

Perceptions of STCT for ERA + PDE5i–initiation, compliance, and therapy. Note: Only participants who selected “always/often” are included in the percentages shown. (a) Respondents were asked, “Would you consider a dual combination ERA + PDE5i to optimize treatment among patients using prostacyclin?”. (b) Respondents were asked, “Would you consider a single tablet combination of ERA + PDE5i as upfront therapy?”. (c) Respondents were asked, “If available, would a single tablet combination therapy (requiring a single prior authorization) allow you to initiate your patients on an ERA + PDE5i sooner?”. (d) Respondents were asked, “If the number of prior authorizations were similar, would you switch a patient from traditional dual combination ERA + PDE5 (two prescriptions) to a single tablet combination therapy?”. (e) Respondents were asked, “Do you believe a single tablet combination therapy (one pill per day) would improve your patients' compliance compared to traditional dual combination ERA + PDE5 therapies (several pills per day)?”.