Targeted DMARDs advantageous in SSc patients with pre-capillary pulmonary hypertension

A significant benefit of targeted disease-modifying antirheumatic drugs (DMARDs) in patients with systemic sclerosis (SSc) and pre-capillary pulmonary hypertension (precapPH) was found in terms of a protective effect on mortality and worsening of precapPH. This outcome was independent of the presence of interstitial lung disease (ILD).

“We all know that precapPH is a life-threatening complication in SSc,” Dr Cosimo Bruni (University Hospital Zurich, Switzerland) stated, further pointing out that its treatment currently relies on medications for pulmonary arterial hypertension or ILD [1]. As specific knowledge on the efficacy of targeted DMARDs on precapPH is still unsatisfactory, a retrospective observational study was performed to gain further insight into their possible benefit.

Patients with SSc from the EUSTAR registry with data on their immunosuppressive therapy and who fulfilled the haemodynamic criteria for precapPH after performing a right heart catheterisation were included. Immunosuppressive drugs included conventional synthetic DMARDs or targeted therapies (abatacept, rituximab, tocilizumab, TNF inhibitors, JAK inhibitors). The analysis focused on death or a predefined worsening of precapPH as the outcome, comparing patients with or without immunosuppressants. It also took into account a wide variety of potentially confounding covariates regarding risk stratification, among them gender, age, lung function, cardiac insufficiency markers, renal history, and medication levels.

Out of 755 patients, 82% were women, the mean age was 63 years, 29% had diffuse cutaneous SSc, and SSc with precapPH was present for a mean of 11 years. Half were treated with immunosuppressants, and 94% in this group had ≥1 conventional synthetic DMARD.

After a follow-up of 2.9 years, 72% had either died or experienced an event of pulmonary worsening. “These events were numerically higher in the immunosuppressants-exposed group, both for the combined outcome or for the separate outcomes (death or precapPH worsening),” Dr Bruni described.

Primarily, the Cox-regression modelling failed to find significance in the effect of immunosuppressants overall (P=0.551). However, after stratification according to the type of treatment, targeted therapy demonstrated a significant effect (P=0.021) on protection against the combined outcome of death or precapPH worsening. As the presence or absence of ILD might have influenced this result, a further categorisation was performed that again yielded significance for targeted therapies (P=0.026), confirming that the effect was independent of ILD. “The signals that we noted were mostly related to tocilizumab, having a statistically significant protective effect, and a trend was also noted for rituximab,” Dr Bruni further specified.

“Now, randomised clinical trials exploring targeted therapies should be designed using long-term morbidity and mortality outcomes to validate our results further and possibly improve the care of our patients,” Dr Bruni recommended in his conclusion.

1. Bruni C. Immunosuppression with targeted DMARDs reduces morbidity and mortality in pre-capillary pulmonary hypertension associated with systemic sclerosis: a EUSTAR OP0238, EULAR 2023, 31 May–3 June, Milan, Italy.

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Posted on 31 July, 202323 April, 2024