The Repair study: Effects of macitentan on RV structure and function in pulmonary arterial hypertension1

VIEW THE SERAPHIN CLINICAL DATA to learn more about a large, outcomes-based pivotal trial in PAH.

Important Considerations1

  • Data are based on a single-arm, open-label clinical trial and not on a randomized, placebo-controlled clinical trial
  • CMR parameters have not been accepted as primary endpoints for pivotal studies in PAH, so these data are hypothesis generating and further research is needed for a better understanding of the significance of CMR parameters as proxy for disease progression
  • The open-label design and study size of the Repair study limited subgroup analyses
  • OPSUMIT® (macitentan) is an ERA indicated for the treatment of PAH (WHO Group I) (FC II-III) to reduce the risks of disease progression and hospitalization for PAH2
  • This study was funded by Actelion Pharmaceuticals Ltd, a part of Johnson & Johnson Innovative Medicine

REPAIR was a 52-week, prospective, multicenter, single-arm, open-label, phase 4 study

Study objectives

  • To evaluate the effect of OPSUMIT® on RV and hemodynamic properties in patients with PAH
    • Primary endpoints were assessed at Week 26
  • To evaluate the safety and tolerability of OPSUMIT® in patients with symptomatic PAH
    • Patients’ median exposure time was 52 weeks

Inclusion criteria

  • 18 to 74 years of age
  • Idiopathic or heritable PAH, PAH related to CTD, drug use or toxin exposure, or simple congenital systemic-to-pulmonary shunts at least 2 years after repair (RHC required to confirm diagnosis)
  • Patients who are PAH-treatment naïve or receiving a stable background PDE5 inhibitor for at least 3 months, have a 6MWD of ≥150 m, and a WHO FC I-III

Study population

  • Primary interim analysis set: n=42*
  • Final analysis set: n=71†‡
  • Safety set: n=87§ǁ

Exclusion criteria

  • Prior use of ERAs, stimulators of soluble guanylate cyclase, or prostacyclin/prostacyclin analogs

The primary endpoints in REPAIR were RVSV (assessed by CMR) and PVR (measured by RHC)1

Primary endpoints:
Change from baseline to Week 26
RVSV assessed by CMR
PVR measured by RHC
Secondary endpoints:
Change from baseline to Week 26
RVESV, RVEDV, RVEF, and RV mass assessed by CMR
6MWD
WHO FC

The single-arm, open-label design and study size of the Repair study limited subgroup analyses.

Patient demographics1

Baseline characteristics (finals analysis set, n=71)

Female patients

 

80.3%

(n=57)

Median age

 

45
years

WHO FC#

I:

1.4%

(n=1)

II:

47.9%

(n=34)

III:

50.7%

(n=36)

6MWD (mean)

 

411.2
meters

Etiology

5-1-etiology-mobile

Monotherapy and combination therapy

5-1-monotherapy-mobile

The single-arm, open-label design and study size of the Repair study limited subgroup analyses.

REPAIR Primary Endpoints: RVSV and PVR at Week 26

  • The primary interim analysis set (n=42) was declared positive and enrollment was stopped at Week 26 as both primary endpoints (RVSV and PVR) were met
  • The final analysis set (n=71) was consistent with the primary interim analysis set

Primary interim analysis set
(n=42)

Heart graphic

RVSV


15.2 mL
increase

Change from baseline
to Week 26††

LS mean (96% CL)
15.2 (9.3-21.0) mL
Baseline (mean±SD):
50.7±17.5 mL

PVR

Repair study primary endpoint: PVR primary interim analysis set, 37% decrease

Week 26/baseline ratio‡‡
Geometric mean (99% CL)
0.63 (0.54-0.74) dyn·sec/cm5
Baseline (mean±SD):
900.2±457.6 dyn·sec/cm5

Final analysis set
(n=71)

Heart graphic

RVSV


12.0 mL
increase

Change from baseline
to Week 26††

LS mean (96% CL)
12.0 (8.4-15.6) mL
Baseline (mean±SD):
52.2±17.2 mL

PVR

Repair study primary endpoint: PVR final analysis set, 38% decrease

Week 26/baseline ratio‡‡
Geometric mean (99% CL)
0.62 (0.56-0.69) dyn·sec/cm5
Baseline (mean±SD):
974.6±679.0 dyn·sec/cm5

CMR parameters have not been accepted as primary endpoints for pivotal studies in PAH, so these data are hypothesis generating and further research is needed for a better understanding of the significance of CMR parameters as proxy for disease progression.

Observations of RV stroke volume, ejection fraction, and mass at Week 261§§

Final analysis set (n=70)
Change from baseline to Week 26‖‖ in RV parameters
LS mean (95% CL)

RVESV
(mL)

–16.1

(–20.0 to –12.2)
Baseline (mean±SD):
90.2±40.6

RVEDV
(mL)

–6.2

(–12.8 to 0.4)
Baseline (mean±SD):
149.8±49.1

RVEF¶¶
(%)

+10.6

(7.9 to 13.3)
Baseline (mean±SD):
37.7±14.3

RV mass
(g)

–10.5

(–14.0 to –7.1)
Baseline (mean±SD):
110.4±47.5

Observations of 6MWD and WHO FC at Week 261

Exercise capacity at Week 26 (n=71)

Baseline
(mean±SD)
Change from baseline
to Week 26##
LS mean (95% CL)
6MWD (m) 411.2±120.5 35.6 (19.0-52.3)

FC at Week 26 (n=70)

Repair study secondary endpoint: WHO FC

Zero patients worsened in WHO FC.

Baseline WHO FC#: WHO FC I, 1 (1.4%);
WHO FC II, 34 (48.6%); WHO FC III, 35 (50.0%).

Secondary efficacy analyses were performed with no correction for multiple testing; thus, these analyses are of an exploratory nature.

Safety and tolerability in the Repair study

Adverse events observed in the safety set (n=87)

Treatment-emergent adverse events

Patients with ≥1 treatment-emergent adverse event in ≥10% of patients, n (%) 75 (86.2)
Peripheral edema 19 (21.8)
Headache 18 (20.7)
Dizziness 12 (13.8)
Cough 10 (11.5)
Hemoglobin decreased 10 (11.5)
Upper respiratory tract infection 10 (11.5)
Myalgia 9 (10.3)

Adverse events leading to discontinuation of study treatment

Patients with ≥1 adverse event leading to discontinuation of study treatment, n (%) 7 (8.0)
Aspartate aminotransferase increased 2 (2.3)
Transaminases increased 2 (2.3)
Hypersensitivity 1 (1.1)
Liver function test increased 1 (1.1)
Edema peripheral 1 (1.1)

Select treatment-emergent serious adverse events***

Patients with ≥1 treatment-emergent serious adverse event, n (%) 14 (16.1)
Pneumonia 3 (3.4)
Acute myocardial infarction 2 (2.3)
Pulmonary arterial hypertension 2 (2.3)
Pulmonary embolism 2 (2.3)
Sepsis 2 (2.3)
Cardiac arrest (1 death recorded was the result of a fatal cardiac arrest, which occurred after the patient experienced a pulmonary embolism) 1 (1.1)
  • Laboratory abnormalities of ALT/AST ≥3 x the ULN were reported for 5 (5.8%) patients in the safety set1

7-Year Data

VIEW RESULTS

Safety and Tolerability

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*Primary results were based on the interim analysis set: Prespecified set of the first 42 patients who received at least 1 dose of OPSUMIT® and had valid measurements for both primary endpoints at baseline and at Week 26.

71 patients with both RVSV and PVR measures at baseline and Week 26.

Final analysis set: All enrolled patients who received at least 1 dose of OPSUMIT® and had valid measurement for both primary endpoints at baseline and at Week 26.

§87 patients received ≥1 dose of OPSUMIT®.

ǁSafety set: All screened patients who received at least 1 dose of OPSUMIT®.

Reference supplemental methods for a complete list of the exclusion criteria.

#OPSUMIT® is only indicated in WHO FC II and III.

**Only simple congenital systemic-to-pulmonary shunts at ≥2 years postsurgical repair.

††Adjusted change using an ANCOVA model with a factor for PAH-targeted background therapy and a covariate for baseline parameter value.

‡‡Adjusted change using an ANCOVA model with a factor for PAH-targeted background therapy and a covariate for baseline log PVR.

§§Not adjusted for multiplicity.

ǁǁAnalyzed using an ANCOVA with a factor for PAH-targeted background therapy and a covariate for baseline parameter value.

¶¶From pulmonary artery flow.

##From ANCOVA model on parameter change from baseline with factors for PAH-targeted treatment strategy, baseline WHO FC, and parameter at baseline as a covariate.

***Reference supplemental table 6 for a complete list of treatment-emergent serious adverse events.

6MWD=6-minute walk distance; ALT=alanine aminotransferase; ANCOVA=analysis of covariance; AST=aspartate aminotransferase; CL=confidence limit; CMR=cardiac magnetic resonance; CTD=connective tissue disease; ERA=endothelin receptor antagonist; FC=Functional Class; IPAH=idiopathic PAH; LS=least squares; PAH=pulmonary arterial hypertension; PAH-CTD=PAH associated with connective tissue disease; PDE5i=phosphodiesterase type 5 inhibitor; PVR=pulmonary vascular resistance; REPAIR=Right vEntricular remodeling in Pulmonary ArterIal hypeRtension; RHC=right heart catheterization; RV=right ventricular; RVEDV=RV end-diastolic volume; RVEF=RV ejection fraction; RVESV=RV end-systolic volume; RVSV=RV stroke volume; ULN=upper limit of normal; WHO=World Health Organization.
References: 1. Vonk Noordegraaf A, Channick R, Cottreel E, et al. The Repair study: Effects of macitentan on RV structure and function in pulmonary arterial hypertension. JACC Cardiovasc Imaging. 2021;S1936-878X(21)00635-5 and suppl 1-15. doi:10.1016/j.jcmg.2021.07.027 2. OPSUMIT® (macitentan) full Prescribing Information. Actelion Pharmaceuticals US, Inc.

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