Dr Simon Gibbs Outlines Monotherapy vs Combination Therapy in Pulmonary Hypertension

The majority of patients with pulmonary arterial hypertension, except for a few special circumstances, will begin treatment on combination therapy, instead of monotherapy, because combination therapy has been shown in trials to ahve better outcomes, explained Simon Gibbs, MD, Reader in Pulmonary Hypertension at the National Heart and Lung Institute, Imperial College London.

How do you weigh the benefits of monotherapy versus combination therapy in patients with pulmonary hypertension?
I think nowadays, I wouldn't normally, I would no longer start monotherapy. I would start with combination therapy in pulmonary arterial hypertension, except in very special circumstances, such as you have a responder to nitric oxide—a vasoreactivity test, in other words—and they would go onto long-term treatment with calcium channel blockers. And there are a few other circumstances. Perhaps patients with portal hypertension or pulmonary veno-occlusive disease, one would use monotherapy.

But in the vast majority of patients with pulmonary arterial hypertension, I would use initial combination therapy, because it has been shown in clinical trials of initial combination that the outcomes are better and in sequential combination that the outcomes are better too. There are a small group of patients who've been on monotherapy for 5 or 10 years, and they're completely stable. And I wouldn't go around changing them at all. But the majority of patients now are going to be on combination therapy, if not initially, very quickly.
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