There was no effect of macitentan on bile salts

indicating no detrimental effect on hepatic function. 92,93 Figure 8. Principal steps in the chemical synthesis of macitentan from bosentan. The clinical benefit of macitentan was recently demonstrated in the SERAPHIN trial that involved 742 patients. The placebo group of 250 patients were compared to 250 patients who received 3 mg daily Vismodegib structure and 242 patients received 10 mg daily of the drug. Patients with either idiopathic or heritable PAH or PAH associated with connective-tissue disease, congenital left-to-right shunts, HIV infection, or drug/toxin use/exposure participated in the trial. Macitentan significantly improved the morbidity and mortality of patients with PAH irrespective of whether they had previously received treatment for the disease or not. Improvements in the 6-minute walk test, WHO functional class and reductions of PVR were seen for both concentrations of macitentan. A number of patients withdrew from the trial due to adverse effects that included worsening of PAH, upper respiratory tract infection, peripheral oedema and right ventricular failure.

Compared to patients in the placebo group, higher percentages of patients in the two macitentan groups had nasopharyngitis, headache and anaemia. There was no significant incidence in elevations of liver enzymes in any of the three groups. The SERAPHIN trial is discussed in greater detail by Karim Said elsewhere in this issue. Macitentan is now approved for use in the treatment of PAH in the USA and Canada and it has received a positive opinion from regulatory authorities in Europe. Combination therapy with ET-receptor antagonists In addition to ET-1 receptor blockade, there are a number of other established and new therapies used for the treatment of PAH. These include prostacyclin analogues (epoprostenol, treprostinil, iloprost, beraprost), phosphodiesterase-5 (PDE-5) inhibitors (sildenafil, tadalafil, vardenafil) and more recently activators of cGMP (Riociguat). 94 There have been several small studies that have specifically

examined the benefits of combinations of some of these agents. These studies have Batimastat shown that combining bosentan with sildenafil is safe and effective in patients with PAH and that the beneficial effects of sildenafil are maintained despite the reduced bioavailability of the PDE-5 inhibitor caused by bosentan. 95,96 Combining bosentan with prostacyclin analogues was also shown to be safe and effective, with additional improvements seen with bosentan when added to poprostenol or treprostinil therapy. 97,98 One case report showed recovery over a 6-month period of a woman suffering from progressive right heart failure and severe PAH after treatment was commenced with a combination of bosentan, tadalafil, and beraprost.