ERS recommends sotatercept for everyone above low risk in pulmonary arterial hypertension

The edition in brief

A European Respiratory Society task force has updated its pulmonary arterial hypertension treatment guideline around two questions. It recommends add-on sotatercept, an activin signalling inhibitor, for patients already on pulmonary arterial hypertension drugs who are at intermediate-low, intermediate-high or high risk of death, on high-certainty randomised evidence, and gives no recommendation at low risk. It suggests right heart catheterisation during follow-up in the same above-low-risk groups where a therapeutic consequence is expected. A review of airway mucus plugs argues they are now a treatable trait rather than an incidental finding: plug burden scored on computed tomography has been associated with more exacerbations and faster spirometric decline in both asthma and COPD and with higher mortality in COPD, and several biologic therapies have reduced plug burden with accompanying spirometric improvement. The FDA approved an abbreviated new drug application for triamcinolone acetonide from an Indian manufacturer, with the formulation not specified in the approval record. A systematic review of five retrospective studies, all from one US health system, found robotic-assisted bronchoscopy and CT-guided transthoracic biopsy comparable for diagnostic yield (risk ratio 0.99) with about three-quarters fewer pneumothoraces requiring drainage or admission (0.25, 95 per cent CI 0.14 to 0.46) at low certainty. In 3370 CPAP-treated patients followed nine years, adherence was associated with fewer major cardiovascular events, and much more so in those with a high hypoxic or autonomic burden.