Eligibility Details:
Inclusion Criteria:
- Signed and dated informed consent form (ICF).
- Confirmed diagnosis of symptomatic PAH in WHO FC II or III.
- Symptomatic PAH belonging to one of the following subgroups of WHO Group 1 pulmonary
hypertension:
- Idiopathic.
- Heritable.
- Drug- or toxin-induced.
- Associated with connective tissue disease, HIV infection, portal hypertension or
congenital heart disease with simple systemic-to-pulmonary shunt with persistent
pulmonary hypertension documented by a right heart catheterization (RHC) ≥ 1 year
after surgical repair.
- PAH diagnosis confirmed by hemodynamic evaluation at rest (through central reading),
evaluated within 5 weeks prior to randomization:
- Mean pulmonary artery pressure (mPAP) ≥ 25 mmHg, AND
- Pulmonary artery wedge pressure (PAWP) or left ventricular end diastolic pressure
(LVEDP) ≤ 15 mmHg, AND
- Pulmonary vascular resistance (PVR) ≥ 3 WU (i.e., ≥ 240 dyn∙sec∙cm−5)
- Negative vasoreactivity test in idiopathic, heritable, and drug/toxin-induced PAH
- Neither no history of PAH-specific treatment or currently receiving a stable dose of
ERA or PDE-5i monotherapy for at least 3 months prior to baseline RHC, within the
specified doses in the study protocol.
- Subject able to perform the 6MWT with a minimum distance of 100 m and maximum distance
of 450 m at Screening.
- A woman of childbearing potential must:
- have negative serum pregnancy test at Screening and a negative urine pregnancy
test at Randomization.
- agree to undertake monthly urine pregnancy tests during the study and up to at
least 30 days after study treatment discontinuation.
- agree to follow the contraception scheme from Screening up to at least 30 days
after study treatment discontinuation.
Exclusion Criteria:
- Treatment with a soluble guanylate cyclase stimulator, L-arginine, any form of
prostanoids or prostacyclin-receptor agonists (including oral, inhaled, or infused
routes) in the 3-month period prior to start of treatment.
- Treatment with combination therapy of ERA and PDE-5i in the 3-month period prior to
start of treatment or history of intolerance to ERA and PDE-5i combination therapy.
- Hypersensitivity to any of the study treatments or any excipient of their
formulations.
- Treatment with a strong cytochrome P450 3A4 (CYP3A4) inducer in the 1-month period
prior to start of treatment.
- Treatment with a strong CYP3A4 inhibitor in the 1-month period prior to start of
treatment.
- Treatment with doxazosin.
- Treatment with any form of organic nitrate, either regularly or intermittently
- Diuretic treatment initiated or dose changed within 1 week prior to the RHC or start
of treatment.
- Treatment with another investigational drug in the 3-month period prior to start of
treatment.
- Body mass index (BMI) > 40 kg/m2 at Screening.
- Known presence of three or more of the following risk factors for heart failure with
preserved ejection fraction at Screening:
- BMI > 30 kg/m2.
- Diabetes mellitus of any type.
- Essential hypertension (even if well controlled).
- Coronary artery disease, i.e. history of stable angina or known more than 50%
stenosis in a coronary artery or history of myocardial infarction or history of
or planned coronary artery bypass grafting and/or coronary artery stenting.
- Known presence of moderate or severe obstructive lung disease any time prior to
Screening as specified in study protocol.
- Known presence of moderate or severe restrictive lung disease any time prior to
Screening as specified in study protocol.
- Clinically significant aortic or mitral valve disease; pericardial constriction;
restrictive or congestive left-sided cardiomyopathy; life-threatening cardiac
arrhythmias; significant left ventricular dysfunction; or left ventricular outflow
obstruction, in the opinion of the investigator
- Known permanent atrial fibrillation, in the opinion of the investigator
- Known or suspected uncontrolled thyroid disease (hypo- or hyperthyroidism).
- Documented pulmonary veno-occlusive disease.
- Hemoglobin < 100 g/L (<10 g/dL) at Screening.
- Known severe hepatic impairment as specified in study protocol.
- Serum aspartate aminotransferase (AST) and/or alanine aminotransferase (ALT) > 1.5 ×
upper limit of normal (ULN) at Screening.
- Severe renal impairment at Screening as specified in study protocol.
- Systemic hypotension at Screening or Randomization and systemic hypertension at
Screening as specified in study protocol.
- Acute myocardial infarction or cerebrovascular event (e.g., stroke) within the last 26
weeks prior to Screening.
- Known bleeding disorder, in the opinion of the investigator
- Loss of vision in one or both eyes because of non-arteritic anterior ischemic optic
neuropathy
- Hereditary degenerative retinal disorders, including retinitis pigmentosa.
- Difficulty swallowing large pills/tablets that would interfere with the ability to
comply with study treatment regimen.
- Any planned surgical intervention (including organ transplant) during the double-blind
treatment period, except minor interventions.
- Exercise training program for cardiopulmonary rehabilitation in the 12-week period
prior to Start of treatment, or planned to be started during the study.
- Pregnant, planning to become pregnant or lactating.
- Any known factor or disease that might interfere with treatment adherence, full
participation in the study or interpretation of the results as judged by the
investigator (e.g., drug or alcohol dependence etc.).