Characteristics and outcomes of patients developing pulmonary hypertension associated with proteasome inhibitors

Rationale: Pulmonary hypertension (PH) has been described in patients treated with proteasome inhibitors (PI). Objectives: To evaluate the association between PI and precapillary PH. Methods: Characteristics of incident precapillary PH cases treated with carfilzomib and bortezomib from the French PH Registry and the VIGIAPATH program from 2004 to 2022 were analyzed, concurrently with a pharmacovigilance disproportionality analysis using the WHO global database and a meta-analysis. Results: Eleven incident cases of PI associated pulmonary arterial hypertension (PAH) were identified (6 with carfilzomib and 5 with bortezomib) with a F/M ratio of 2.7:1 and a median age of 61 years, 4 patients died. The median delay between PI exposure and PAH was 6 months. At diagnosis, 6 patients were in NYHA functional class III/IV with severe haemodynamic impairment (median mean pulmonary artery pressure of 39 mmHg, cardiac index 2.45 L/min/m² and pulmonary vascular resistance of 7.2 WU). The pharmacovigilance disproportionality analysis identified 131 patients since 2013 and revealed a significant overrepresentation of carfilzomib and bortezomib among reported PH-adverse drug reactions. The meta-analysis identified 8 clinical trials and carfilzomib was associated with a significant higher risk of PH compared to bortezomib with an OR of 7.38. Conclusion: Bortezomib and carfilzomib may induce PAH and patients undergoing those treatments should be closely monitored, carfilzomib emitting a stronger signal than bortezomib.