OBJECTIVES: To estimate comparative efficacy between riociguat (switched from phosphodiesterase-5 inhibitors, PDE5i) and selexipag (added to PDE5i) in patients with pulmonary arterial hypertension (PAH) with inadequate response to PDE5i in combination with an endothelin receptor antagonist (ERA). To evaluate the cost-effectiveness in Czechia.

METHODS: A systematic literature review identified two relevant trials with comparable endpoints to inform a Bucher indirect comparison of relative and absolute effects. Given the comparable efficacy of riociguat and selexipag, a cost-minimization analysis (CMA) was conducted.

RESULTS: A Bucher indirect comparison provided evidence for the comparable relative efficacy of riociguat defined as the odds of unimproved functional class III 0.761 (95% CI 0.372 to 1.558; p=0.455) compared to selexipag and a comparable absolute efficacy defined as a difference in the 6-minute walking distance of 10.560 meters (95% CI -10.692 to 31.812; p=0.330). The CMA identified riociguat as the cost-saving therapy.

CONCLUSIONS: Switching to riociguat represents the cost-saving therapy for PAH patients who were inadequately compensated with the PDE5i+ERA therapy. Consequently, riociguat has been introduced to the list of reimbursed medicines in Czechia from October 2021. This is the first indirect treatment comparison and CMA of these therapies and thus may improve future decision-making for PAH indications.