An emerging class of new therapeutics targeting TGF, Activin, and BMP ligands in pulmonary arterial hypertension

Abstract

Pulmonary arterial hypertension (PAH) is an often fatal condition, the primary pathology of which involves loss of pulmonary vascular perfusion due to progressive aberrant vessel remodeling. The reduced capacity of the pulmonary circulation places increasing strain on the right ventricle of the heart, leading to death by heart failure. Currently, licensed therapies are primarily vasodilators, which have increased the median post‐diagnosis life expectancy from 2.8 to 7 years. Although this represents a substantial improvement, the search continues for transformative therapeutics that reverse established disease. The genetics of human PAH heavily implicates reduced endothelial bone morphogenetic protein (BMP) signaling as a causal role for the disease pathobiology. Recent approaches have focused on directly enhancing BMP signaling or removing the inhibitory influence of pathways that repress BMP signaling. In this critical commentary, we review the evidence underpinning the development of two approaches: BMP‐based agonists and inhibition of activin/GDF signaling. We also address the key considerations and questions that remain regarding these approaches.

Sex-biased TGFβ signalling in pulmonary arterial hypertension

“…The balance of the combinatory levels of circulating TGFβ ligands in the patient and their differential affinities to Sotatercept therefore drives its pharmacological function. However, Sotatercept may also reduce BMP activity, which can underlie the undesirable side effects observed in PAH patients involved in a recent clinical trial (as reviewed in reference 102 ). For instance, the inhibition of BMP10 by high doses of Sotatercept can interfere with BMP10 homeostatic function on the endothelium, 53 maybe resulting in telangiectasias ( Figure 3 ).…”