Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia
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LETTER TO EDITOR Table of Contents   
Year : 2008  |  Volume : 11  |  Issue : 2  |  Page : 138-139
Authors' reply

Department of Cardiothoracic Surgery, Harefield Hospital, Hill End Road, Harefield, Middlesex UB9 6JH, United Kingdom

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How to cite this article:
Raja SG, Dreyfus GD. Authors' reply. Ann Card Anaesth 2008;11:138-9

How to cite this URL:
Raja SG, Dreyfus GD. Authors' reply. Ann Card Anaesth [serial online] 2008 [cited 2022 Dec 8];11:138-9. Available from:

The Editor,

We are grateful to Sethi et al . [1] for reiterating the views that we have expressed in our review article on bosentan. [2] Not only have we alluded to the adverse effects of bosentan on liver and its contraindication in pregnancy, but we have also stressed on the need for rigorous, blinded, placebo-controlled, multicentre randomised clinical trials to establish the safety of long-term bosentan therapy, as well as to confirm its efficacy as a combination therapy with other drugs available for the treatment of pulmonary arterial hypertension (PAH). [2]

It is important to realise that no current treatments of PAH achieve a cure for this devastating condition. [3] However, in less than 20 years, PAH treatment has evolved from a state of "no hope" to one in which prolonged survival and improvements in quality of life can be achieved. Current PAH treatments target the prostacyclin, NO, and endothelin-1 pathways. [3] Together with prostanoids and phosphodiesterase 5 inhibitors, ET receptor antagonists have become mainstays in the current treatment of PAH. Three substances are currently available for the treatment of PAH. One of these substances, bosentan, blocks both ETA and ETB receptors; whereas the two other compounds, sitaxsentan and ambrisentan, are more selective blockers of the ETA receptor. [4]

There is an ongoing debate as to whether selective or nonselective ET receptor blockade is advantageous in the setting of PAH, although there is no clear evidence that receptor selectivity is relevant with regard to the clinical effects of these drugs. Thus for the time being, other features such as safety profiles and the potential for pharmacokinetic interactions with other drugs used in the treatment of PAH may be more important than selectivity or nonselectivity when selecting treatments for individual patients, as rightly suggested by the reader.

Despite all the concerns and controversies, there is no doubt that the use of bosentan as part of a comprehensive management plan has resulted in improvements in exercise capacity, functional class, quality of life, and survival. [5] Patients on bosentan require regular monthly monitoring with liver function tests, and clear guidelines are in place in terms of reducing or stopping bosentan therapy depending upon the results of these liver function tests. In our humble opinion, until compelling evidence is available to withdraw bosentan altogether from the treatment algorithm of PAH because of the hidden hazards referred to by Sethi et al . [1] , it will continue to be extensively used as monotherapy in PAH, especially in patients with idiopathic PAH and scleroderma-associated PAH, as well as part of combination therapy in patients who have responded suboptimally to monotherapy.

   References Top

1.Sethi S, Sethi R, Wareham C. Hidden hazards of Bosentan therapy in pulmonary hypertension. Ann Cardiac Anaesth 2008;11:138.  Back to cited text no. 1    
2.Raja SG, Dreyfus GD. Current status of bosentan for treatment of pulmonary hypertension. Ann Card Anaesth 2008;11:6-14.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Humbert M, Sitbon O, Simonneau G. Treatment of pulmonary arterial hypertension. N Engl J Med 2004;351:1425-36.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Dupuis J, Hoeper MM. Endothelin receptor antagonists in pulmonary arterial hypertension. Eur Respir J 2008;31:407-15.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Gabbay E, Fraser J, McNeil K. Review of bosentan in the management of pulmonary arterial hypertension. Vasc Health Risk Manag 2007;3:887-900.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]

Correspondence Address:
Shahzad G Raja
Department of Cardiothoracic Surgery, Harefield Hospital, Hill End Road, Harefield, Middlesex UB9 6JH
United Kingdom
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-9784.41594

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