Effects of Combination Medical Therapy Followed by BPA on Right Ventricular-PA Coupling and Hemodynamics in CTEPH

1. Is the biology right?

• Somatic driver evidence: no · None of EDNRB, EDNRA, GUCY1B1, GUCY1A2, GUCY1A1 has somatic-mutation evidence in chronic thromboembolic pulmonary hypertension

  Rule: Open Targets has somatic-mutation evidence for the target in this cancer. Source: Open Targets: EDNRB in chronic thromboembolic pulmonary hypertension, 2026-11-11
• Human genetic evidence: no · No germline or somatic evidence for EDNRB, EDNRA, GUCY1B1, GUCY1A2, GUCY1A1 in chronic thromboembolic pulmonary hypertension

  Rule: Any germline or somatic human genetic evidence for the target in this cancer, counted apart from animal-model and literature evidence. Source: Open Targets: EDNRB in chronic thromboembolic pulmonary hypertension, 2026-11-11
• Pediatric target: no · Not on the FDA list

  Rule: Target is on FDA's Pediatric Molecular Target List (relevant targets); membership alone neither requires nor waives a study. Source: FDA Pediatric Molecular Target List (Listed as February 2026 on the FDA Pediatric Oncology page; the file served is 9.7.22_the_relevant_molecular_target_list.xlsx, whose Summary of Changes sheet is headed 'SEPTEMBER 2022 UPDATE' (footnote date 2022-09-01)), 2026-11-11
• Haematologic cancer: no · Solid tumour

  Rule: From the indication, or the registry conditions when no indication matches. Source: ClinicalTrials.gov NCT05140525, 2026-11-11

  Published context: Likelihood of approval from phase 1: 7.5% haematologic vs 4.6% solid (BIO / Informa / QLS 2021, 2011–2020). Population-level, not a prediction.

• EDNRB (via Macitentan): Evidence types in chronic thromboembolic pulmonary hypertension: clinical. Datasources: clinical_precedence. · Open Targets: EDNRB in chronic thromboembolic pulmonary hypertension
• EDNRA (via Macitentan): Evidence types in chronic thromboembolic pulmonary hypertension: literature, clinical; literature listed separately from human genetics. Datasources: clinical_precedence, europepmc. · Open Targets: EDNRA in chronic thromboembolic pulmonary hypertension
• GUCY1B1 (via Riociguat): Evidence types in chronic thromboembolic pulmonary hypertension: clinical. Datasources: clinical_precedence. · Open Targets: GUCY1B1 in chronic thromboembolic pulmonary hypertension
• GUCY1A2 (via Riociguat): Evidence types in chronic thromboembolic pulmonary hypertension: clinical. Datasources: clinical_precedence. · Open Targets: GUCY1A2 in chronic thromboembolic pulmonary hypertension
• GUCY1A1 (via Riociguat): Evidence types in chronic thromboembolic pulmonary hypertension: animal_model, clinical; animal_model listed separately from human genetics. Datasources: clinical_precedence, impc. · Open Targets: GUCY1A1 in chronic thromboembolic pulmonary hypertension

• Not loaded on this app yet: Normal-tissue expression in vital organs. Source: Human Protein Atlas (ticket 36).
• Not loaded on this app yet: Pan-essential in cell lines. Source: DepMap (ticket 36).
• Not loaded on this app yet: Approved drug on this target. Source: Drugs@FDA (ticket 30).

2. Can the result be trusted?

• Randomised: no · Non-randomised

  Rule: Registry allocation field. Source: ClinicalTrials.gov NCT05140525, 2026-11-11
• Small denominator: yes · 7 enrolled; each patient moves a rate by 100 ÷ 7 = 14.3 points

  Rule: Enrolment under 30; the arithmetic is shown, not a benchmark. Source: ClinicalTrials.gov NCT05140525, 2026-11-11
• Primary endpoint is overall survival: no · Change in end-systolic elastance (Ees) divided by arterial elastance (Ea) (Ees/Ea) at three time points: Baseline, Ti…

  Rule: A registered primary outcome measure names overall survival. Source: ClinicalTrials.gov NCT05140525, 2026-11-11

  Published context: Non-OS primary endpoint: odds ratio 2.79 for a positive phase 3 (Otsuka 2021, 400 phase 3 oncology trials, to 2020). Shown with the next figure: a surrogate is easier to hit, and often a weak guide to survival.

  Published context: 52% of surrogate-to-OS correlations are low (Prasad 2015, published to 2014). Shown with the figure above.
• Results overdue: no · Primary completion 2026-03-26, 7 months ago; within 12 months

  Rule: Primary completion (actual) more than 12 months ago and no results posted to the registry. Source: ClinicalTrials.gov NCT05140525, 2026-11-11

• Not loaded on this app yet: Treated and evaluable counts, assessor, confirmed response, follow-up and data cutoff. Source: Readout extraction (ticket 32).
• Not loaded on this app yet: Primary endpoint changed between registry versions. Source: Registry versions in the store (ticket 32).

3. What must it beat?

• Not loaded on this app yet: Control-arm result and approved therapies for the same segment, with label links. Source: Drugs@FDA, FDA labels and readouts (tickets 30, 32).

4. Too crowded, or too late?

• Stopped on this target: 75 terminated, withdrawn or suspended trials of drugs against EDNRB; 8 give no reason. Reasons are quoted as the registry gives them on the target page. · EDNRB: what already stopped

• Not loaded on this app yet: Programs on the target by phase and months behind the leader. Source: Programs and Drugs@FDA (ticket 33).

5. Can it be approved, and stay approved?

• Single-country: yes · The only site is in United States

  Rule: All listed sites are in one country; the share of US sites is shown. Source: ClinicalTrials.gov NCT05140525, 2026-11-11
• EU paediatric investigation plan: yes · EMEA-001032-PIP01-10-M07 (macitentan, Treatment of idiopathic pulmonary fibrosis;Treatment of pulmonary arterial hypertension;Treatment of systemic sclerosis): PM: decision on the application for modification of an agreed PIP, 1 Dec 2023; compliance positive 23 Feb 2024; EMEA-001032-PIP03-19 (macitentan, Treatment of functional single ventricle heart disease with total cavo-pulmonary connection): P: decision agreeing on a investigation plan, with or without partial waiver(s) and or deferral(s), 9 Jul 2021; EMEA-000718-PIP01-09-M06 (riociguat, Treatment of pulmonary hypertension): PM: decision on the application for modification of an agreed PIP, 4 Nov 2016; compliance positive 11 Dec 2020; EMEA-001032-PIP02-17 (macitentan, Treatment of chronic thromboembolic pulmonary hypertension (CTEPH)): W: decision granting a waiver in all age groups for all conditions or indications, 9 Aug 2017; +1 more

  Rule: An EMA PIP decision (agreement, modification or waiver) lists the drug as its active substance, exact name. Source: EMA data download (dated snapshot), 2026-11-11
• EU orphan designation: yes · EU/3/09/707 withdrawn 28 Jan 2010: Treatment of idiopathic pulmonary fibrosis; EU/3/21/2428 withdrawn 20 May 2021: Treatment of functional single ventricle congenital heart disease; EU/3/21/2533 withdrawn 10 Dec 2021: Treatment of chronic thromboembolic pulmonary hypertension; EU/3/11/909 withdrawn 27 Sept 2011: Treatment of pulmonary arterial hypertension; +2 more

  Rule: An EU orphan designation lists the drug as its active substance (exact name) or belongs to a medicine that does; withdrawn and expired designations are listed with their status. Source: EMA data download (dated snapshot), 2026-11-11
• Authorised in the EU: yes · Macitentan Accord: authorised since 24 Sept 2025; Macitentan AccordPharma: authorised since 24 Sept 2025; Riociguat Accord: opinion; Opsumit: authorised since 20 Dec 2013; +2 more

  Rule: An EMA medicine record lists the drug as its active substance or INN, exact name; national-only authorisations are not in this file. Source: EMA data download (dated snapshot), 2026-11-11
• FDA orphan designation: not published · FDA's orphan designation database turns away automated requests, so this app does not read it; search it by hand at the link

  Rule: Would be: an FDA orphan designation names the drug. Source: FDA orphan designations search
• FDA pediatric oncology approval: no · FDA's table lists no pediatric approval of Macitentan, Riociguat

  Rule: FDA's Pediatric Oncology Drug Approvals table names the drug. Source: FDA Pediatric Oncology Drug Approvals (content current as of 2026-03-03), 2026-11-11
• Registered studies open to children: yes · 13 interventional studies of Macitentan, Riociguat include patients under 18; 2 are recruiting, not yet recruiting or active

  Rule: The registry's age group includes Child (birth to 17 years), which also counts studies that set no minimum age. Source: ClinicalTrials.gov search, 2026-11-11

• Caveat: Site counts are not patients per country, and trials registered only outside ClinicalTrials.gov are not covered. Where the sites are is a fact about the record, not a judgement of its quality.
• Rare pediatric disease voucher: FDA, content current as of 29 Apr 2026: “As of February 3, 2026, enactment of the Consolidated Appropriations Act, 2026, the rare pediatric disease PRV program will sunset after September 30, 2029. FDA may not award any PRVs under this program after September 30, 2029.” Voucher sale prices are not shown here; they appear only as company-reported news. · FDA: Rare Pediatric Disease Designation and Priority Review Voucher Programs

• Not loaded on this app yet: Precedent approvals for target, modality and endpoint; accelerated-approval status. Source: Drugs@FDA and FDA accelerated-approval tables (ticket 30).

6. Can the sponsor finish?

• Sponsor: Dr Sudarshan Rajagopal (academic or other) · ClinicalTrials.gov NCT05140525
• principal investigator: Sudarshan Rajagopal, MD, PhD, Duke Health System · Person page

• Not loaded on this app yet: Filed cash, quarterly spend and the runway arithmetic. Source: SEC XBRL company facts (ticket 37).
• Not loaded on this app yet: Sponsor's completed vs stopped oncology trials and results-reporting record. Source: Registry, by company (ticket 37).

What public data cannot tell you

Public records cannot show: sales forecasts; a probability of success for this asset; full deal terms and net prices; FDA designations and action dates before approval (shown only as company-reported); clinical holds unless the company disclosed them; manufacturing; patents on unapproved drugs; whether preclinical findings have been replicated.