Nintedanib in Progressive Fibrosing Interstitial Lung Diseases

Polymorphisms and haplotypes of TOLLIP and MUC5B are associated with susceptibility and survival in patients with fibrotic hypersensitivity pneumonitis

INTRODUCTION AND OBJECTIVES

Hypersensitivity pneumonitis (HP) is an interstitial lung disease with diverse clinical features that can present a fibrotic phenotype similar to idiopathic pulmonary fibrosis (IPF) in genetically predisposed individuals. While several single nucleotide polymorphisms (SNPs) have been associated with IPF, the genetic factors contributing to fibrotic HP (fHP) remain poorly understood. This study investigated the association of MUC5B and TOLLIP variants with susceptibility, clinical presentation and survival in Portuguese patients with fHP.

MATERIAL AND METHODS

A case-control study was undertaken with 97 fHP patients and 112 controls. Six SNPs residing in the MUC5B and TOLLIP genes and their haplotypes were analyzed. Associations with risk, survival, and clinical, radiographic, and pathological features of fHP were probed through comparisons among patients and controls.

RESULTS

MUC5B rs35705950 and three neighboring TOLLIP variants (rs3750920, rs111521887, and rs5743894) were associated with increased susceptibility to fHP. Minor allele frequencies were greater among fHP patients than in controls (40.7% vs 12.1%, P<0.0001; 52.6% vs 40.2%, P = 0.011; 22.7% vs 13.4%, P = 0.013; and 23.2% vs 12.9%, P = 0.006, respectively). Haplotypes formed by these variants were also linked to fHP susceptibility. Moreover, carriers of a specific haplotype (G-T-G-C) had a significant decrease in survival (adjusted hazard ratio 6.92, 95% CI 1.73-27.64, P = 0.006). Additional associations were found between TOLLIP rs111521887 and rs5743894 variants and decreased lung function at baseline, and the MUC5B SNP and radiographic features, further highlighting the influence of genetic factors in fHP.

CONCLUSION

These findings suggest that TOLLIP and MUC5B variants and haplotypes may serve as valuable tools for risk assessment and prognosis in fibrotic hypersensitivity pneumonitis, potentially contributing to its patient stratification, and offer insights into the genetic factors influencing the clinical course of the condition.

The clinical meaning of the UIP pattern in fibrotic hypersensitivity pneumonitis on cryobiopsy: A multicentre retrospective study

Fibrotic hypersensitivity pneumonitis (f-HP) is an interstitial lung disease in which various antigens in susceptible individuals may play a pathogenetic role. This study evaluates the role of transbronchial lung cryobiopsy (TBLC) and bronchoalveolar lavage (BAL) in identifying a UIP-like pattern and its association with fibrosis progression. We conducted a multicentre retrospective cohort study of patients diagnosed with f-HP who underwent BAL and TBLC between 2011 and 2023. A UIP-like pattern was defined by the presence of (A) patchy fibrosis and fibroblastic foci or (B) honeycombing ± (A). We investigated BAL's role in predicting UIP-like patterns within a clinical-radiological-serological framework, examining disease progression in these patients using spirometry and mortality data. A total of 195 patients were enrolled, 59 (30%) of whom exhibited a UIP-like pattern. These patients showed greater lung function decline, lower BAL lymphocytosis (14.4% vs. 37.4%, p < 0.001), higher nintedanib prescription (35% vs. 14%, p < 0.001), and higher 10-year mortality (HR 2.8, 95% CI 1.3-5.8, p = 0.004). f-HP patients with a UIP-like pattern exhibit worse clinical outcomes and higher mortality. In cases of low BAL lymphocytosis with a high pre-test clinical suspicion of f-HP, lung biopsy may not be necessary as it increases the likelihood of identifying a UIP-like pattern.

Progressive Pulmonary Fibrosis: Current Status in Terminology and Future Directions

The latest clinical practice guidelines for idiopathic pulmonary fibrosis (IPF) and progressive pulmonary fibrosis (PPF) were jointly published by the American Thoracic Society (ATS), European Respiratory Society (ERS), Japanese Respiratory Society (JRS), and Asociacion Latinoamericana de Thorax (ALAT) in 2022, and a new term-"PPF"-has been proposed to describe patients with non-IPF fibrosing interstitial lung diseases (ILDs), with defined criteria. However, the proposal of this new term has caused confusion amongst experts at a time when use of the term "progressive fibrosing interstitial lung disease" (PF-ILD), proposed in the phase 3 INBUILD trial of nintedanib, has become widely adopted by pulmonologists and rheumatologists in clinical practice. In this commentary, we discuss the background and concepts underpinning the terms PPF and PF-ILD and seek to provide pulmonologists and rheumatologists with a deeper understanding of the concept of PPF.

Antifibrotic agents in progressive pulmonary fibrosis and non-progressive pulmonary fibrosis of fibrotic hypersensitivity pneumonitis

BACKGROUND

In patients with fibrotic hypersensitivity pneumonitis (HP), the effect of antifibrotic agents in those with progressive pulmonary fibrosis (PPF) and non-PPF remain unclear. This study aims to evaluate the effects of antifibrotic agents in patients with fibrotic HP by comparing outcomes between the PPF and non-PPF groups.

METHODS

This single-center retrospective study included patients diagnosed with pathologically confirmed fibrotic HP who received antifibrotic agents. Patients were classified as PPF or non-PPF based on disease progression in the year before antifibrotic treatment.

RESULTS

In this study, 63 were classified as PPF and 33 as non-PPF. Overall survival differed significantly between the groups (hazard ratio [HR] = 3.28, 95 % confidence interval [CI]: 1.48-7.28, p = 0.002). The incidence of acute exacerbation was also higher in the PPF group (HR = 2.45, 95 % CI: 1.05-5.75, p = 0.033). In the PPF group, the annual forced vital capacity (FVC) decline improved from -11.5 % before treatment to -4.2 % in the first year after treatment (p < 0.001). In the non-PPF group, the annual FVC change before and after treatment was not significantly different (1.6 % vs. -1.7 %, p = 0.065). Serum Krebs von den Lungen-6 (KL-6) levels decreased in the PPF group after 12 months of treatment (24.9 % vs. -2.7 %, p = 0.002), while no significant change was observed in the non-PPF group (8.6 % vs. 4.3 %, p = 0.800).

CONCLUSIONS

In fibrotic HP, antifibrotic agents seemed to contribute to a reduction in FVC decline and lower KL-6 levels in patients with PPF.

Risk factors and prognostic indicators for progressive fibrosing interstitial lung disease: a deep learning-based CT quantification approach

OBJECTIVES

To investigate the value of deep learning-based quantitative CT (QCT) in predicting progressive fibrosing interstitial lung disease (PF-ILD) and assessing prognosis.

MATERIALS AND METHODS

This single-center retrospective study included ILD patients with CT examinations between January 2015 and June 2021. Each ILD finding (ground-glass opacity (GGO), reticular opacity (RO), honeycombing) and fibrosis (sum of RO and honeycombing) was quantified from baseline and follow-up CTs. Logistic regression was performed to identify predictors of PF-ILD, defined as radiologic progression along with forced vital capacity (FVC) decline ≥ 5% predicted. Cox proportional hazard regression was used to assess mortality. The added value of incorporating QCT into FVC was evaluated using C-index.

RESULTS

Among 465 ILD patients (median age [IQR], 65 [58-71] years; 238 men), 148 had PF-ILD. After adjusting for clinico-radiological variables, baseline RO (OR: 1.096, 95% CI: 1.042, 1.152, p < 0.001) and fibrosis extent (OR: 1.035, 95% CI: 1.004, 1.067, p = 0.025) were PF-ILD predictors. Baseline RO (HR: 1.063, 95% CI: 1.013, 1.115, p = 0.013), honeycombing (HR: 1.074, 95% CI: 1.034, 1.116, p < 0.001), and fibrosis extent (HR: 1.067, 95% CI: 1.043, 1.093, p < 0.001) predicted poor prognosis. The Cox models combining baseline percent predicted FVC with QCT (each ILD finding, C-index: 0.714, 95% CI: 0.660, 0.764; fibrosis, C-index: 0.703, 95% CI: 0.649, 0.752; both p-values < 0.001) outperformed the model without QCT (C-index: 0.545, 95% CI: 0.500, 0.599).

CONCLUSION

Deep learning-based QCT for ILD findings is useful for predicting PF-ILD and its prognosis.

KEY POINTS

Question Does deep learning-based CT quantification of interstitial lung disease (ILD) findings have value in predicting progressive fibrosing ILD (PF-ILD) and improving prognostication? Findings Deep learning-based CT quantification of baseline reticular opacity and fibrosis predicted the development of PF-ILD. In addition, CT quantification demonstrated value in predicting all-cause mortality. Clinical relevance Deep learning-based CT quantification of ILD findings is useful for predicting PF-ILD and its prognosis. Identifying patients at high risk of PF-ILD through CT quantification enables closer monitoring and earlier treatment initiation, which may lead to improved clinical outcomes.

Mechanisms on How Matricellular Microenvironments Sustain Idiopathic Pulmonary Fibrosis

In a susceptible individual, persistent, low-level injury to the airway epithelium initiates an exaggerated wound repair response, ultimately leading to idiopathic pulmonary fibrosis (IPF). The mechanisms driving this fibroproliferative response are not fully understood. Here, we review recent spatially resolved transcriptomics and proteomics studies that provide insight into two distinct matricellular microenvironments important in this pathological fibroproliferation. First, in response to alveolar epithelial injury, alveolar differentiation intermediate (ADI) basal cells arising from Secretoglobin (Scgb1a1) progenitors re-populate the injured alveolus remodeling the extracellular matrix (ECM). ADI cells exhibit an interconnected cellular stress response involving the unfolded protein response (UPR), epithelial-mesenchymal transition (EMT) and senescence pathways. These pathways reprogram cellular metabolism to support fibrillogenic ECM remodeling. In turn, the remodeled ECM tonically stimulates EMT in the ADI population, perpetuating the transitional cell state. Second, fibroblastic foci (FF) are a distinct microenvironment composed of activated aberrant "basaloid" cells supporting transition of adjacent mesenchyme into hyaluronan synthase (HAShi)-expressing fibroblasts and myofibroblasts. Once formed, FF are the major matrix-producing factories that invade and disrupt the alveolar airspace, forming a mature scar. In both microenvironments, the composition and characteristics of the ECM drive persistence of atypical epithelium sustaining matrix production. New approaches to monitor cellular trans-differentiation and matrix characteristics using positron emission tomography (PET)-magnetic resonance imaging (MRI) and optical imaging are described, which hold the potential to monitor the effects of therapeutic interventions to modify the ECM. Greater understanding of the bidirectional interrelationships between matrix and cellular phenotypes will identify new therapeutics and diagnostics to affect the outcomes of this lethal disease.

Cough burden and quality of life in patients with progressive pulmonary fibrosis: A multicenter observational study

BACKGROUND

Cough is a prevalent symptom in patients with interstitial lung disease (ILD), often significantly impacting quality of life (QoL). However, there is limited data on cough's burden and its effects on QoL in patients with progressive pulmonary fibrosis (PPF).

AIM

This study aimed to evaluate the impact of cough burden on QoL among a cohort of patients with PPF.

PATIENTS AND METHOD

This multicenter, cross-sectional cohort study focused on PPF. Cough severity and its impact on QoL were assessed using the Visual Analogue Scale (VAS) and Leicester Cough Questionnaire (LCQ) scores.

RESULTS

Of the 248 patients included, 136 (54.8 %) had PPF due to rheumatic diseases, and 193 (77.8 %) reported experiencing cough. Patients with fibrotic nonspecific interstitial pneumonia had the highest cough frequency (p = 0.019). Correlations between cough measures and other variables were generally weak. The mean total LCQ score was 16.1 ± 4.7, with correlations between age and LCQ sub-scores. LCQ total scores positively correlated with FVC (%) (r = 0.202, p = 0.002), DLCO (%) (r = 0.255, p < 0.001), and 6MWT distance (r = 0.277, p = 0.001). VAS scores showed a negative correlation with DLCO, FVC (%), FVC (L), and 6MWT distance. No factor was significantly associated with cough presence in logistic regression, but longer antifibrotic treatment duration and higher LCQ scores were linked to lower VAS scores in linear regression.

CONCLUSION

Cough is highly prevalent in PPF patients and significantly impacts health-related QoL, underscoring the need for targeted management of this symptom in PPF.

Perioperative nintedanib for lung resection in patients with idiopathic pulmonary fibrosis

Although nintedanib, an anti-fibrotic drug, relieves the chronological worsening of pulmonary function and prevents acute exacerbations of interstitial pneumonia, the perioperative safety and efficacy of nintedanib remains to be elucidated. The present study aimed to examine the safety and efficacy of nintedanib in patients with interstitial pneumonia. This study included 12 patients who underwent lung resection, including bilobectomy (n=2), lobectomy (n=7), segmentectomy (n=2) and wedge resection (n=1) between January 2020 and August 2023 at Juntendo University Nerima Hospital (Tokyo, Japan). Nintedanib was administered preoperatively to 10 male and two female patients with idiopathic pulmonary fibrosis and stage I to III lung cancer. The nintedanib dosing period ranged from 14 to 43 days. None of the patients canceled or postponed surgery because of side effects of nintedanib. Although prolonged air leak (n=3), surgical site infection (n=2), pyothorax (n=1), heart failure (n=1) and pleurisy (n=1) were observed postoperatively, the 30-day mortality rate was 0, with no acute exacerbation of interstitial pneumonia. These results encourage further investigation into the potential of nintedanib treatment in a larger patient cohort through prospective verification.

Transcriptomics of interstitial lung disease: a systematic review and meta-analysis

OBJECTIVE

Gene expression (transcriptomics) studies have revealed potential mechanisms of interstitial lung disease, yet sample sizes of studies are often limited and between-subtype comparisons are scarce. The aim of this study was to identify and validate consensus transcriptomic signatures of interstitial lung disease subtypes.

METHODS

We performed a systematic review and meta-analysis of fibrotic interstitial lung disease transcriptomics studies using an individual participant data approach. We included studies examining bulk transcriptomics of human adult interstitial lung disease samples and excluded those focusing on individual cell populations. Patient-level data and expression matrices were extracted from 43 studies and integrated using a multivariable integrative algorithm to develop interstitial lung disease classification models.

RESULTS

Using 1459 samples from 24 studies, we identified transcriptomic signatures for idiopathic pulmonary fibrosis, hypersensitivity pneumonitis, idiopathic nonspecific interstitial pneumonia and systemic sclerosis-associated interstitial lung disease against control samples, which were validated on 308 samples from eight studies (idiopathic pulmonary fibrosis area under receiver operating curve (AUC) 0.99, 95% CI 0.99-1.00; hypersensitivity pneumonitis AUC 0.91, 95% CI 0.84-0.99; nonspecific interstitial pneumonia AUC 0.94, 95% CI 0.88-0.99; systemic sclerosis-associated interstitial lung disease AUC 0.98, 95% CI 0.93-1.00). Significantly, meta-analysis allowed us to identify, for the first time, robust lung transcriptomics signatures to discriminate idiopathic pulmonary fibrosis (AUC 0.71, 95% CI 0.63-0.79) and hypersensitivity pneumonitis (AUC 0.76, 95% CI 0.63-0.89) from other fibrotic interstitial lung disease, and unsupervised learning algorithms identified putative molecular endotypes of interstitial lung disease associated with decreased forced vital capacity and diffusing capacity of the lungs for carbon monoxide % predicted. Transcriptomics signatures were reflective of both cell-specific and disease-specific changes in gene expression.

CONCLUSION

We present the first systematic review and largest meta-analysis of fibrotic interstitial lung disease transcriptomics to date, identifying reproducible transcriptomic signatures with clinical relevance.

External validation of the 2017 EULAR/ACR classification criteria for idiopathic inflammatory myopathies in anti-MDA5 antibody-positive interstitial lung disease patients: A multicenter retrospective cohort study in China

The aim of this study was to assess the 2017 EULAR/ACR classification criteria performance for determining idiopathic inflammatory myopathies (IIMs) in a cohort of patients with anti-MDA5 antibody-positive IIM-related interstitial lung disease (anti-MDA5+IIM-ILD). The outcomes of patients, who did not meet the EULAR/ACR criteria, and who had interstitial pneumonia and exhibited an autoimmune phenotype associated with anti-MDA5 positivity were also investigated.

METHODS

This retrospective study recruited adult patients from four hospitals in China who were diagnosed with anti-MDA5 antibody-positive IIM-related interstitial lung disease. Data on disease manifestations, laboratory findings, and imaging findings were collected through electronic medical records. The performance and consistency of the 2017 EULAR/ACR classification criteria were compared with those of the Bohan/Peter criteria combined with Sontheimer's CADM criteria. Additionally, this study evaluated the performance of incorporating anti-MDA5 antibodies into the EULAR/ACR criteria and explored the criteria proposed by Casal-Domingez based on myositis-specific antibodies (MSAs). Finally, clinical characteristics and prognoses were compared between patients with MDA5+IIM-ILD who met the EULAR/ACR criteria and those who did not meet the EULAR/ACR criteria.

RESULTS

A total of 250 patients with anti-MDA5-related IIM-ILD, including those with dermatomyositis (DM, 23.6 %) and clinically amyopathic dermatomyositis (CADM, 76.4 %), were recruited. Of these, 175 (70 %) and 64 (25.7 %) patients met the EULAR/ACR and Bohan/Peter criteria, respectively. According to Sontheimer's CADM criteria, 60.4 % of patients could be classified according to the Bohan and Peter criteria. Thirty percent of the anti-MDA5 antibody-positive patients did not meet the EULAR/ACR criteria but met the IPAF criteria. The sensitivity of the EULAR/ACR criteria increased to 99.2 % when anti-JO-1 antibodies were replaced with anti-MDA5 antibodies. In this cohort, a sensitivity of 100 % was obtained using the Casal-Domingez criteria. There were no significant differences in clinical characteristics or prognoses between MDA5+IIM-ILD patients who met the EULAR/ACR criteria, those who did not meet the criteria, and those who met the IPAF criteria.

CONCLUSION

Approximately 30 % of clinically diagnosed anti-MDA5 antibody-positive IIM-ILD patients cannot be classified according to the EULAR/ACR criteria, suggesting that such patients should be managed as IIM-ILD patients. Modifying the existing criteria by including other MSAs, such as anti-MDA5 antibodies, as one of the scoring criteria is recommended. Future IIM guidelines should consider incorporating ILD into the diagnostic criteria.

[Antifibrotic therapies: Where do we stand 10years later?]

INTRODUCTION

Fibrosing interstitial lung diseases (ILD) are severe respiratory conditions that can lead to respiratory failure and death. Over the past decade, antifibrotic therapies have represented a significant therapeutic advancement and are now widely used.

STATE OF THE ART

Pirfenidone and nintedanib have been approved for the treatment of idiopathic pulmonary fibrosis (IPF), while only nintedanib has been approved for systemic sclerosis-related ILD and progressive pulmonary fibrosis (PPF). Both drugs help to reduce the decline in forced vital capacity (FVC) characterizing these three indications and to decrease mortality, acute exacerbations, and quality of life impairment in patients with IPF and PPF.

PERSPECTIVES

Tolerance to these treatments remains a major challenge, prompting evaluation of alternative administration routes, such as inhalation. Numerous ongoing clinical trials and encouraging results from phase 3 studies are expected to lead to the approval of new antifibrotic molecules.

CONCLUSIONS

Antifibrotic therapies have proven to be crucial in the management of IPF and PPF. Prescription should be a shared decision with the patient and may be considered at an early stage, even in elderly individuals, provided that dedicated support is avaialble.

Efficacy, safety, and tolerability of antifibrotic agents in rheumatoid arthritis-associated interstitial lung disease: A systematic review and meta-analysis

OBJECTIVE

To evaluate the efficacy, safety, and tolerability of antifibrotic agents, nintedanib and pirfenidone, in the treatment of rheumatoid arthritis-associated interstitial lung disease (RA-ILD).

METHODS

A systematic literature review was conducted following PRISMA and MOOSE guidelines. Studies assessing nintedanib or pirfenidone in RA-ILD were included. A meta-analysis was performed using a random-effects model.

RESULTS

Six studies (2 randomized controlled trials and 4 observational) involving 270 RA-ILD patients met the inclusion criteria. In total, 148 received nintedanib and 122 received pirfenidone. Nearly 70 % had a usual interstitial pneumonia pattern. The pooled analysis revealed a mean FVC decline of -68.97 mL/year (95 % CI: -104.85 to -32.49; p < 0.001) and a mean difference of 1.15 % (p = 0.33; after excluding influential studies: -0.28, p = 0.54). Their impact on %pDLCO has been less extensively evaluated, with a mean difference of -1.76 % (p = 0.36; after excluding influential studies: effect size -3.78, p < 0.001). The changes in pulmonary function tests were comparable between nintedanib and pirfenidone. Mortality rates ranged from 15 % to 35 %, with respiratory-specific mortality reported at 44 % to 100 %. Lung transplantation rates were 4-5 %. Antifibrotic therapy was associated with a pooled adverse event (AE) rate of 73 % (95 % CI: 0.38-0.97; p < 0.001), with gastrointestinal symptoms and hepatotoxicity being the most frequently reported. Treatment discontinuation due to AEs occurred in nearly 24 % of patients (95 % CI: 0.16-0.40; p < 0.001).

CONCLUSION

Antifibrotic agents demonstrated stabilization of %pFVC, with less robust evidence for %pDLCO in RA-ILD. Nearly one quarter of patients discontinued therapy due to AEs.

Effect and mechanism of Nintedanib on acute and chronic radiation-induced lung injury in mice

OBJECTIVE

To investigate the efficacy of Nintedanib in treating acute and chronic radiation-induced lung injury and its mechanism of action.

METHODS

A radiation-induced lung injury model was established in mice using 6MV X-rays at 18Gy to irradiate the lungs. The mice were randomly divided into four groups: control group, radiation therapy group, low-dosage Nintedanib + radiation therapy group, and high dosage Nintedanib + radiation therapy group. The mice were euthanized on day 14 and 3 months post-radiation to observe changes in acute and chronic inflammation and the expression of related proteins.

RESULTS

Compared to the radiation therapy group, the low and high-dosage Nintedanib groups showed varying degrees of improvement in mental state, responsiveness, food and water intake, and fur condition. During the acute inflammatory phase, HE staining revealed inflammatory changes in the lung tissues of both Nintedanib groups, but the pathology was less severe than in the radiation group, with the high-dosage group showing more significant reduction. Serum levels of IL-6, TNF-α and TGF-β1 were significantly reduced (P < 0.05), suggesting that Nintedanib can decrease the expression of serum inflammatory factors. The percentage of Smad2-positive area in the low and high-dosage Nintedanib groups was (7.395 ± 0.90)% and (5.577 ± 1.56)%, respectively, both significantly lower than the radiation group (P < 0.05). At 3 months post-radiation, Masson's trichrome staining showed that the Ashcroft score in the Nintedanib groups was significantly lower than in the radiation group (P < 0.05). There were statistically significant differences between the low and high-dosage groups in the percentage of Smad2 and αSMA-positive areas and the levels of serum TGF-β1 (all P < 0.05), and both were significantly lower compared to the radiation group (P < 0.05).

CONCLUSION

(1) Nintedanib can improve the general condition of mice with acute and chronic radiation-induced lung injury and reduce pathological damage to lung tissue. (2) Nintedanib may exert a protective effect on mice with acute and chronic radiation-induced lung injury by downregulating the TGF-β1/Smad2 signaling pathway, thereby inhibiting inflammatory and fibrotic responses.

Patient characteristics and pharmacologic treatment patterns in antifibrotic-treated patients with fibrosing interstitial lung diseases: real-world results from a claims database

BACKGROUND

Antifibrotics have been approved for use in many countries, including Japan, based on the results of several phase III clinical trials in patients with IPF, SSc-ILD, and PPF, which showed slower lung function decline with antifibrotic treatment. There is a paucity of information on the real-world use of antifibrotics in clinical practice.

METHODS

Baseline characteristics, comorbidities, and drugs used prior to and concomitant with antifibrotics were collected for patients with IPF, SSc-ILD, and PPF using a health insurance claims database in Japan from 1 January 2013 to 30 June 2023. Descriptive statistics were generated for all study variables.

RESULTS

This study included 657 nintedanib users with IPF; 418 pirfenidone users with IPF; 4160 nintedanib users with PPF; 18,403 users of glucocorticoids/immunosuppressants for ILD treatment with PPF; 676 nintedanib users with SSc-ILD; and 698 users of glucocorticoids/immunosuppressants for ILD treatment with SSc-ILD. At index, pirfenidone users with IPF were the oldest (mean [SD] 74.8 [7.3] years), and nintedanib users with SSc-ILD were the youngest (mean [SD] 65.6 [11.7] years). In nintedanib users with IPF, 76.7% were prescribed nintedanib as monotherapy, and 75.6% of pirfenidone users were prescribed pirfenidone, as monotherapy. In patients with IPF, 75.2% were prescribed nintedanib, and 76.1% were prescribed pirfenidone, as first-line therapy. In patients with SSc-ILD, 34.9% were prescribed nintedanib as monotherapy for ILD treatment, and 38.6% as first-line therapy. Approximately half of patients with PPF were prescribed nintedanib concomitantly with other glucocorticoids/immunosuppressant drugs, and after one or more glucocorticoids/immunosuppressant drugs. The most common concomitant drug in all patient groups was glucocorticoids. In patients with IPF, 18.6% of nintedanib users and 18.2% of pirfenidone users were prescribed glucocorticoids concomitantly. Concomitant glucocorticoid use was 52.7% for nintedanib users with SSc-ILD, and 44.1% for nintedanib users with PPF.

CONCLUSIONS

These results provide real-world evidence of antifibrotic use in clinical practice. Most patients with IPF were prescribed antifibrotics as monotherapy for ILD treatment whereas antifibrotics were used concomitantly with glucocorticoids/immunosuppressants in many patients with SSc-ILD and PPF. While most patients with IPF were prescribed antifibrotics as first-line therapy, patients with SSc-ILD and PPF were more likely to be prescribed nintedanib as second-line or later-line treatment after glucocorticoids/immunosuppressants.

Huaxian formula alleviates nickel oxide nanoparticle-induced pulmonary fibrosis via PI3K/AKT signaling

As a progressive fibrotic lung disorder with high mortality, pulmonary fibrosis (PF) suffers from inadequate treatment options. While the traditional Chinese medicine (TCM) formulation Huaxian Formula (HXF) demonstrates multi-target therapeutic potential against PF, the identity of its active components and their mechanistic basis of action require systematic investigation. To elucidate the therapeutic effects and pharmacological mechanisms of HXF in treating PF induced by nickel oxide nanoparticles (nano NiO), utilizing network pharmacology (NP), molecular docking, as well as in vivo and in vitro experiments. A comprehensive analysis of authoritative databases identified 121 active compounds, 202 potential therapeutic targets, and 1664 PF-related genes. Among these, 105 overlapping targets were found between HXF and PF. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses identified the PI3K/AKT signaling pathway as both a pivotal mechanism in PF pathogenesis and a primary target of HXF's therapeutic effects. Molecular docking studies revealed that the six core compounds (quercetin, luteolin, kaempferol, β-sitosterol, isorhamnetin, and formononetin) of HXF exhibited strong binding affinity to proteins involved in the PI3K/AKT pathway. In the rat and A549 cell model, HXF treatment reduced collagen deposition and downregulated the expression of type I collagen (Col-I). Mechanistically, HXF inhibited the phosphorylation of PI3K and AKT. Collectively, these findings suggested that HXF alleviated PF by modulating the PI3K/AKT signaling pathway, providing valuable insights and methods for the development of TCM for PF.

Dynamic perfusion area-detector CT in non-small cell lung cancer with progressive fibrosing interstitial lung disease

OBJECTIVES

To determine the capability of dynamic contrast-enhanced (CE-) perfusion area-detector CT (ADCT) for detecting pathological structural changes in stage I non-small cell lung cancer (NSCLC) patients.

MATERIALS AND METHODS

Sixty-three consecutive stage I NSCLC patients with progressive fibrosing interstitial lung disease (PF-ILD) underwent dynamic CE-perfusion ADCT analyzed by dual-input maximum slope (DMS) methods for total, pulmonary arterial and systemic arterial perfusion (TPDMS, PAPDMS and SAPDMS) maps, surgical treatment and pathological examination. Multicentric ROIs were then placed over sites assessed as normal lung, pulmonary emphysema, GGO or reticular pattern without traction bronchiectasis, reticular pattern with traction bronchiectasis and honeycombing in the resected lung. Next, an analysis of variance (ANOVA) followed by Tukey's honest significant difference (HSD) multiple comparison test was performed for a comparison of each of the perfusion parameters for five groups. Finally, discrimination accuracy for evaluation of lung parenchymal change was compared for all indexes and combined methods.

RESULTS

PAPDMSs of abnormal lungs were significantly lower than that of normal lungs (p < 0.0001). SAPDMSs of normal or emphysematous lungs were significantly lower than those of others (p < 0.0001). SAPDMS of GGO or reticular pattern without traction bronchiectasis was significantly lower than that for reticular pattern with traction bronchiectasis and honeycombing (p < 0.0001). Discrimination accuracy of combined perfusion index was significantly higher than that of each index (p < 0.0001).

CONCLUSION

Dynamic CE-perfusion ADCT is useful for detecting pathological structural changes in stage I NSCLC patients with PF-ILD.

KEY POINTS

Question Can dynamic first-pass contrast-enhanced perfusion matrices evaluate parenchymal lung changes and disease severity of parenchymal diseases in stage I non-small cell lung cancer (NSCLC) patients? Findings Perfusion indexes differentiated significantly among normal lung, emphysema, GGO or reticular pattern without traction bronchiectasis, reticular pattern with traction bronchiectasis and honeycombing and significantly improved discrimination accuracy by combined methods. Clinical relevance Dynamic first-pass contrast-enhanced perfusion area-detector CT has the potential to assess underlying pathologies and pulmonary functional changes in stage I non-small cell carcinoma patients with progressive fibrosing interstitial lung disease.

Spatial multiomics decipher fibroblast-macrophage dynamics in systemic sclerosis

OBJECTIVES

Stromal-immune crosstalk shapes the pathogenic microenvironment of systemic sclerosis (SSc), but the spatial regulatory networks underlying fibrogenesis remain poorly defined. We aimed to explore tissue organisation and cell coordination in SSc skin, providing spatiotemporal insights into disease mechanisms and bridging the gap between omics discovery and precision medicine.

METHODS

We performed spatial transcriptomics on skin biopsies from 10 patients with diffuse cutaneous SSc and 4 healthy controls using the 10× Visium platform. These findings were confirmed using higher-resolution Stereo-seq transcriptomics, spatial proteomics, and single-cell RNA sequencing data from patients with SSc, SSc mouse models, and wound-healing reindeer models. In vivo and in vitro studies were conducted to validate the key regulatory pathways.

RESULTS

Fourteen skin biopsies were analysed, revealing significant expansion of fibrotic niches enriched with fibroblasts and macrophages in SSc, correlating with clinical severity. We revealed disease-specific cell states of fibroblasts and macrophages and evaluated their spatial dependency and cell-cell communication. Stratification based on signature genes enabled the identification of patients with SSc with progressive disease and treatment-nonresponsive phenotype. ACKR3 (a CXCL12 decoy receptor) was selectively expressed in myofibroblast progenitors, which diminished during differentiation towards mature myofibroblast, potentially serving to regulate CXCL12/CXCR4-mediated proinflammatory macrophage recruitment. Inhibition of CXCR4 attenuated skin and lung fibrosis in experimental fibrosis mouse models.

CONCLUSIONS

Our spatially resolved atlas uncovered dynamic fibroblast-macrophage interplay as a hallmark of fibrotic niche expansion. These findings offer spatiotemporal insights into disease mechanisms and pave the way for advanced mechanistic and therapeutic studies, bridging the gap between omics discovery and precision medicine.

Nerandomilast in Patients with Progressive Pulmonary Fibrosis

BACKGROUND

Nerandomilast (BI 1015550) is an orally administered preferential inhibitor of phosphodiesterase 4B with antifibrotic and immunomodulatory properties. Nerandomilast has been shown to slow the progression of idiopathic pulmonary fibrosis, but an assessment of its effects in other types of progressive pulmonary fibrosis is needed.

METHODS

In a phase 3, double-blind trial, we randomly assigned patients with progressive pulmonary fibrosis in a 1:1:1 ratio to receive nerandomilast at a dose of 18 mg twice daily, nerandomilast at a dose of 9 mg twice daily, or placebo, with stratification according to background therapy (nintedanib vs. none) and fibrotic pattern on high-resolution computed tomography (usual interstitial pneumonia-like pattern vs. other patterns). The primary end point was the absolute change from baseline in the forced vital capacity (FVC), measured in milliliters, at week 52.

RESULTS

A total of 1176 patients received at least one dose of nerandomilast or placebo, of whom 43.5% were taking background nintedanib therapy at baseline. The adjusted mean change in the FVC at week 52 was -98.6 ml (95% confidence interval [CI], -123.7 to -73.4) in the nerandomilast 18-mg group, -84.6 ml (95% CI, -109.6 to -59.7) in the nerandomilast 9-mg group, and -165.8 ml (95% CI, -190.5 to -141.0) in the placebo group. The adjusted difference between the nerandomilast 18-mg group and the placebo group was 67.2 ml (95% CI, 31.9 to 102.5; P<0.001), and the adjusted difference between the nerandomilast 9-mg group and the placebo group was 81.1 ml (95% CI, 46.0 to 116.3; P<0.001). The most frequent adverse event was diarrhea, reported in 36.6% of the patients in the nerandomilast 18-mg group, 29.5% of those in the nerandomilast 9-mg group, and 24.7% of those in the placebo group. Serious adverse events occurred in similar percentages of patients in the trial groups.

CONCLUSIONS

In patients with progressive pulmonary fibrosis, treatment with nerandomilast led to a smaller decline in the FVC than placebo over a period of 52 weeks. (Funded by Boehringer Ingelheim; FIBRONEER-ILD ClinicalTrials.gov number, NCT05321082.).

Comparing the efficacy of exertional oxygen delivery by continuous versus demand-based flow systems during 6-minute walk test in patients with fibrotic interstitial lung disease and COPD in a hospital setting (OXYCODE): a protocol for a randomised trial

INTRODUCTION

Fibrotic interstitial lung diseases (F-ILD) are severe and often progressive lung disorders that frequently lead to respiratory failure, with patients experiencing high symptom burdens, including severe dyspnoea. This is also evident in patients with severe chronic obstructive pulmonary disease (COPD). Many patients will eventually require ambulatory oxygen therapy (AOT) due to exertional desaturation. Although AOT has shown benefits like increased walking distance and improved quality of life, adherence remains a challenge due to practical issues. AOT can be given by oxygen bottles that provide continuous oxygen flow or as portable concentrators; however, there is a lack of studies comparing the different methods and assessing patient preferences. Data from the present study help guide the selection of patients for different AOTs and provide information on patient preferences.

METHODS AND ANALYSIS

The study design is a single-centre, randomised, open-label cross-over exploratory comparative study to investigate the efficacy of two different oxygen delivery systems. Patients with COPD or F-ILD who, during a 6-minute walk test (6MWT), can walk at least 50 m and desaturate below 88% are eligible for inclusion in the study. The participants are randomised to perform the 6MWT with either oxygen bottles or portable concentrators first. The primary endpoint is the difference in the lowest oxygen saturation (SpO2) between the two systems. Secondary endpoints include, among others, the difference in percentage of time and number of minutes when SpO2 falls below 88%, mean and maximum pulse rate, and distance and time taken to recover during the 6MWT. Quality of life and patient preferences will be evaluated by scores from the COPD assessment test and the King's Brief Interstitial Lung Disease health status questionnaire to help gain a better understanding of symptom impact during activity and limitations in daily life.

ETHICS AND DISSEMINATION

The study has been approved by the Central Denmark Region Committees on Health Research Ethics (1-10-72-115-24). The results of this trial will be submitted for publication in an international peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT06767904.

Sarcoidosis: Key disease aspects and update on management

Sarcoidosis is a complex disease of unknown origin, primarily affecting the lungs but capable of involving almost any organ. Diagnosis is challenging due to the lack of specific markers and requires assessment of clinical features, careful imaging, exclusion of other conditions and, ideally, a tissue biopsy demonstrating non-necrotising granulomas. Over 90% of patients have pulmonary involvement, presenting with symptoms like dry cough and breathlessness, along with systemic signs such as fever and weight loss. Extrapulmonary manifestations occur in about 30% of cases and can affect any organ, including the heart, nervous system and eyes. Management involves a multidisciplinary approach with some patients requiring immunosuppressive and antifibrotic therapies. Despite generally good outcomes, sarcoidosis can lead to significant morbidity and mortality, particularly from pulmonary and cardiac complications. Emerging treatments like infliximab and nintedanib offer hope for refractory cases, although they carry risks of serious infections and other side effects.

Yi-Fei-Tong-Bi Decoction Alleviates Bleomycin Induced Pulmonary Fibrosis in Mice

Background

Fei-Bi decoction, a Chinese ancient experience decoction collected in the book of Bianzhenglu (Syndrome Differentiation Record). Based on Fei-Bi Decoction, Yi-Fei-Tong-Bi decoction (YFTBD) is developed and has a significant effect in the treatment of pulmonary fibrosis. However, the underlying mechanisms of YFTBD affects pulmonary fibrosis remain to be elucidated.

Purpose

To investigate the protective effect and the underlying mechanism of YFTBD on bleomycin-induced pulmonary fibrosis in mice.

Methods

The chemical components of water extract of YFTBD were analyzed by combining the high performance liquid chromatography (HPLC) coupled with mass spectrometry (MS). A mouse model was established by intratracheal injection of bleomycin, and the effects of YFTBD were evaluated through pathological staining, immunohistochemistry analyses, and Enzyme-Linked Immunosorbent Assay (ELISA). Subsequently, the effect of YFTBD on the gut microbiota of mice was analyzed by 16S rRNA high-throughput gene sequencing.

Results

Compared with the model group, the survival rate and lung coefficient of mice with pulmonary fibrosis were increased after the intervention of YFTBD, the pathological morphology of lung tissue was improved, and the expression of the inflammatory factor levels were decreased. The expression of α-SMA, TGF-β1, p21, and p16 senescence-related proteins was significantly down-regulated. The expression of Smad7 and PGC-1α senescence-related proteins was significantly up-regulated. Meanwhile, gut microbiota analysis showed that YFTBD could induce changes in the abundance of Alloprevotella, unclassified Muribaculaceae, and Lachnospiraceae NK4A136 group.

Conclusion

Our findings suggest that YFTBD could alleviate the bleomycin-induced pulmonary fibrosis in mice via regulating TGF-β1/Smad signaling pathway, inflammation and gut microbiota. It provides experimental evidence and a theoretical basis for the application of YFTBD in pulmonary fibrosis.

Predicting the risk of subsequent progression in patients with systemic sclerosis-associated interstitial lung disease with progression: a multicentre observational cohort study

BACKGROUND

In patients with systemic sclerosis, it is common practice to treat interstitial lung disease (ILD) in patients in whom progression has already occurred. We sought to clarify whether observed progression of systemic sclerosis-associated ILD confers risk for subsequent progression.

METHODS

In this multicentre observational cohort study, based on an analysis of prospectively collected data, we included patients with systemic sclerosis-associated ILD aged 18 years or older at diagnosis, who fulfilled the 2013 American College of Rheumatology-European Association of Alliances in Rheumatology systemic sclerosis classification criteria. The main cohort (diagnosed between January 2001 and December 2019) was consecutively followed up annually over 4 years at the Department of Rheumatology at the Oslo University Hospital, Norway, and the Department of Rheumatology at the University Hospital Zurich, Switzerland. We applied four definitions of ILD progression: the primary definition was forced vital capacity (FVC) decline of 5% or more, and secondary definitions included FVC decline of 10% or more, progressive pulmonary fibrosis (PPF), and progressive fibrosing ILD (PF-ILD). We applied these definitions at each annual visit after the first (visit 1). We validated our findings in an enriched cohort that included patients from the main cohort with systemic sclerosis-associated ILD and short disease duration of less than 3 years along with patients diagnosed between January 2003 and September 2019 from the Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA. Multivariable logistic regression analyses were applied to predict ILD progression and its effect on mortality. There was no involvement of people with lived experience in this study.

FINDINGS

Of 231 patients with systemic sclerosis-associated ILD from the main cohort (mean age 48·0 years [SD 14·6], 176 [76%] female and 55 [24%] male), 71 (31%) had ILD progression as defined by an FVC decline of 5% or more between visit 1 and visit 2, 38 (16%) as defined by an FVC decline of 10% or more, 39 (17%) as defined by PPF, and 89 (39%) defined by PF-ILD. In multivariable logistic regression analyses, adjusted for risk factors for progressive systemic sclerosis-associated ILD and immunosuppressive treatment, we found that ILD progression, defined by FVC decline of 5% or more, from visit 1 to visit 2 reduced the risk for further progression from visit 2 to visit 3 (odds ratio [OR] 0·28 [95% CI 0·12-0·63]; p=0·002) and that there was no risk for subsequent progression using the other definitions (FVC decline of ≥10%: 0·57 [0·16-1·99; p=0·38]; PPF: 0·93 [0·39-2·22; p=0·88]; and PF-ILD: 0·69 [0·35-1·36]; p=0·28]). Using the primary definition of progression, we found the same results in the enriched systemic sclerosis-associated ILD cohort, wherein 41 (34%) of 121 patients had progression defined by an FVC decline of 5% or more (OR 0·22 [95% CI 0·06-0·87]; p=0·031). FVC decline of 5% or more was significantly associated with mortality (hazard ratio 1·66 [95% CI 1·05-2·62]; p=0·030) adjusted for other risk factors.

INTERPRETATION

Systemic sclerosis-associated ILD progression does not predict further ILD progression at the next annual follow-up visit, even in an enriched population, but progression was associated with mortality. These results have implications for clinical practice because they support a paradigm shift in treatment strategy, advocating for initiating therapy in patients at risk of progression. Further research is needed to confirm these findings.

FUNDING

None.

TRANSLATIONS

For the German and Norwegian translations of the abstract see Supplementary Materials section.

Natural products for anti-fibrotic therapy in idiopathic pulmonary fibrosis: marine and terrestrial insights

Idiopathic Pulmonary Fibrosis (IPF) is a chronic fibrotic interstitial lung disease (ILD) of unknown etiology, characterized by increasing incidence and intricate pathogenesis. Current FDA-approved drugs suffer from significant side effects and limited efficacy, highlighting the urgent need for innovative therapeutic agents for IPF. Natural products (NPs), with their multi-target and multifaceted properties, present promising candidates for new drug development. This review delineates the anti-fibrotic pathways and targets of various natural products based on the established pathological mechanisms of IPF. It encompasses over 20 compounds, including flavonoids, saponins, polyphenols, terpenoids, natural polysaccharides, cyclic peptides, deep-sea fungal alkaloids, and algal proteins, sourced from both terrestrial and marine environments. The review explores their potential roles in mitigating pulmonary fibrosis, such as inhibiting inflammatory responses, protecting against lipid peroxidation damage, suppressing mesenchymal cell activation and proliferation, inhibiting fibroblast migration, influencing the synthesis and secretion of pro-fibrotic factors, and regulating extracellular matrix (ECM) synthesis and degradation. Additionally, it covers various in vivo and in vitro disease models, methodologies for analyzing marker expression and signaling pathways, and identifies potential new therapeutic targets informed by the latest research on IPF pathogenesis, as well as challenges in bioavailability and clinical translation. This review aims to provide essential theoretical and technical insights for the advancement of novel anti-pulmonary fibrosis drugs.

Use of rituximab in connective tissue disease-associated interstitial lung disease: a narrative review

This narrative review examines the therapeutic potential of rituximab, a monoclonal antibody targeting CD20 antigens, for treating connective tissue disease-associated interstitial lung disease. It outlines how rituximab offers a promising therapeutic option, particularly for patients who exhibit limited responses to standard therapies like glucocorticoids and immunosuppressive agents. Rituximab's mechanism of action, involving B lymphocyte depletion, contributes to attenuated inflammation and may slow pulmonary fibrosis progression. The article synthesizes findings from studies assessing rituximab's effects on lung function, clinical outcomes, and safety across distinct subtypes of connective tissue disease. It also discusses differential treatment responses based on disease characteristics and pathological subtypes, noting evidence that rituximab may be more effective as an initial treatment in some cases, though further investigation into long-term efficacy remains essential. Despite some associated risks, particularly infections, rituximab generally presents a favorable safety profile compared with conventional immunosuppressive therapies. Future research directions include optimizing dosing protocols, treatment intervals, and patient selection criteria, with emphasis on conducting rigorous, long-term randomized controlled trials to more definitively establish rituximab's role in managing interstitial lung disease in the context of connective tissue diseases.

Pulmonary fibrosis: from mechanisms to therapies

Pulmonary fibrosis (PF) is a chronic, progressive interstitial lung disease characterized by excessive deposition of extracellular matrix (ECM) and abnormal fibroblast proliferation, which is mainly caused by air pollution, smoking, aging, occupational exposure, environmental pollutants exposure, and microbial infections. Although antifibrotic agents such as pirfenidone and nintedanib, approved by the United States (US) Food and Drug Administration (FDA), can slow the decline in lung function and disease progression, their side effects and delivery inefficiency limit the overall prognosis of PF. Therefore, there is an urgent need to develop effective therapeutic targets and delivery approaches for PF in clinical settings. This review provides an overview of the pathogenic mechanisms, therapeutic drug targeting signaling pathways, and promising drug delivery strategies for treating PF.

Evaluation of efficacy and safety of rituximab in patients with progressive interstitial lung disease (ILD) with inflammatory component (EvER-ILD2): A multicentre double-blind placebo-controlled randomized trial

INTRODUCTION

Progressive interstitial lung diseases (ILDs) are rare but severe diseases, with high mortality and morbidity, with no effective pharmacological treatment allowing for long-term remission, and therefore no clear therapeutic recommendations. Several ILDs present inflammatory components (ILDic), which may justify the use of anti-inflammatory and immunosuppressive drugs, as first-step therapy. Except for systemic sclerosis (SSc)-ILD and sarcoidosis, the evidence in favor of this approach is very weak. The EvER-ILD2 study is the first one to prospectively evaluate the efficacy and safety of rituximab (RTX) versus placebo in a broad range of progressive ILD outside sarcoidosis and connective tissue diseases. A pharmacokinetic-pharmacodynamic analysis based on RTX serum concentrations will allow identification of potential factors associated with therapeutic response and/or adverse effects.

METHODS

EvER-ILD2 study is a French multicentre, prospective, randomized, double blind, placebo-controlled, superiority trial. Patients with progressive ILDic will be randomized into 2 groups of treatment: one course of RTX (RTX group) and one course of placebo (Placebo group). The primary outcome is the change in Forced Vital Capacity (FVC, mL) from baseline to 6 months. Several clinical, biological, and quality of life secondary outcomes will be measured at 3 and 6 months. A sample size of 126 patients (63 patients per group) would allow to show a 100 mL difference between groups in the change of FVC from baseline to 6 months, based on a common standard deviation for FVC change of 200 mL with a power of 80% and a two-sided alpha of 5%.

ETHICS AND DISSEMINATION

The protocol was approved by the French Research Ethics Committee (CPP Ile de France VI) on September 27, 2022, and by the French competent authority on October 02, 2022. This article refers to protocol V1, dated September 2022. An independent data safety monitoring board will review safety data for the duration of the trial. Results will be disseminated via peer reviewed publication and presentation at international conferences.

TRIAL REGISTRATION NUMBER

NCT05596786 (clinicaltrials.gov), EU-CT number 2022-500,375-31-00 (European Medicines agency).

Bogaarts B, Kramer H, Marges ER, Boerrigter BB, Bresser P, Schakenraad EL, van der Maten J, van der Sloot NC, Walen S, Afonso PM, Wijsenbeek MS, Grutters JC. Lung Function Course of Patients With Pulmonary Fibrosis After Initiation of Anti-Fibrotic Treatment: Real-World Data From the Dutch National Registry

BACKGROUND AND OBJECTIVE

Real-world data on lung function course of patients with progressive pulmonary fibrosis (PPF) treated with anti-fibrotic medication are limited. We evaluated forced vital capacity (FVC) decline in patients with PPF and idiopathic pulmonary fibrosis (IPF) who started anti-fibrotic treatment.

METHODS

This was a nationwide multi-centre registry study in 16 hospitals throughout the Netherlands. Patients treated with anti-fibrotic medication, with at least two in-hospital pulmonary function tests before and after the initiation of anti-fibrotic treatment, were included. Linear mixed-effects modelling was used to analyse lung function trajectories 1 year before and after the start of anti-fibrotic treatment.

RESULTS

Data from 538 patients (n = 142 with PPF, n = 396 with IPF) were analysed. In PPF, the mean annualised FVC decline was 412 mL (95% confidence interval [CI]: 308-517 mL) before the initiation of anti-fibrotic treatment, and 18 mL (95% CI: 9-124 mL) in the first year after. The corresponding declines for IPF were 158 mL (95% CI: 78-239 mL) and 38 mL (95% CI: 24-101 mL). In both groups, treatment significantly slowed down FVC decline, although the change was larger in the PPF group (p = 0.0006). In the first year after treatment initiation, 23.9% of patients with PPF and 28.0% with IPF had disease progression.

CONCLUSION

The FVC decline significantly slowed after the initiation of treatment for both IPF and PPF. Nevertheless, a significant proportion of patients exhibited disease progression, despite the start of anti-fibrotic treatment. Early identification of these patients is crucial for treatment adaptations and inclusion in clinical trials.

One-minute sit-to-stand test to detect gas exchange capacity during exercise stress in patients with idiopathic or progressive pulmonary fibrosis: A randomized, crossover trial

BACKGROUND

The 6-min walk test (6MWT), used to monitor disease progression or exacerbation in interstitial lung disease, faces challenges such as requiring a 30-m walking path and difficulty assessing patients with gait disturbance. The 1-min sit-to-stand test (1STST) offers a convenient alternative, potentially addressing these issues. Despite its advantages, the effectiveness of the 1STST in patients with idiopathic pulmonary fibrosis (IPF) and progressive pulmonary fibrosis (PPF) still needs to be explored. We assessed 1STST's ability to detect exercise-induced desaturation in a randomized, crossover trial involving patients with IPF or PPF.

METHODS

Participants were divided into group A (6MWT to 1STST) and B (1STST to 6MWT), with a 30-min rest period between the tests. The primary endpoint was the difference in nadir oxygen saturation (SpO2) between the groups throughout the study. Secondary endpoints included the percentage of participants with a nadir SpO₂ <88% during the tests, a decline of ≥4% in SpO2, and the variation in Borg scores post-tests.

RESULTS

Twenty-three participants (91.3% male; mean age ± standard deviation: 77.2 ± 7.4 years) diagnosed with IPF and PPF were enrolled in this study. The difference in nadir SpO2 between the 1STST and 6MWT was 1.14% (95% confidence interval: -0.18, 2.48), with the 95% confidence intervals falling within the predefined equivalence range. No significant differences were observed in the secondary endpoints.

CONCLUSIONS

The results suggest that the 1STST is as effective as the 6MWT in detecting desaturation in patients with IPF and PPF.

TRIAL REGISTRATION

This study was registered on the website of the Japan Registry of Clinical Trials (jRCT1032230037; URL: https://jrct.niph.go.jp/).

Inhalable Hsa-miR-30a-3p Liposomes Attenuate Pulmonary Fibrosis

Idiopathic pulmonary fibrosis (IPF) remains an incurable form of interstitial lung disease with sub-optimal treatments that merely address adverse symptoms or slow fibrotic progression. Here, inhalable hsa-miR-30a-3p-loaded liposomes (miR-30a) for the treatment of bleomycin-induced pulmonary fibrosis in mice are presented. It was previously found that exosomes (Exo) derived from lung spheroid cells are therapeutic in multiple animal models of pulmonary fibrosis and are highly enriched for hsa-miR-30a-3p. The present study investigates this miRNA as a singular factor to treat IPF. Liposomes containing miR-30a mimic can be delivered to rodents through dry powder inhalation. Inhaled miR-30a and Exo consistently lead to improved pulmonary function across six consecutive pulmonary function tests and promote de-differentiation of profibrotic myofibroblasts. The heterogenous composure of Exo also promotes reparative alveolar type I and II cell remodeling and vascular wound healing through broad transforming growth factor-beta signaling downregulation, while miR-30a targets myofibroblast de-differentiation through CNPY2/PERK/DDIT3 signaling. Overall, inhaled miR-30a represses the epithelial-mesenchymal transition of myofibroblasts, providing fibrotic attenuation and subsequent improvements in pulmonary function.

Nintedanib in Rheumatoid Arthritis-Related Interstitial Lung Disease: Real-World Safety Profile and Risk of Side Effects and Discontinuation

OBJECTIVE

Some concerns remain about the safety of nintedanib in patients with rheumatoid arthritis-related interstitial lung disease (RA-ILD), such as in the presence of comorbidities or in combination with biologic, targeted synthetic, and/or conventional synthetic disease-modifying antirheumatic drugs (DMARDs). In this multicenter study, we retrospectively evaluated the safety of nintedanib in a real-world population of patients with RA-ILD from the Italian Group for the Study of Early Arthritis (GISEA) registry and the possible role of comorbidities and DMARDs on drug safety and withdrawal. Our secondary aim was to investigate the causes of nintedanib discontinuation.

METHODS

Sixty-five patients treated with nintedanib in accordance with the current therapeutic indications were enrolled in the study. Nintedanib was prescribed in combination with DMARDs and/or steroids in 62 patients (95.4%).

RESULTS

The 12-month retention rate of nintedanib was 76.7% and the drug was effective in about 80% of patients with ≥ 6 months of follow-up. Adverse events (AEs) were recorded in 36 subjects (55.3%), and these were mainly gastroenteric. Thirty-one subjects required a reduction of the nintedanib dose; among them, a transient or permanent reduction of the daily dose of nintedanib allowed the continuation of the treatment in 22, whereas 15 (23.1%) withdrew from the drug. All reductions and discontinuations were owing to treatment-related AEs. Comorbidities were significantly associated with side effects in multivariate analysis, whereas AEs due to nintedanib were the main cause of discontinuation.

CONCLUSION

Combination therapy with DMARDs did not reduce the safety and effectiveness of nintedanib, and AEs were the main cause of drug withdrawal or dose reduction, mainly owing to comorbidities.

Association of serum interferon alpha-2a levels with disease severity and prognosis in systemic sclerosis

OBJECTIVE

To determine serum type I IFN (IFN-α2a) concentrations in SSc patients, explore its association with cytokine/chemokine expressions and evaluate correlation with the phenotype including the predictive value for interstitial lung disease (ILD) progression.

METHODS

Serum samples were obtained from 200 SSc patients and 29 healthy controls. IFN-α2a levels were measured by ultrasensitive electrochemiluminescence assay. Pro-inflammatory and chemokine panels were determined by Luminex® Discovery Assay multiplex kit. Baseline SSc disease characteristics were recorded together with longitudinal data for determining ILD progression after 2 years.

RESULTS

IFN-α2a concentrations were higher in SSc patients compared with controls, although not reaching significance [means ± SD of 49.20 ± 156.8 fg/ml vs 9.606 ± 4.399 fg/ml, respectively (P = 0.158)]. Using the cut-off of 15.9 fg/ml, we identified 62 patients as having a type 1 (T1) IFN signature in their circulation. Patients with an IFN signature had significantly higher levels of chemokines (CCL8, CCL19, CXCL10, CXCL11) and the cytokine IL-1α compared with those without an IFN signature. IFN-α2a concentrations strongly correlated with a T1 IFN-related chemokine score supporting activation of this pathway. Phenotyping association queries revealed association between IFN values and both skin and ILD involvements at baseline. Longitudinal data did not identify IFN as a predictive marker for ILD progression.

CONCLUSION

Using serum determinations, the activation of the T1 IFN pathway showed strong correlations with inflammatory mediators and associations with clinical manifestations, especially skin fibrosis and ILD in SSc patients. However, activated IFN pathway was not predictive of ILD progression.

Insights from the INSIGHTS-ILD Registry: real-world heterogeneity in treatment patterns for patients with fibrotic interstitial lung disease

An interim analysis of the INSIGHTS-ILD registry provides important real-world insights into clinical characteristics and practice patterns for patients with non-IPF fibrotic ILD https://bit.ly/4fXcHpn.

Real-life characteristics and management of patients with fibrosing interstitial lung disease: INSIGHTS-ILD registry

Background

This study aims to report real-life data on the characteristics and treatment patterns of patients with fibrosing interstitial lung disease (ILD; except idiopathic pulmonary fibrosis) across multiple specialised centres in Germany. Eligibility criteria included ILD affecting >10% of lung parenchyma on high-resolution computed tomography, a single breath diffusion capacity for carbon monoxide (D LCO) ≤80% predicted and active treatment of lung disease.

Methods

As of the interim analysis cut-off, 655 patients (mean±sd age 65.9±11.7 years, 54.5% male) were included. The most common ILD subtypes were fibrosing hypersensitivity pneumonitis (31.2%), fibrosing ILD (22.0%), rheumatoid arthritis and connective tissue disease ILDs (13.0%) and unclassifiable fibrosing ILD (13.0%).

Results

Lung function metrics included total lung capacity at 68.3±17.6% predicted, forced vital capacity at 69.8±19.8% predicted, forced expiratory volume in 1 s at 73.7±19.5% predicted and D LCO at 33.8±15.6% predicted. Current treatments included oral steroids (62.6%), antifibrotic therapy (50.7%), azathioprine (14.4%), methotrexate (10.2%) and mycophenolate mofetil (11.1%). Patients on antifibrotic therapy were typically older at diagnosis and registry inclusion, more often male, had more comorbidities, a lower 6-min walk distance and reduced lung function metrics compared with those not on antifibrotic therapy. Notably, 27.3% of the patients on antifibrotic therapy did not meet progression criteria (INBUILD), whereas 40.1% of patients not receiving antifibrotic therapy did meet those criteria.

Conclusion

The patient characteristics observed align with those observed in randomised controlled trials and other noninterventional studies. Patients on antifibrotic therapy generally had more severe disease profiles.

Prognostic prediction for newly diagnosed patients with idiopathic interstitial pneumonia: JIPS Registry (NEJ030)

BACKGROUND

Prognostic factors in patients with newly diagnosed idiopathic interstitial pneumonia (IIP) have rarely been analyzed using prospective data. This study investigated prognostic factors in patients with IIP.

METHODS

Central interstitial lung disease (ILD) experts established the diagnoses for fibrotic ILD. Prognostic factors using baseline data, including the pathological confidence level of usual interstitial pneumonia (UIP) assessed on a 0%-100% linear analog scale by high-resolution CT (HRCT), pulmonary function tests, and patient-reported outcomes were investigated.

RESULTS

Overall, 866 eligible patients were registered. Patients with unclassifiable idiopathic interstitial pneumonia (n = 272) survived longer than those with idiopathic pulmonary fibrosis (IPF) (n = 469) (hazard ratio [HR] = 0.67; [95% confidence interval [CI]: 0.47-0.95]; P = 0.022); however, IPF as IIPs classification was not a significant prognostic factor at diagnosis (P = 0.577). UIP pattern on HRCT, age, body mass index, forced vital capacity, diffusing capacity of the lungs for carbon monoxide, and St. George's Respiratory Questionnaire were risk factors for survival (P < 0.05). Patients with proposed progressive pulmonary fibrosis (PPF) had poorer prognoses than those without proposed PPF (HR = 5.63; [95% CI: 3.17-10.00]; P < 0.001). Patients with progressive fibrosing ILD (PF-ILD) had poorer prognoses than those without PF-ILD (HR = 7.85; [95% CI: 3.38-18.3]; P < 0.001).

CONCLUSIONS

A prospective registry of patients with newly diagnosed IIP provided evidence that the UIP pattern on HRCT by analog scale was a prognostic predictor. Proposed PPF and PF-ILD were valuable for discriminating prognosis. (JIPS Registry, ClinTrials.gov, NCT03041623).

Development of cysteine-sensitive bimodal probes for in situ monitoring of early-stage pulmonary fibrosis progression and therapeutic effects

Pulmonary fibrosis (PF) is a chronic interstitial lung disease characterized by excessive extracellular matrix deposition and lung scarring, leading to impaired lung function, severe respiratory distress, and potentially fatal outcomes. Early diagnosis of PF is crucial for optimizing treatment strategies to improve patient prognosis. However, an activated near-infrared fluorescent (NIRF) and photoacoustic (PA) bimodal probe for non-invasive in situ imaging of PF is still lacking. In this study, we developed a novel cysteine-sensitive NIRF/PA dual-modal probe, MR-Cys, for in situ monitoring of early progression and the therapeutic response in a mouse model of PF. The probe MR-Cys selectively detects cysteine (Cys) levels in vivo, thereby activating both NIRF and PA signals. Using NIRF/PA dual-modal imaging technology, MR-Cys successfully tracked fluctuations in Cys levels within the PF mouse model. After treatment with nintedanib (OFEV), a notable decrease in both PA and NIRF signal intensities was observed in the treated mice, indicating that MR-Cys can be used to assess the therapeutic efficacy for PF. Therefore, MR-Cys not only holds great promise for early detection of pulmonary fibrosis progression, but also offers a precise monitoring tool for the optimization of personalized treatment plans.

Emodin nanocrystals enhanced mucus penetration and ameliorated bleomycin-induced pulmonary fibrosis by pulmonary delivery

Pulmonary fibrosis (PF) is a progressive interstitial disease characterised by extracellular matrix deposition and destruction of lung tissue structure. Emodin (Emo) is a natural active compound with anti-inflammatory and antioxidant properties. The initiation of PF is prevented by reducing oxidative stress-induced damage to alveolar epithelial cells." to meet the word count requirement. However, Emo is featured low water solubility, a rapid metabolic rate and low oral bioavailability, which limit its application in the treatment of PF. Therefore, this study formulated emodin as nanocrystals (Emo-NCs) and delivered Emo directly to the lesion site via pulmonary delivery to enhance drug efficacy. The Emo-NCs exhibited a square crystal structure with particle sizes suitable for pulmonary absorption and an appropriate polydispersity index. They released 99.38% over 48 h and significantly improved permeability efficiency in simulated pulmonary mucus. The ability of Emo-NCs to inhibit abnormal fibroblast proliferation and oxidative damage was significantly enhanced compared with Emo. In contrast to the BLM group, the inflammatory cells in the lung tissue sections of the Emo-NCs group were significantly reduced, the alveolar structure was largely restored, and no evident collagen fibre deposition was observed. In summary, Emo-NCs could serve as a viable delivery system for site-specific treatment of PF.

The Role of the Extracellular Matrix in Cancer Prevention

The extracellular matrix (ECM) is a major driver of tumorigenesis, yet its role in cancer prevention has received relatively little attention. Here, we discuss studies linking the ECM to cancer initiation with an emphasis on ECM stiffness and remodeling, pericytes, and hyaluronan (hyaluronic acid). We then share our thoughts on how an ECM viewpoint could lead to new insights and directions in cancer-prevention research. Topics discussed include mouse experiments, clinical studies, risk factors, biomarkers for risk prediction or the early detection of cancer, surrogate endpoints, and targets for preventive interventions.

Updates in Diagnostic Tools for ILD

Interstitial lung disease (ILD) is a group of diffuse parenchymal disorders, which are diagnosed in many cases by multidisciplinary discussion (MDD). In some cases, diagnosis can be challenging, and the addition of histopathology can increase diagnostic confidence. The tools to obtain a histopathological sample to diagnose ILD are expanding. In this review, we will discuss the various modalities, their sensitivities and specificities, and procedural complication rates. In this review, we conducted a comprehensive review of literature focusing on emerging and established diagnostic tools for ILD. A systematic search of peer-reviewed publications was performed using PubMed with a focus on clinical trials, retrospective and prospective cohort studies, and systematic reviews. The key diagnostic modalities in focus were genomic classifier (GC), transbronchial cryobiopsy (TBLC), surgical lung biopsy (SLB), endobronchial ultrasound cryobiopsy (EBUS-C), genetic testing, and speckled transthoracic echocardiography (STE). Data extracted from these studies focused on diagnostic yield, specificity, sensitivity, and procedural complication rate. Genomic classifier, a gene-based molecular diagnostic tool, has a high specificity for histological usual interstitial pneumonia (UIP). However, in cases of a negative result, it often results in a need for further invasive sampling by TBLC or SLB. TBLC results in a larger histological sample, which can increase diagnostic yield and increase diagnostic confidence at MDD. Recent prospective trials have compared this modality with SLB and found 63-77% interobserver agreement between pathologists. SLB remains the gold standard with diagnostic yields reported to be more than 90%. EBUS-C has shown promising results increasing diagnostic yield in patients with suspected sarcoidosis or lymphoma. All diagnostic modalities have procedural complications with most common being pneumothorax, bleeding and, rarely, death. Advancements in diagnostic tools for interstitial lung disease (ILD) have significantly improved accuracy. Even though surgical lung biopsy remains the gold standard, the alternative modalities are promising and provide a promising yield with a lower procedural risk.

Advances in management of pulmonary fibrosis

Pulmonary fibrosis care, affecting both idiopathic pulmonary fibrosis and other forms of interstitial lung disease (ILD) characterised by fibrosis, has transformed with a range of innovations that affect the diagnosis, treatment and prognosis of this condition. Pharmacotherapeutic options have expanded, with increased indications for the application of effective antifibrotic therapy in non-IPF progressive pulmonary fibrosis as a solo treatment or combined with immunosuppression, emerging evidence for immunomodulatory therapy including biologic agents and greater access to clinical trials. The diagnostic approach to unclassifiable ILD now includes transbronchial lung cryobiopsy, a less invasive method to obtain histopathology with reduced morbidity and mortality compared to surgical lung biopsy. A multidisciplinary approach optimises the care of people with ILD and includes non-pharmacological management, addressing significant comorbidities, symptom care and advanced care planning. This review will summarise recent updates in pulmonary fibrosis management.

Development of a prediction model for progression of rheumatoid arthritis-associated interstitial lung disease using serologic and clinical factors: The prospective KORAIL cohort

OBJECTIVE

To develop a prediction model for rheumatoid arthritis-associated interstitial lung disease (RA-ILD) progression.

METHODS

We investigated predictors of RA-ILD progression in the Korean RA-ILD (KORAIL) cohort, a prospective study that enrolled patients with RA meeting ACR/EULAR criteria and ILD on chest computed tomography (CT) scans and followed for 3 years. Pulmonary function tests (PFTs) and chest CT scans were conducted annually. RA-ILD progression was defined as both physiological and radiological worsening, adapted from the 2023 ATS/ERS/JRS/ALAT definition of progressive pulmonary fibrosis. Baseline factors included clinical factors and biomarkers (autoantibodies, inflammatory markers, and pulmonary damage markers).

RESULTS

We analyzed 138 RA-ILD patients (mean age 66.4 years, 30.4 % male, 60.1 % usual interstitial pneumonia [UIP] pattern). During a median follow-up of 2.9 years, 34.8 % (n = 48) had RA-ILD progression. Baseline associations with progression included: UIP pattern, ILD extent >10 %, DLCO %pred., anti-cyclic citrullinated peptide (anti-CCP), Krebs von den Lungen-6 (KL-6), and human surfactant protein D. We developed prediction models using UIP pattern, ILD extent, DLCO % pred., and anti-CCP titer with or without serum KL-6 levels. The models had areas under the curve (AUCs) of 0.73 and 0.75, respectively. The high-risk group had a positive predictive value for progression of 85.7 %, while the low-risk group had a negative predictive value of 94.7 %.

CONCLUSION

In this prospective cohort, UIP pattern, ILD extent, lower DLCO, RA disease activity, anti-CCP levels, and pulmonary damage biomarkers were associated with RA-ILD progression. We developed prediction models that may be clinically useful to risk stratify once externally validated.

Targeted Collagen Degradation by an MRI Probe Facilitates siRNA Delivery for Sequential Theranostics in Pulmonary Fibrosis

Pulmonary fibrosis (PF) is characterized by dense collagen and mucus barriers that significantly limit drug delivery to the lungs. Clearing the collagen barrier can enhance drug delivery efficiency. Nevertheless, the heterogeneity of collagen states among patients poses a challenge. Therefore, real-time monitoring of the collagen clearance status is essential for PF personalized therapy. Herein, sequential theranostic platforms are proposed for collagen targeting and magnetic resonance imaging (MRI) monitoring to guide small interfering RNA (siRNA) delivery. First, for collagen barrier targeting-degrading, collagenase is conjugated with a collagen-targeting peptide capable of chelating the MRI contrast agent Gd(III), forming Col I T-D. This allows real-time, noninvasive MRI monitoring of the dynamic collagen clearance process. Second, guided by MRI, the zwitterionic polymer-based siRNA vectors (siTGF-β1@TZ) with mucus-penetrating and fibroblast-targeting capabilities are inhaled under an optimal state of collagen barrier. The sequential application of Col I T-D and siTGF-β1@TZ demonstrates significant lesion enrichment and therapeutic efficacy in PF treatment. Collectively, this study provides a novel perspective on dynamically monitoring collagen clearance status and guiding the sequential delivery of siRNA, offering a promising strategy for personalized PF therapy.

Early nintedanib deployment in COVID-19 interstitial lung disease (ENDCOV-I): study protocol of a randomised, double-blind, placebo-controlled trial

INTRODUCTION

In December 2019, the novel SARS-CoV-2 triggered a global pneumonia outbreak, leading to millions of deaths worldwide. A subset of survivors faces increased morbidity and mortality, particularly due to subacute lung injury evolving to chronic fibrosing interstitial lung disease. While nintedanib, a tyrosine-kinase inhibitor, shows promise in treating progressive fibrotic lung disease, limited randomised trial data exists for post-COVID-19-induced lung injury. We hypothesise that treatment with nintedanib may attenuate advancement to the fibrotic stages, offering a potential avenue for improving outcomes in this specific patient subset.

METHODS AND ANALYSIS

We describe the design of a multicentre, randomised, double-blind, placebo-controlled trial involving approximately 170 patients with subacute lung injury secondary to COVID-19, who required respiratory support with oxygen supplementation. Patients are randomised by site and disease phenotype (fibrotic vs non-fibrotic) in a 1:1 ratio to either oral nintedanib or placebo. Patients will be followed for 180 days. The primary endpoint is to assess change from baseline in forced vital capacity (FVC, mL) at 180 days. Secondary objectives include change in FVC (mL) at 90 days; diffusing capacity of carbon monoxide (% of predicted) and 6-min walk test (feet) at 180 days; and mortality at 90 and 180 days. Qualitative and quantitative changes in high-resolution computerised tomography (HRCT), change in patient-reported outcome measures (PROMs) and safety endpoints will also be assessed. Analysis will be performed according to the intention-to-treat principle.

ETHICS AND DISSEMINATION

The study is conducted in accordance with the Good Clinical Practices as outlined by the Food and Drug Administration and the Declaration of Helsinki 2008. This study received approval from participating sites' Institutional Review Boards and committees, including The Ethics Committee of the Medical Board at the Mount Sinai Hospital (ID: HS#20-01166). The Independent Oversight Committee oversees study conduct, data and patient safety for the duration of the study investigation. The trial details presented align with the trial protocol V.8. (April 2022). Results will be presented at national and international conferences, published in a peer-reviewed journal and disseminated to patients, funders and researchers on data analysis completion.

TRIAL REGISTRATION NUMBER

NCT04619680. First posted 6 November 2020.

Antifibrotic therapeutic strategies in systemic sclerosis: Critical role of the Wnt/β-catenin and TGF-β signal transduction pathways as potential targets

Systemic sclerosis (SSc) is a prototypic fibrosing disorder characterized by widespread fibrosis and immune dysregulation. Current evidence highlights the intricate cross-talk between the canonical Wnt/β-catenin signaling pathway and transforming growth factor-beta (TGF-β) signaling, both of which play fundamental roles in the pathogenesis of fibrosis. This review aims to elucidate the central role of the Wnt/β-catenin-TGF-β pathway and TGF-β signal transduction pathway in fibrotic diseases, focusing on SSc. We summarized evidence from cellular biology studies, animal model investigations and clinical observations to provide a comprehensive view of the mechanisms causing pathological fibrosis. In addition, we explore the possibilities of antifibrotic therapeutic strategies against Wnt/β-catenin-TGF-β signaling to counteract fibrosis, delineating approaches for treatment of SSc patients by targeting these interconnected signaling pathways.