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Mismetti V, Si-Mohamed S, Cottin V. Interstitial Lung Disease Associated with Systemic Sclerosis. Semin Respir Crit Care Med 2024; 45:342-364. [PMID: 38714203 DOI: 10.1055/s-0044-1786698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2024]
Abstract
Systemic sclerosis (SSc) is a rare autoimmune disease characterized by a tripod combining vasculopathy, fibrosis, and immune-mediated inflammatory processes. The prevalence of interstitial lung disease (ILD) in SSc varies according to the methods used to detect it, ranging from 25 to 95%. The fibrotic and vascular pulmonary manifestations of SSc, particularly ILD, are the main causes of morbidity and mortality, contributing to 35% of deaths. Although early trials were conducted with cyclophosphamide, more recent randomized controlled trials have been performed to assess the efficacy and tolerability of several medications, mostly mycophenolate, rituximab, tocilizumab, and nintedanib. Although many uncertainties remain, expert consensus is emerging to optimize the therapeutic management and to provide clinicians with evidence-based clinical practice guidelines for patients with SSc-ILD. This article provides an overview, in the light of the latest advances, of the available evidence for the diagnosis and management of SSc-ILD.
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Affiliation(s)
- Valentine Mismetti
- Department of Respiratory Medicine, National Coordinating Reference Centre for Rare Pulmonary Diseases, ERN-LUNG, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Salim Si-Mohamed
- INSA-Lyon, University of Lyon, University Claude-Bernard Lyon 1, Lyon, France
- Radiology Department, Hospices Civils de Lyon, Lyon, France
| | - Vincent Cottin
- Department of Respiratory Medicine, National Coordinating Reference Centre for Rare Pulmonary Diseases, ERN-LUNG, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
- UMR 754, INRAE, Claude Bernard University Lyon 1, Lyon, France
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2
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Kang HK, Song JW. Progressive Pulmonary Fibrosis: Where Are We Now? Tuberc Respir Dis (Seoul) 2024; 87:123-133. [PMID: 38111100 PMCID: PMC10990610 DOI: 10.4046/trd.2023.0119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 11/14/2023] [Accepted: 12/04/2023] [Indexed: 12/20/2023] Open
Abstract
Interstitial lung diseases (ILDs) are a diverse collection of lung disorders sharing similar features, such as inflammation and fibrosis. The diagnosis and management of ILD require a multidisciplinary approach using clinical, radiological, and pathological evaluation. Progressive pulmonary fibrosis (PPF) is a distinct form of progressive and fibrotic disease, occurring in ILD cases other than in idiopathic pulmonary fibrosis (IPF). It is defined based on clinical symptoms, lung function, and chest imaging, regardless of the underlying condition. The progression to PPF must be monitored through a combination of pulmonary function tests (forced vital capacity [FVC] and diffusing capacity of the lung for carbon monoxide), an assessment of symptoms, and computed tomography scans, with regular follow-up. Although the precise mechanisms of PPF remain unclear, there is evidence of shared pathogenetic mechanisms with IPF, contributing to similar disease behavior and worse prognosis compared to non-PPF ILD. Pharmacological treatment of PPF includes immunomodulatory agents to reduce inflammation and the use of antifibrotics to target progressive fibrosis. Nintedanib, a known antifibrotic agent, was found to be effective in slowing IPF progression and reducing the annual rate of decline in FVC among patients with PPF compared to placebos. Nonpharmacological treatment, including pulmonary rehabilitation, supplemental oxygen therapy, and vaccination, also play important roles in the management of PPF, leading to comprehensive care for patients with ILD. Although there is currently no cure for PPF, there are treatments that can help slow the progression of the disease and improve quality of life.
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Affiliation(s)
- Hyung Koo Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Republic of Korea
| | - Jin Woo Song
- Department of Pulmonology and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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3
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Elhennawy MG, Akl Y, Abbassi M, Sabry NA. The effectiveness and pharmacoeconomic study of using different corticosteroids in the treatment of hypersensitivity pneumonitis. BMC Pulm Med 2024; 24:87. [PMID: 38360614 PMCID: PMC10870560 DOI: 10.1186/s12890-024-02896-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 02/03/2024] [Indexed: 02/17/2024] Open
Abstract
PURPOSE Interstitial lung diseases (ILDs) are caused by inflammation and/or fibrosis of alveolar walls resulting in impaired gas exchange. Hypersensitivity pneumonitis (HP) is the third most common type of ILDs. Corticosteroids are the mainstay treatment for HP. The use of intramuscular (IM) betamethasone or intravenous (IV) dexamethasone as weekly pulse doses has shown higher benefit than daily oral prednisolone for HP patients. The aim of this study is to directly compare different corticosteroids in terms of effectiveness and in monetary values and perform an economic evaluation. METHODS One hundred and seven patients were tested for pulmonary function tests (PFTs) and inflammatory markers to assess the treatment effectiveness. A cost-effectiveness analysis (CEA) was performed. ICERs between 3 treatment groups were calculated. RESULTS Post treatment, Krebs von den Lungen-6 (KL-6) levels significantly improved in betamethasone group from 723.22 ± 218.18 U/ml to 554.48 ± 129.69 U/ml (p = 0.001). A significant improvement in erythrocyte sedimentation rate (ESR) occurred in the dexamethasone group from 56.12 ± 27.97 mm to 30.06 ± 16.04 mm (p = 0.048). A significant improvement in forced expiratory volume (FEV1), forced vital capacity (FVC) and six-minute walk distance (6MWD) was observed within the three treatment groups. A significant improvement in oxygen desaturation percentage (SpO2) occurred within dexamethasone and betamethasone groups. Betamethasone and dexamethasone were found more cost-effective than prednisolone as their ICERs fell in quadrant C. Furthermore, ICER between betamethasone and dexamethasone was performed; a small difference in cost was found compared to the higher benefit of betamethasone. CONCLUSION Betamethasone and dexamethasone were found to be more effective than prednisolone in improving the inflammatory reaction and the clinical features of HP patients. Betamethasone was found to be the best intervention in terms of cost against the effect.
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Affiliation(s)
- Marwa G Elhennawy
- Department of Clinical Pharmacy, Faculty of Pharmacy, Cairo University, 11562, Cairo, Egypt.
| | - Yosri Akl
- Department of Pulmonology, Faculty of Medicine, Cairo University, 11562, Cairo, Egypt
| | - Maggie Abbassi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Cairo University, 11562, Cairo, Egypt
| | - Nirmeen A Sabry
- Department of Clinical Pharmacy, Faculty of Pharmacy, Cairo University, 11562, Cairo, Egypt
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Wang H, Wang Y, Sun D, Yu S, Du X, Ye Q. Progressive pulmonary fibrosis in myositis-specific antibody-positive interstitial pneumonia: a retrospective cohort study. Front Med (Lausanne) 2024; 10:1325082. [PMID: 38274458 PMCID: PMC10808296 DOI: 10.3389/fmed.2023.1325082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 12/30/2023] [Indexed: 01/27/2024] Open
Abstract
Objectives Idiopathic inflammatory myopathy (IIM) frequently coexists with interstitial pneumonia (IP) and is commonly the initial or sole manifestation accompanied by positive myositis-specific autoantibodies (MSAs), even in the absence of meeting diagnostic criteria. This study aims to evaluate the proportion of progressive pulmonary fibrosis (PPF) and identify potential predictors influencing the progression of pulmonary fibrosis in patients with MSA-IP. Methods This descriptive study employed a retrospective cohort design, enrolling patients diagnosed with interstitial pneumonia and positive MSAs at Beijing Chao-Yang Hospital in a sequential manner. Clinical data were systematically collected from the patients' medical records during regular follow-up visits conducted every 3 to 6 months. Cox regression analysis was utilized to identify independent predictors of PPF in patients with positive MSAs and interstitial pneumonia. Results A total of 307 patients were included in the study, with 30.6% of them developing PPF during a median follow-up period of 22 months. Kaplan-Meier survival curves demonstrated a significantly lower survival in the PPF patients compared to the non-PPF patients (median 11.6 months vs. 31 months, p = 0.000). An acute/subacute onset of interstitial pneumonia (HR 3.231, 95%CI 1.936-5.392, p = 0.000), lower diffusing capacity of the lungs for carbon monoxide (DLCO) % predicted (HR 6.435, 95%CI 4.072-10.017, p = 0.001), and the presence of diffuse alveolar damage (DAD) on high-resolution computed tomography (HRCT) (HR 8.679, 95%CI 1.974-38.157, p = 0.004) emerged as independent predictors of PPF. Notably, the implementation of triple therapy comprising glucocorticoids, immunosuppressants, and antifibrotic drugs was associated with a reduced risk of developing PPF (HR 0.322, 95%CI 0.115-0.899, p = 0.031). Conclusion Approximately 30.6% of patients with MSA-IP may develop PPF within the follow-up period. Patients presenting with an acute/subacute onset of interstitial pneumonia, lower predicted DLCO SB% and evidence of DAD on HRCT are more susceptible to developing PPF. Conversely, the administration of triple therapy appears to serve as a protective factor against the development of PPF in patients with MSA-IP.
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Affiliation(s)
- Huijuan Wang
- Clinical Center for Interstitial Lung Diseases, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yuanying Wang
- Clinical Center for Interstitial Lung Diseases, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Di Sun
- Clinical Center for Interstitial Lung Diseases, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Shiwen Yu
- Clinical Center for Interstitial Lung Diseases, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
- Department of Occupational Medicine and Toxicology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xuqin Du
- Clinical Center for Interstitial Lung Diseases, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
- Department of Occupational Medicine and Toxicology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Qiao Ye
- Clinical Center for Interstitial Lung Diseases, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
- Department of Occupational Medicine and Toxicology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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Kolb M, Flaherty KR, Silva RS, Prasse A, Vancheri C, Mueller H, Sroka-Saidi K, Wells AU. Effect of Nintedanib in Patients with Progressive Pulmonary Fibrosis in Subgroups with Differing Baseline Characteristics. Adv Ther 2023; 40:5536-5546. [PMID: 37751022 PMCID: PMC10611817 DOI: 10.1007/s12325-023-02668-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 08/25/2023] [Indexed: 09/27/2023]
Abstract
INTRODUCTION In the INBUILD trial in patients with progressive pulmonary fibrosis other than idiopathic pulmonary fibrosis (IPF), nintedanib slowed the rate of decline in forced vital capacity (FVC; mL/year) over 52 weeks compared with placebo. We assessed the efficacy of nintedanib across subgroups in the INBUILD trial by baseline characteristics. METHODS We assessed the rate of decline in FVC over 52 weeks and time to progression of interstitial lung disease (ILD) (absolute decline from baseline in FVC % predicted > 10%) or death over the whole trial in subgroups based on sex, age, race, body mass index (BMI), time since diagnosis of ILD, FVC % predicted, diffusing capacity of the lungs for carbon monoxide (DLco) % predicted, composite physiologic index (CPI), GAP (gender, age, lung physiology) stage, use of anti-acid therapy and use of disease-modifying antirheumatic drugs (DMARDs) at baseline. RESULTS The effect of nintedanib versus placebo on reducing the rate of decline in FVC over 52 weeks was consistent across the subgroups by baseline characteristics analysed. Interaction p values did not indicate heterogeneity in the treatment effect between these subgroups (p > 0.05). Over the whole trial (median follow-up time ∼19 months), progression of ILD or death occurred in similar or lower proportions of patients treated with nintedanib than placebo across the subgroups analysed, with no heterogeneity detected between the subgroups. CONCLUSIONS In the INBUILD trial, no heterogeneity was detected in the effect of nintedanib on reducing the rate of ILD progression across subgroups based on demographics, ILD severity or use of anti-acid therapy or DMARDs. These data support the use of nintedanib as a treatment for progressive pulmonary fibrosis. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Identifier: NCT02999178.
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Affiliation(s)
- Martin Kolb
- Department of Medicine, McMaster University and St. Joseph's Healthcare, T2117 50 Charlton Ave. E., Hamilton, ON, L8N 4A6, Canada.
| | - Kevin R Flaherty
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Rafael S Silva
- Unidad de Respiratorio, Hospital Regional de Talca, Talca, Chile
| | - Antje Prasse
- Department of Respiratory Medicine, MHH Hannover Medical School, Hannover, Germany
| | - Carlo Vancheri
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Heiko Mueller
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | | | - Athol U Wells
- National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, and National Heart and Lung Institute, Imperial College, London, UK
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Koduri G, Solomon JJ. Identification, Monitoring, and Management of Rheumatoid Arthritis-Associated Interstitial Lung Disease. Arthritis Rheumatol 2023; 75:2067-2077. [PMID: 37395725 DOI: 10.1002/art.42640] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 05/23/2023] [Accepted: 06/27/2023] [Indexed: 07/04/2023]
Abstract
Interstitial lung disease (ILD) is a frequent complication of rheumatoid arthritis (RA) that is associated with a significant increase in mortality. Several risk factors for the development of ILD in patients with RA have been identified, but ILD can still develop in the absence of these risk factors. Screening tools for RA-ILD are required to facilitate early detection of RA-ILD. Close monitoring of patients with RA-ILD for progression is crucial to enable timely implementation of treatment strategies to improve outcomes. Patients with RA are commonly treated with immunomodulatory therapies, although their efficacy in slowing the progression of RA-ILD remains the subject of debate. Clinical trials have shown that antifibrotic therapies slow decline in lung function in patients with progressive fibrosing ILDs, including patients with RA-ILD. The management of patients with RA-ILD should be based on multidisciplinary evaluation of the severity and progression of their ILD and the activity of their articular disease. Close collaboration between rheumatologists and pulmonologists is essential to optimize patient care.
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Affiliation(s)
- Gouri Koduri
- Southend University Hospital NHS Foundation Trust, Chelmsford, UK
- Anglia Ruskin University, Chelmsford, UK
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Asif H, Ribeiro Neto M, Culver D. Pulmonary fibrosis in sarcoidosis. SARCOIDOSIS, VASCULITIS, AND DIFFUSE LUNG DISEASES : OFFICIAL JOURNAL OF WASOG 2023; 40:e2023027. [PMID: 37712364 PMCID: PMC10540713 DOI: 10.36141/svdld.v40i3.14830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 07/06/2023] [Indexed: 09/16/2023]
Abstract
Sarcoidosis may progress to pulmonary fibrosis in 5% of patients with significantly increased mortality. Histopathology shows fibrosis in a lymphangitic pattern surrounding the granulomas. Th1 to Th2 shift in environment along with angiogenesis is implicated in exuberant fibrosis. Clinical features include dyspnea, cough, and frequently with pulmonary function tests showing a mixed ventilatory defect with severely decreased diffusion capacity of carbon monoxide. Serologic markers including soluble interleukin 2 receptor, chitotriosidase and kern von den lunges 6, and chemokine ligand 18 are elevated and implicated in progression of disease. CT imaging shows fibrosis along bronchovascular bundles with reticulations, traction bronchiectasis and honeycombing predominantly in the upper and central distribution. Complications include sarcoidosis-associated pulmonary hypertension (SAPH) and chronic pulmonary aspergillosis. Treatment involves glucocorticoids and steroid-sparing agents in the presence of active granulomas. Anti-fibrotic agents such as pirfenidone and nintedanib have been shown to slow down pulmonary function decline in randomized clinical trials involving sarcoidosis-associated pulmonary fibrosis. Transplant workup is indicated in New York Heart Association class III or IV with similar success rates as in other lung transplant patients.
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Affiliation(s)
- Huda Asif
- University of South Florida, FL, USA .
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8
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Matteson EL, Aringer M, Burmester GR, Mueller H, Moros L, Kolb M. Effect of nintedanib in patients with progressive pulmonary fibrosis associated with rheumatoid arthritis: data from the INBUILD trial. Clin Rheumatol 2023; 42:2311-2319. [PMID: 37209188 PMCID: PMC10412475 DOI: 10.1007/s10067-023-06623-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 04/28/2023] [Accepted: 05/02/2023] [Indexed: 05/22/2023]
Abstract
OBJECTIVES Some patients with rheumatoid arthritis develop interstitial lung disease (RA-ILD) that develops into progressive pulmonary fibrosis. We assessed the efficacy and safety of nintedanib versus placebo in patients with progressive RA-ILD in the INBUILD trial. METHODS The INBUILD trial enrolled patients with fibrosing ILD (reticular abnormality with traction bronchiectasis, with or without honeycombing) on high-resolution computed tomography of >10% extent. Patients had shown progression of pulmonary fibrosis within the prior 24 months, despite management in clinical practice. Subjects were randomised to receive nintedanib or placebo. RESULTS In the subgroup of 89 patients with RA-ILD, the rate of decline in FVC over 52 weeks was -82.6 mL/year in the nintedanib group versus -199.3 mL/year in the placebo group (difference 116.7 mL/year [95% CI 7.4, 226.1]; nominal p = 0.037). The most frequent adverse event was diarrhoea, which was reported in 61.9% and 27.7% of patients in the nintedanib and placebo groups, respectively, over the whole trial (median exposure: 17.4 months). Adverse events led to permanent discontinuation of trial drug in 23.8% and 17.0% of subjects in the nintedanib and placebo groups, respectively. CONCLUSIONS In the INBUILD trial, nintedanib slowed the decline in FVC in patients with progressive fibrosing RA-ILD, with adverse events that were largely manageable. The efficacy and safety of nintedanib in these patients were consistent with the overall trial population. A graphical abstract is available at: https://www.globalmedcomms.com/respiratory/INBUILD_RA-ILD . Key Points • In patients with rheumatoid arthritis and progressive pulmonary fibrosis, nintedanib reduced the rate of decline in forced vital capacity (mL/year) over 52 weeks by 59% compared with placebo. • The adverse event profile of nintedanib was consistent with that previously observed in patients with pulmonary fibrosis, characterised mainly by diarrhoea. • The effect of nintedanib on slowing decline in forced vital capacity, and its safety profile, appeared to be consistent between patients who were taking DMARDs and/or glucocorticoids at baseline and the overall population of patients with rheumatoid arthritis and progressive pulmonary fibrosis.
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Affiliation(s)
- Eric L Matteson
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
| | - Martin Aringer
- Rheumatology, Medicine III, University Medical Center & Faculty of Medicine, TU Dresden, Dresden, Germany
| | - Gerd R Burmester
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Heiko Mueller
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
| | - Lizette Moros
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Martin Kolb
- Department of Medicine, McMaster University and St. Joseph's Healthcare, Hamilton, Ontario, Canada
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Yang M, Wu YQ, Liu XM, Zhao C, Li T, Li TQ, Zhang XW, Jiang HL, Mao B, Liu W. Efficacy and safety of antifibrotic agents in the treatment of CTD-ILD and RA-ILD: A systematic review and meta-analysis. Respir Med 2023:107329. [PMID: 37315742 DOI: 10.1016/j.rmed.2023.107329] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 05/23/2023] [Accepted: 06/11/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE The clinical spectrum of connective tissue disease-associated interstitial lung disease (CTD-ILD) and rheumatoid arthritis-associated interstitial lung disease (RA-ILD) ranges from asymptomatic findings on radiographic imaging to a rapidly progressive illness leading to respiratory failure and death. The treatment is always challenging due to the paucity of proven effective treatments. Nintedanib and pirfenidone are recently approved antifibrotics in idiopathic pulmonary fibrosis. This study aimed to investigate the efficacy and safety of antifibrotic agents in the treatment of CTD-ILD and RA-ILD. METHODS Relevant databases were searched for randomized controlled trials that compared pirfenidone or nintedanib with placebo in patients with CTD-ILD and RA-ILD. The primary outcome was the change in forced vital capacity (FVC). The odds ratio or risk ratio with 95% confidence interval (CI) was estimated for categorical data, and the mean difference with 95% CI was estimated for continuous data. The I2 statistic was used to assess heterogeneity, and meta-analysis was performed when possible. RESULTS Ten studies with a total of 880 participants met the inclusion criteria. Of these, four studies were included in the meta-analysis. According to the pooled result, the annual decline of FVC was significantly decreased in the antifibrotic agent arm compared to that in the placebo arm (MD 70.58 mL/yr, 95% CI 40.55 to 100.61). CONCLUSION This review suggests a potential benefit and safety of antifibrotic treatment in slowing the decline of FVC in patients with CTD-ILD and RA-ILD. Further large-sample, random-controlled, high-quality trials are needed to provide more evidence in the decision-making regarding the use of antifibrotics in this group of patients. CLINICAL TRIAL REGISTRATION PROSPERO; No.: CRD42022369112; URL: https://www.crd.york.ac.uk/prospero/.
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Affiliation(s)
- Mei Yang
- Division of Pulmonary Medicine, Institute of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, PR China
| | - Yan-Qing Wu
- Division of Pulmonary Medicine, Institute of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, PR China
| | - Xue-Mei Liu
- Division of Pulmonary Medicine, Institute of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, PR China; Department of Pulmonary Diseases, State Key Laboratory of Biotherapy of China, West China Hospital of Sichuan University, Chengdu, PR China
| | - Chen Zhao
- Department of Oral Medicine, Stomatological Hospital and Dental School of Tongji University, Shanghai Engineering Research Center of Tooth Restoration and Regeneration, Shanghai, PR China
| | - Ting Li
- Division of Pulmonary Medicine, Institute of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, PR China
| | - Ting-Qian Li
- Division of Pulmonary Medicine, Institute of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, PR China
| | - Xia-Wei Zhang
- Respiratory Medicine Unit and National Institute for Health Research (NIHR), Nuffield Department of Medicine Experimental Medicine, Oxford Biomedical Research Centre (BRC), University of Oxford, Oxfordshire, United Kingdom
| | - Hong-Li Jiang
- Division of Pulmonary Medicine, Institute of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, PR China
| | - Bing Mao
- Division of Pulmonary Medicine, Institute of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, PR China.
| | - Wei Liu
- Division of Pulmonary Medicine, Institute of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, PR China.
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Amati F, Stainer A, Polelli V, Mantero M, Gramegna A, Blasi F, Aliberti S. Efficacy of Pirfenidone and Nintedanib in Interstitial Lung Diseases Other than Idiopathic Pulmonary Fibrosis: A Systematic Review. Int J Mol Sci 2023; 24:ijms24097849. [PMID: 37175556 PMCID: PMC10178294 DOI: 10.3390/ijms24097849] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/24/2023] [Accepted: 01/26/2023] [Indexed: 05/15/2023] Open
Abstract
Pirfenidone and nintedanib are antifibrotic medications approved for idiopathic pulmonary fibrosis treatment by regulatory agencies and available for clinical use worldwide. These drugs have been shown to reduce the rate of decline in forced vital capacity and the risk of acute exacerbation among patients with idiopathic pulmonary fibrosis. Recent data suggest that different interstitial lung diseases with a progressive pulmonary fibrosis phenotype can share similar pathogenetic and biological pathways and could be amenable to antifibrotic therapies. Indeed, historical management strategies in interstitial lung disease have failed to identify potential treatments once progression has occurred despite available drugs. In this systematic review, we summarized data on the efficacy of pirfenidone and nintedanib in interstitial lung diseases other than idiopathic pulmonary fibrosis as well as ongoing and upcoming clinical trials. We identify two well-designed trials regarding nintedanib demonstrating the efficacy of this drug in slowing disease progression in patients with interstitial lung diseases other than idiopathic pulmonary fibrosis. On the other hand, results on the use of pirfenidone in interstitial lung diseases other than idiopathic pulmonary fibrosis should be interpreted with more caution on the basis of trial limitations. Several randomized control trials are underway to improve the quality of evidence in the interstitial lung disease field.
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Affiliation(s)
- Francesco Amati
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Respiratory Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Anna Stainer
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Respiratory Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Veronica Polelli
- Respiratory Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Marco Mantero
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy
| | - Andrea Gramegna
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy
| | - Francesco Blasi
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy
| | - Stefano Aliberti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Respiratory Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
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Boutel M, Boutou A, Pitsiou G, Garyfallos A, Dimitroulas T. Efficacy and Safety of Nintedanib in Patients with Connective Tissue Disease-Interstitial Lung Disease (CTD-ILD): A Real-World Single Center Experience. Diagnostics (Basel) 2023; 13:diagnostics13071221. [PMID: 37046439 PMCID: PMC10093288 DOI: 10.3390/diagnostics13071221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/19/2023] [Accepted: 03/21/2023] [Indexed: 04/14/2023] Open
Abstract
Connective Tissue Disease-Interstitial Lung Disease (CTD-ILD) is a severe and fatal manifestation of systemic autoimmune disorders. Therapies rely on immunomodulators but their efficacy in ILD progression remains uncertain. Nintedanib, an antifibrotic agent that slows pulmonary function decline, has been approved for CTD-ILD treatment. The aim of this study was to assess the effectiveness and safety of nintedanib in CTD-ILD patients in a real-world data setting. A single-center, retrospective, and descriptive analysis of CTD-ILD patients treated with nintedanib from June 2019 to November 2022 was performed. The assessment of nintedanib treatment's efficacy was judged solely on the evolution of pulmonary function tests (PFTs), which were evaluated before and after treatment. Twenty-one patients (67% females, median age 64 years (IQR = 9) with CTD-ILD (systemic sclerosis n = 9, rheumatoid arthritis n = 5, dermatomyositis n = 4, juvenile rheumatoid arthritis n = 1, undifferentiated CTD n = 1, interstitial pneumonia with autoimmune features n = 1), 18 of whom were on concomitant immunosuppressives, had a median follow-up period of 10 months (IQR = 5). PFTs before and after treatment did not significantly differ. The mean FVC% difference was +0.9 (sd = 7.6) and the mean DLco% difference was +3.4 (sd = 12.6), suggesting numerical improvement of PFTs. The average percentage change was -0.3% and +7.6% for FVC% and DLco%, respectively, indicating stabilization of lung function. Our real-world data across a broad spectrum of CTD-ILD suggest that nintedanib could be beneficial in combination with immunosuppressives in slowing the rate of lung function decline.
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Affiliation(s)
- Maria Boutel
- Fourth Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
| | - Afroditi Boutou
- Department of Respiratory Medicine, G. Papanikolaou Hospital, Aristotle University of Thessaloniki, 57010 Pylaia-Chortiatis, Greece
| | - Georgia Pitsiou
- Department of Respiratory Failure, G. Papanikolaou Hospital, Aristotle University of Thessaloniki, 57010 Pylaia-Chortiatis, Greece
| | - Alexandros Garyfallos
- Fourth Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
| | - Theodoros Dimitroulas
- Fourth Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
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12
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Rajan SK, Cottin V, Dhar R, Danoff S, Flaherty KR, Brown KK, Mohan A, Renzoni E, Mohan M, Udwadia Z, Shenoy P, Currow D, Devraj A, Jankharia B, Kulshrestha R, Jones S, Ravaglia C, Quadrelli S, Iyer R, Dhooria S, Kolb M, Wells AU. Progressive pulmonary fibrosis: an expert group consensus statement. Eur Respir J 2023; 61:2103187. [PMID: 36517177 PMCID: PMC10060665 DOI: 10.1183/13993003.03187-2021] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 11/17/2022] [Indexed: 12/23/2022]
Abstract
This expert group consensus statement emphasises the need for standardising the definition of progressive fibrosing interstitial lung diseases (F-ILDs), with an accurate initial diagnosis being of paramount importance in ensuring appropriate initial management. Equally, case-by-case decisions on monitoring and management are essential, given the varying presentations of F-ILDs and the varying rates of progression. The value of diagnostic tests in risk stratification at presentation and, separately, the importance of a logical monitoring strategy, tailored to manage the risk of progression, are also stressed. The term "progressive pulmonary fibrosis" (PPF) exactly describes the entity that clinicians often face in practice. The importance of using antifibrotic therapy early in PPF (once initial management has failed to prevent progression) is increasingly supported by evidence. Artificial intelligence software for high-resolution computed tomography analysis, although an exciting tool for the future, awaits validation. Guidance is provided on pulmonary rehabilitation, oxygen and the use of non-invasive ventilation focused specifically on the needs of ILD patients with progressive disease. PPF should be differentiated from acute deterioration due to drug-induced lung toxicity or other forms of acute exacerbations. Referral criteria for a lung transplant are discussed and applied to patient needs in severe diseases where transplantation is not realistic, either due to access limitations or transplantation contraindications. In conclusion, expert group consensus guidance is provided on the diagnosis, treatment and monitoring of F-ILDs with specific focus on the recognition of PPF and the management of pulmonary fibrosis progressing despite initial management.
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Affiliation(s)
- Sujeet K Rajan
- Bombay Hospital Institute of Medical Sciences and Bhatia Hospital, Mumbai, India
| | - Vincent Cottin
- National French Reference Coordinating Center for Rare Pulmonary Diseases, Louis Pradel Hospital Hospices Civils de Lyon, Université Claude Bernard Lyon 1, INRAE, Member of ERN-LUNG, Lyon, France
| | | | - Sonye Danoff
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Kevin K Brown
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Anant Mohan
- All India Institute of Medical Sciences, New Delhi, India
| | | | | | | | - Padmanabha Shenoy
- Department of Rheumatology, Centre for Arthritis and Rheumatism Excellence, Kochi, India
| | | | - Anand Devraj
- Department of Radiology, Royal Brompton Hospital, London, UK
| | | | - Ritu Kulshrestha
- Department of Pathology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Steve Jones
- European Idiopathic Pulmonary Fibrosis Federation (EU-IPFF), Peterborough, UK
| | - Claudia Ravaglia
- Pulmonology Unit, GB Morgagni Hospital/University of Bologna, Forlì, Italy
| | | | - Rajam Iyer
- Bhatia Hospital and PD Hinduja Hospital, Mumbai, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Martin Kolb
- Firestone Institute for Respiratory Heath, St Joseph's Healthcare and McMaster University, Hamilton, ON, Canada
- Co-senior authors
| | - Athol U Wells
- Interstitial Lung Disease Unit, Royal Brompton and Harefield NHS Foundation Trust, London, UK
- Co-senior authors
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13
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Behr J, Bonella F, Frye BC, Günther A, Hagmeyer L, Henes J, Klemm P, Koschel D, Kreuter M, Leuschner G, Nowak D, Prasse A, Quadder B, Sitter H, Costabel U. [Pharmacological treatment of idiopathic pulmonary fibrosis (update) and progressive pulmonary fibrosis - S2k Guideline of the German Respiratory Society]. Pneumologie 2023; 77:94-119. [PMID: 36791790 DOI: 10.1055/a-1983-6796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Affiliation(s)
- Jürgen Behr
- Medizinische Klinik und Polklinik V, LMU Klinikum der Universität München, Mitglied des Deutschen Zentrums für Lungenforschung; Delegierte/r der DGP
| | - Francesco Bonella
- Zentrum für interstitielle und seltene Lungenerkrankungen, Klinik für Pneumologie, Ruhrlandklinik, Universitätsmedizin Essen; Delegierter der DGP
| | - Björn C Frye
- Klinik für Pneumologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Deutschland; Delegierter der DGP
| | - Andreas Günther
- Center for Interstitial and Rare Lung Diseases, University Hospital Giessen Marburg, Giessen, Agaplesion Evangelisches Krankenhaus Mittelhessen, Giessen, Germany; Delegierter der DGP
| | - Lars Hagmeyer
- Krankenhaus Bethanien Solingen, Klinik für Pneumologie und Allergologie, Zentrum für Schlaf- und Beatmungsmedizin, Institut für Pneumologie an der Universität zu Köln; Delegierter der DGP
| | - Jörg Henes
- Zentrum für interdisziplinäre Rheumatologie, Immunologie und Autoimmunerkrankungen (INDIRA) und Innere Medizin II; Delegierter DGRh
| | - Philipp Klemm
- Abt. Rheumatologie und klinische Immunologie, Kerckhoff Klinik und Campus Kerckhoff der Justus-Liebig-Universität Gießen, Bad Nauheim; Delegierter der DGRh
| | - Dirk Koschel
- Fachkrankenhaus Coswig, Lungenzentrum und Medizinische Klinik 1, Universitätsklinik Carl Gustav Carus der TU Dresden; Delegierter der DGP
| | - Michael Kreuter
- Zentrum für interstitielle und seltene Lungenerkrankungen & interdisziplinäres Sarkoidosezentrum, Thoraxklinik, Universitätsklinikum Heidelberg, Deutsches Zentrum für Lungenforschung Heidelberg und Klinik für Pneumologie, Interdisziplinäres Lungenzentrum Ludwigsburg, RKH Klinik Ludwigsburg; Delegierter der DGIM
| | - Gabriela Leuschner
- Medizinische Klinik und Polklinik V, LMU Klinikum der Universität München, Mitglied des Deutschen Zentrums für Lungenforschung; Delegierte/r der DGP
| | - Dennis Nowak
- Institut und Poliklinik für Arbeits-, Sozial- und Umweltmedizin, LMU Klinikum der Universität München, Comprehensive Pneumology Center (CPC) München, Mitglied des Deutsches Zentrums für Lungenforschung; Delegierter der DGAUM
| | - Antje Prasse
- Klinik für Pneumologie und Infektiologie, Medizinische Hochschule Hannover, DZL BREATH und Abteilung für Fibroseforschung, Fraunhofer ITEM, Hannover, Delegierte der DGP
| | | | - Helmut Sitter
- Institut für Theoretische Chirurgie, Philipps-Universität Marburg, Moderator
| | - Ulrich Costabel
- Zentrum für interstitielle und seltene Lungenerkrankungen, Klinik für Pneumologie, Ruhrlandklinik, Universitätsmedizin Essen; Delegierter der DGP
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14
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Nasonov EL, Ananyeva LP, Avdeev SN. Interstitial lung disease in rheumatoid arthritis: A multidisciplinary problem in rheumatology and pulmonology. RHEUMATOLOGY SCIENCE AND PRACTICE 2022. [DOI: 10.47360/1995-4484-2022-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Rheumatoid arthritis (RA) is an immune-mediated rheumatic disease (IMRDs) characterized by chronic erosive arthritis and systemic damage to internal organs, leading to early disability and reduced life expectancy in patients. A particularly important place among the systemic manifestations of RA is occupied by interstitial lung diseases (ILD) – the most severe form of pulmonary pathology in RA, defined as RA-ILD, which is pathogenetically associated with risk factors (smoking, etc.) and autoimmune mechanisms underlying RA. RA-ILD is a subtype of RA characterized by a severe course and a poor prognosis и неблагоприятным прогнозом. The review presents new data regarding risk factors and biomarkers for RA-ILD; modern diagnostic capabilities based on the use of functional lung tests, high-resolution computed tomography, ultrasound examination of the lungs. Particular attention is paid to the efficacy and safety of pharmacotherapy, including methotrexate, biologics, JAK inhibitors, and antifibrotic therapy. An algorithm for the pharmacotherapy of RA-ILD has been proposed.
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Affiliation(s)
- E. L. Nasonov
- V.A. Nasonova Research Institute of Rheumatology; I.M. Sechenov First Moscow State Medical University of the Ministry of Health Care of Russian Federation (Sechenov University)
| | | | - S. N. Avdeev
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health Care of Russian Federation (Sechenov University)
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15
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Shao G, Hawle P, Akbari K, Horner A, Hintenberger R, Kaiser B, Lamprecht B, Lang D. Clinical, imaging, and blood biomarkers to assess 1-year progression risk in fibrotic interstitial lung diseases-Development and validation of the honeycombing, traction bronchiectasis, and monocyte (HTM)-score. Front Med (Lausanne) 2022; 9:1043720. [PMID: 36465895 PMCID: PMC9709148 DOI: 10.3389/fmed.2022.1043720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 10/28/2022] [Indexed: 09/08/2023] Open
Abstract
INTRODUCTION Progression of fibrotic interstitial lung disease (ILD) leads to irreversible loss of lung function and increased mortality. Based on an institutional ILD registry, we aimed to evaluate biomarkers derived from baseline patient characteristics, computed tomography (CT), and peripheral blood for prognosis of disease progression in fibrotic ILD patients. METHODS Of 209 subsequent ILD-board patients enregistered, 142 had complete follow-up information and were classified fibrotic ILD as defined by presence of reticulation or honeycombing using a standardized semi-quantitative CT evaluation, adding up typical ILD findings in 0-6 defined lung fields. Progression at 1 year was defined as relative loss of ≥10% in forced vital capacity, of ≥15% in diffusion capacity for carbon monoxide, death, or lung transplant. Two-thirds of the patients were randomly assigned to a derivation cohort evaluated for the impact of age, sex, baseline lung function, CT finding scores, and blood biomarkers on disease progression. Significant variables were included into a regression model, its results were used to derive a progression-risk score which was then applied to the validation cohort. RESULTS In the derivation cohort, age, monocyte count ≥0.65 G/L, honeycombing and traction bronchiectasis extent had significant impact. Multivariate analyses revealed the variables monocyte count ≥0.65 G/L (1 point) and combined honeycombing or traction bronchiectasis score [0 vs. 1-4 (1 point) vs. 5-6 lung fields (2 points)] as significant, so these were used for score development. In the derivation cohort, resulting scores of 0, 1, 2, and 3 accounted for 1-year progression rates of 20, 25, 46.9, and 88.9%, respectively. Similarly, in the validation cohort, progression at 1 year occurred in 0, 23.8, 53.9, and 62.5%, respectively. A score ≥2 showed 70.6% sensitivity and 67.9% specificity, receiver operating characteristic analysis for the scoring model had an area under the curve of 71.7%. CONCLUSION The extent of honeycombing and traction bronchiectasis, as well as elevated blood monocyte count predicted progression within 1 year in fibrotic ILD patients.
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Affiliation(s)
- Guangyu Shao
- Department of Internal Medicine 4 – Pneumology, Kepler University Hospital, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Patricia Hawle
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Kaveh Akbari
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria
- Central Radiology Institute, Kepler University Hospital, Linz, Austria
| | - Andreas Horner
- Department of Internal Medicine 4 – Pneumology, Kepler University Hospital, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Rainer Hintenberger
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria
- Department of Internal Medicine 2, Kepler University Hospital, Linz, Austria
| | - Bernhard Kaiser
- Department of Internal Medicine 4 – Pneumology, Kepler University Hospital, Linz, Austria
| | - Bernd Lamprecht
- Department of Internal Medicine 4 – Pneumology, Kepler University Hospital, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - David Lang
- Department of Internal Medicine 4 – Pneumology, Kepler University Hospital, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria
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16
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Rai DK, Tripathi S. Antifibrotic in interstitial lung diseases: When, where, and how long? Lung India 2022; 39:491-494. [PMID: 36629226 PMCID: PMC9746283 DOI: 10.4103/lungindia.lungindia_283_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 07/27/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Deependra K. Rai
- Department of Pulmonary Medicine, AIIMS, Patna, Bihar, India E-mail:
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17
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New Paradigms in Hypersensitivity Pneumonitis. CURRENT PULMONOLOGY REPORTS 2022. [DOI: 10.1007/s13665-022-00295-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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18
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Piotrowski WJ, Martusewicz-Boros MM, Białas AJ, Barczyk A, Batko B, Błasińska K, Boros PW, Górska K, Grzanka P, Jassem E, Jastrzębski D, Kaczyńska J, Kowal-Bielecka O, Kucharz E, Kuś J, Kuźnar-Kamińska B, Kwiatkowska B, Langfort R, Lewandowska K, Mackiewicz B, Majewski S, Makowska J, Miłkowska-Dymanowska J, Puścińska E, Siemińska A, Sobiecka M, Soroka-Dąda RA, Szołkowska M, Wiatr E, Ziora D, Śliwiński P. Guidelines of the Polish Respiratory Society on the Diagnosis and Treatment of Progressive Fibrosing Interstitial Lung Diseases Other than Idiopathic Pulmonary Fibrosis. Adv Respir Med 2022; 90:425-450. [PMID: 36285980 PMCID: PMC9717335 DOI: 10.3390/arm90050052] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 08/24/2022] [Accepted: 09/05/2022] [Indexed: 11/16/2023]
Abstract
The recommendations were developed as answers to previously formulated questions concerning everyday diagnostic and therapeutic challenges. They were developed based on a review of the current literature using the GRADE methodology. The experts suggest that PF-ILD be diagnosed based on a combination of different criteria, such as the aggravation of symptoms, progression of radiological lesions, and worsening of lung function test parameters. The experts recommend a precise diagnosis of an underlying disease, with serological testing for an autoimmune disease always being included. The final diagnosis should be worked out by a multidisciplinary team (MDT). Patients with an interstitial lung disease other than IPF who do not meet the criteria for the progressive fibrosis phenotype should be monitored for progression, and those with systemic autoimmune diseases should be regularly monitored for signs of interstitial lung disease. In managing patients with interstitial lung disease associated with autoimmune diseases, an opinion of an MDT should be considered. Nintedanib rather than pirfenidon should be introduced in the event of the ineffectiveness of the therapy recommended for the treatment of the underlying disease, but in some instances, it is possible to start antifibrotic treatment without earlier immunomodulatory therapy. It is also admissible to use immunomodulatory and antifibrotic drugs simultaneously. No recommendations were made for or against termination of anti-fibrotic therapy in the case of noted progression during treatment of a PF-ILD other than IPF. The experts recommend that the same principles of non-pharmacological and palliative treatment and eligibility for lung transplantation should be applied to patients with an interstitial lung disease other than IPF with progressive fibrosis as in patients with IPF.
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Affiliation(s)
| | - Magdalena M. Martusewicz-Boros
- 3rd Lung Diseases and Oncology Department, National Tuberculosis and Lung Diseases Research Institute in Warsaw, 01-138 Warsaw, Poland
| | - Adam J. Białas
- Department of Pathobiology of Respiratory Diseases, Medical University of Lodz, 90-153 Lodz, Poland
| | - Adam Barczyk
- Department of Pneumonology, School of Medicine in Katowice, Medical University of Silesia, 40-635 Katowice, Poland
| | - Bogdan Batko
- Department of Rheumatology and Immunology, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski University, 30-705 Krakow, Poland
| | - Katarzyna Błasińska
- Department of Radiology, National Tuberculosis and Lung Diseases Research Institute in Warsaw, 01-138 Warsaw, Poland
| | - Piotr W. Boros
- Lung Pathophysiology Department, National Tuberculosis and Lung Diseases Research Institute in Warsaw, 01-138 Warsaw, Poland
| | - Katarzyna Górska
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Piotr Grzanka
- Department of Radiology, Voivodeship Hospital in Opole, 45-061 Opole, Poland
| | - Ewa Jassem
- Department of Allergology and Pneumonology, Medical University of Gdansk, 80-214 Gdańsk, Poland
| | - Dariusz Jastrzębski
- Department of Lung Diseases and Tuberculosis, Medical University of Silesia, 41-803 Zabrze, Poland
| | | | - Otylia Kowal-Bielecka
- Department of Rheumatology and Internal Medicine, Medical University of Białystok, 15-276 Białystok, Poland
| | - Eugeniusz Kucharz
- Department of Internal Medicine, Rheumatology and Clinical Immunology, Medical University of Silesia, 40-635 Katowice, Poland
| | - Jan Kuś
- 1st Lung Diseases Department, National Tuberculosis and Lung Diseases Research Institute in Warsaw, 01-138 Warsaw, Poland
| | - Barbara Kuźnar-Kamińska
- Department of Pulmonology, Allergology and Respiratory Oncology, University of Medical Sciences in Poznan, 61-701 Poznan, Poland
| | - Brygida Kwiatkowska
- Department of Rheumatology, Eleonora Reicher Rheumatology Institute, 02-637 Warszawa, Poland
| | - Renata Langfort
- Department of Pathology, National Tuberculosis and Lung Diseases Research Institute in Warsaw, 01-138 Warszawa, Poland
| | - Katarzyna Lewandowska
- 1st Lung Diseases Department, National Tuberculosis and Lung Diseases Research Institute in Warsaw, 01-138 Warsaw, Poland
| | - Barbara Mackiewicz
- Department of Pneumonology, Oncology and Allergology, Medical University, Lublin, 20-090 Lublin, Poland
| | - Sebastian Majewski
- Department of Pneumology, Medical University of Lodz, 90-153 Lodz, Poland
| | - Joanna Makowska
- Department of Rheumatology, Medical University of Lodz, 92-213 Lodz, Poland
| | | | - Elżbieta Puścińska
- 2nd Department of Respiratory Medicine, National Tuberculosis and Lung Diseases Research Institute in Warsaw, 01-138 Warsaw, Poland
| | - Alicja Siemińska
- Department of Allergology, Medical University of Gdańsk, 80-214 Gdansk, Poland
| | - Małgorzata Sobiecka
- 1st Lung Diseases Department, National Tuberculosis and Lung Diseases Research Institute in Warsaw, 01-138 Warsaw, Poland
| | | | - Małgorzata Szołkowska
- Department of Pathology, National Tuberculosis and Lung Diseases Research Institute in Warsaw, 01-138 Warszawa, Poland
| | - Elżbieta Wiatr
- 3rd Lung Diseases and Oncology Department, National Tuberculosis and Lung Diseases Research Institute in Warsaw, 01-138 Warsaw, Poland
| | - Dariusz Ziora
- Department of Lung Diseases and Tuberculosis, Medical University of Silesia, 41-803 Zabrze, Poland
| | - Paweł Śliwiński
- 2nd Department of Respiratory Medicine, National Tuberculosis and Lung Diseases Research Institute in Warsaw, 01-138 Warsaw, Poland
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Cottin V, Valenzuela C. Progressive pulmonary fibrosis: all roads lead to Rome (but not all at the same speed). Eur Respir J 2022; 60:60/4/2201449. [DOI: 10.1183/13993003.01449-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 07/25/2022] [Indexed: 11/05/2022]
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20
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Mehta P, Aggarwal R, Porter JC, Gunawardena H. Management of interstitial lung disease (ILD) in myositis syndromes: A practical guide for clinicians. Best Pract Res Clin Rheumatol 2022; 36:101769. [PMID: 35840503 DOI: 10.1016/j.berh.2022.101769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Inflammatory myopathies are heterogeneous clinico-serological syndromes, with variable clinical manifestations. Interstitial lung disease (ILD) is a major cause of morbidity and mortality in patients with myositis. The clinical manifestation of myositis-ILD is heterogeneous, e.g., with acute-on-chronic presentations, as well as the chronic aftermath of acute disease. Here, we have largely divided myositis-ILD into three main prognostic groups which require different treatment approaches: mild-moderate (subacute), severe or progressive (acute or subacute) and rapidly progressive, life-threatening. In current clinical practice, the treatment of myositis-ILD involves immunomodulation in an induction-maintenance treatment paradigm. There is now an option to add antifibrotics to slow the progression of established fibrosis in selected cases with chronic progressive phenotype. Here, we describe current concepts in myositis-ILD and aim to provide a practical guide for clinicians on how to approach assessment, including early identification of ILD, phenotyping of patients according to clinical trajectory and likely prognosis and stratified management adopting multi-disciplinary cross-speciality expertise, with close collaboration between rheumatology and respiratory physicians.
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Affiliation(s)
- Puja Mehta
- Centre for Inflammation and Tissue Repair, UCL Respiratory, Division of Medicine, University College London (UCL), London, UK; Department of Rheumatology, University College London Hospital (UCLH), UK.
| | - Rohit Aggarwal
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joanna C Porter
- Centre for Inflammation and Tissue Repair, UCL Respiratory, Division of Medicine, University College London (UCL), London, UK; Department of Respiratory Medicine, University College London Hospital (UCLH), UK
| | - Harsha Gunawardena
- Department of Rheumatology, North Bristol NHS Trust and University of Bristol, Bristol, UK.
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21
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Diesler R, Cottin V. Pulmonary fibrosis associated with rheumatoid arthritis: from pathophysiology to treatment strategies. Expert Rev Respir Med 2022; 16:541-553. [PMID: 35695895 DOI: 10.1080/17476348.2022.2089116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Rheumatoid arthritis (RA) is the most common inflammatory autoimmune disease, characterised by symmetric destructive arthritis and synovitis. Lung involvement is frequent, including in the form of interstitial lung disease (ILD). RA-ILD often presents with a radiologic and pathologic pattern of usual interstitial pneumonia, similar to idiopathic pulmonary fibrosis, highlighting the similarities between the two diseases, but other patterns and pathological associations are described. AREAS COVERED This article reviews the pathogenesis of pulmonary fibrosis in the setting of rheumatoid arthritis as well as the current and future therapeutic options. EXPERT OPINION Pulmonary fibrosis in the setting of RA-ILD is an example of genotype-environment interaction and involves multiple mechanisms including autoimmunity, inflammation and fibrogenesis. Despite that ILD conveys most of the exceeding mortality in RA patients, there are no official guidelines for the management of RA-ILD. Attention should be paid to potential lung toxicity of RA treatment even though some of them might help stabilise the ILD. Current standard of care is often composed of glucocorticoids that may be associated with immunosuppressive therapy. Following the approval of antifibrotic therapy for ILDs with a progressive fibrosing phenotype, current works are evaluating the benefit of such treatment in RA-ILD.
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Affiliation(s)
- Rémi Diesler
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, University of Lyon, INRAE, Lyon, France
| | - Vincent Cottin
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, University of Lyon, INRAE, Lyon, France
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22
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Matteson EL, Kelly C, Distler JHW, Hoffmann-Vold AM, Seibold JR, Mittoo S, Dellaripa PF, Aringer M, Pope J, Distler O, James A, Schlenker-Herceg R, Stowasser S, Quaresma M, Flaherty KR. Nintedanib in Patients With Autoimmune Disease-Related Progressive Fibrosing Interstitial Lung Diseases: Subgroup Analysis of the INBUILD Trial. Arthritis Rheumatol 2022; 74:1039-1047. [PMID: 35199968 PMCID: PMC9321107 DOI: 10.1002/art.42075] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 11/26/2021] [Accepted: 01/21/2022] [Indexed: 11/18/2022]
Abstract
Objective To analyze the efficacy and safety of nintedanib in patients with fibrosing autoimmune disease–related interstitial lung diseases (ILDs) with a progressive phenotype. Methods The INBUILD trial enrolled patients with a fibrosing ILD other than idiopathic pulmonary fibrosis, with diffuse fibrosing lung disease of >10% extent on high‐resolution computed tomography, forced vital capacity percent predicted (FVC%) ≥45%, and diffusing capacity of the lungs for carbon monoxide percent predicted ≥30% to <80%. Patients fulfilled protocol‐defined criteria for progression of ILD within the 24 months before screening, despite management deemed appropriate in clinical practice. Subjects were randomized to receive nintedanib or placebo. We assessed the rate of decline in FVC (ml/year) and adverse events (AEs) over 52 weeks in the subgroup with autoimmune disease–related ILDs. Results Among 170 patients with autoimmune disease–related ILDs, the rate of decline in FVC over 52 weeks was −75.9 ml/year with nintedanib versus −178.6 ml/year with placebo (difference 102.7 ml/year [95% confidence interval 23.2, 182.2]; nominal P = 0.012). No heterogeneity was detected in the effect of nintedanib versus placebo across subgroups based on ILD diagnosis (P = 0.91). The most frequent AE was diarrhea, reported in 63.4% and 27.3% of subjects in the nintedanib and placebo groups, respectively. AEs led to permanent discontinuation of trial drug in 17.1% and 10.2% of subjects in the nintedanib and placebo groups, respectively. Conclusion In the INBUILD trial, nintedanib slowed the rate of decline in FVC in patients with progressive fibrosing autoimmune disease–related ILDs, with AEs that were manageable for most patients. Video Abstract
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Affiliation(s)
- Eric L Matteson
- Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Clive Kelly
- Newcastle University, Newcastle-upon-Tyne, UK
| | - Jörg H W Distler
- Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | | | | | | | | | | | - Janet Pope
- University of Western Ontario, London, Ontario, Canada
| | | | | | | | - Susanne Stowasser
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Manuel Quaresma
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
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Bonella F, Cottin V, Valenzuela C, Wijsenbeek M, Voss F, Rohr KB, Stowasser S, Maher TM. Meta-Analysis of Effect of Nintedanib on Reducing FVC Decline Across Interstitial Lung Diseases. Adv Ther 2022; 39:3392-3402. [PMID: 35576048 PMCID: PMC9239974 DOI: 10.1007/s12325-022-02145-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 03/24/2022] [Indexed: 11/30/2022]
Abstract
Introduction The effect of nintedanib on slowing the rate of decline in forced vital capacity (FVC) has been investigated in randomized placebo-controlled trials in subjects with idiopathic pulmonary fibrosis (IPF), other progressive fibrosing interstitial lung diseases (ILDs), and ILD associated with systemic sclerosis (SSc-ILD). We assessed the consistency of the effect of nintedanib on the rate of decline in FVC over 52 weeks across four placebo-controlled phase III trials. Methods We used data on FVC decline from the INPULSIS-1 and INPULSIS-2 trials in subjects with IPF, the INBUILD trial in subjects with progressing fibrosing ILDs other than IPF, and the SENSCIS trial in subjects with SSc-ILD. In each trial, the primary endpoint was the annual rate of decline in FVC (mL/year) assessed over 52 weeks. We performed fixed effect and random effects meta-analyses based on the relative treatment effect of nintedanib versus placebo on the rate of decline in FVC (mL/year) over 52 weeks. Heterogeneity of the relative treatment effect of nintedanib across populations was assessed using the I2 statistic, τ2 and corresponding p value from a Q test for heterogeneity. Results The combined analysis comprised 1257 subjects treated with nintedanib and 1042 subjects who received placebo. Nintedanib reduced the rate of decline in FVC (mL/year) over 52 weeks by 51.0% (95% CI 39.1, 63.0) compared with placebo. The relative effect (95% CI) was the same using the fixed effect and random effects models. There was no evidence of heterogeneity in the relative treatment effect of nintedanib across the populations studied (I2 = 0%, τ2 = 0, p = 0.93). Conclusions A meta-analysis of data from four placebo-controlled trials demonstrated that nintedanib approximately halved the rate of decline in FVC over 52 weeks across subjects with different forms of pulmonary fibrosis, with no evidence of heterogeneity in its relative treatment effect across patient populations. Graphical abstract ![]()
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Affiliation(s)
- Francesco Bonella
- Interstitial and Rare Lung Disease Unit, Pneumology Department, Ruhrlandklinik, Duisburg-Essen University, Essen, Germany.
| | - Vincent Cottin
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, UMR 754, Lyon, France
| | - Claudia Valenzuela
- Hospital Universitario de la Princesa, Universidad Autonoma de Madrid, Madrid, Spain
| | - Marlies Wijsenbeek
- Centre for Interstitial Lung Diseases and Sarcoidosis, Department of Respiratory Medicine, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Florian Voss
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
| | - Klaus B Rohr
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Susanne Stowasser
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Toby M Maher
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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24
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Safety and tolerability of nintedanib in patients with progressive fibrosing interstitial lung diseases: data from the randomized controlled INBUILD trial. Respir Res 2022; 23:85. [PMID: 35392908 PMCID: PMC8991727 DOI: 10.1186/s12931-022-01974-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 02/24/2022] [Indexed: 11/15/2022] Open
Abstract
Background In the INBUILD trial in patients with progressive fibrosing interstitial lung diseases (ILDs), nintedanib reduced the rate of decline in forced vital capacity compared with placebo, with side-effects that were manageable for most patients. We used data from the INBUILD trial to characterize further the safety and tolerability of nintedanib. Methods Patients with fibrosing ILDs other than idiopathic pulmonary fibrosis (IPF), who had experienced progression of ILD within the 24 months before screening despite management deemed appropriate in clinical practice, were randomized to receive nintedanib 150 mg twice daily or placebo. To manage adverse events, treatment could be interrupted or the dose reduced to 100 mg twice daily. We assessed adverse events and dose adjustments over the whole trial. Results A total of 332 patients received nintedanib and 331 received placebo. Median exposure to trial drug was 17.4 months in both treatment groups. Adverse events led to treatment discontinuation in 22.0% of patients treated with nintedanib and 14.5% of patients who received placebo. The most frequent adverse event was diarrhea, reported in 72.3% of patients in the nintedanib group and 25.7% of patients in the placebo group. Diarrhea led to treatment discontinuation in 6.3% of patients in the nintedanib group and 0.3% of the placebo group. In the nintedanib and placebo groups, respectively, 48.2% and 15.7% of patients had ≥ 1 dose reduction and/or treatment interruption. Serious adverse events were reported in 44.3% of patients in the nintedanib group and 49.5% of patients in the placebo group. The adverse event profile of nintedanib was generally consistent across subgroups based on age, sex, race and weight, but nausea, vomiting and dose reductions were more common among female than male patients. Conclusions The adverse event profile of nintedanib in patients with progressive fibrosing ILDs other than IPF is consistent with its established safety and tolerability profile in patients with IPF and characterized mainly by gastrointestinal events, particularly diarrhea. Management of adverse events using symptomatic therapies and dose adjustment is important to minimize the impact of adverse events and help patients remain on therapy. Trial registration Registered 21 December 2016, https://clinicaltrials.gov/ct2/show/NCT02999178 Graphical Abstract A video abstract summarizing the key results presented in this manuscript is available at: https://www.globalmedcomms.com/respiratory/cottin/INBUILDsafety. Supplementary Information The online version contains supplementary material available at 10.1186/s12931-022-01974-2.
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25
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Hamblin M, Prosch H, Vašáková M. Diagnosis, course and management of hypersensitivity pneumonitis. Eur Respir Rev 2022; 31:31/163/210169. [PMID: 35140104 DOI: 10.1183/16000617.0169-2021] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 11/21/2021] [Indexed: 11/05/2022] Open
Abstract
Hypersensitivity pneumonitis (HP) is a complex and heterogeneous interstitial lung disease (ILD) that occurs when susceptible individuals develop an exaggerated immune response to an inhaled antigen. In this review, we discuss the latest guidelines for the diagnostic evaluation of patients with suspected HP, the importance of identifying patients with fibrotic and progressive disease, and the evidence supporting the drugs commonly used in the treatment of HP. Differential diagnosis of HP can be challenging and requires a thorough exposure history, multidisciplinary discussion of clinical and radiologic data, and, in some cases, assessment of bronchoalveolar lavage lymphocytosis and histopathologic findings. Patients with HP may be categorised as having non-fibrotic or fibrotic HP. The presence of fibrosis is associated with worse outcomes. A proportion of patients with fibrotic HP develop a progressive phenotype, characterised by worsening fibrosis, decline in lung function and early mortality. There are no established guidelines for the treatment of HP. Antigen avoidance should be implemented wherever possible. Immunosuppressants are commonly used in patients with HP but have not been shown to slow the worsening of fibrotic disease. Nintedanib, a tyrosine kinase inhibitor, has been approved by the US Food and Drug Administration for slowing the progression of chronic fibrosing ILDs with a progressive phenotype, including progressive fibrotic HP. Non-pharmacological interventions, such as oxygen therapy, pulmonary rehabilitation and supportive care, may be important components of the overall care of patients with progressive HP.
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Affiliation(s)
- Mark Hamblin
- Department of Pulmonary and Critical Care Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Helmut Prosch
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Martina Vašáková
- Department of Respiratory Medicine, University Thomayer Hospital, Prague, Czech Republic
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26
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Kreuter M, Maher TM, Corte TJ, Molina-Molina M, Axmann J, Gilberg F, Kirchgaessler KU, Cottin V. Pirfenidone in Unclassifiable Interstitial Lung Disease: A Subgroup Analysis by Concomitant Mycophenolate Mofetil and/or Previous Corticosteroid Use. Adv Ther 2022; 39:1081-1095. [PMID: 34936057 PMCID: PMC8866297 DOI: 10.1007/s12325-021-02009-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 11/29/2021] [Indexed: 01/13/2023]
Abstract
Introduction There are currently no approved treatments solely for unclassifiable interstitial lung disease (uILD); however, a recent trial showed this population can benefit from pirfenidone. We report a subgroup analysis of this trial to assess the effects of immunomodulators (concomitant mycophenolate mofetil [MMF] and/or previous corticosteroids) with pirfenidone in patients with uILD. Methods This was a multicenter, international, double-blind, randomized, placebo-controlled phase II trial of patients with progressive fibrosing uILD (NCT03099187). Patients were randomized (1:1) to receive pirfenidone 2403 mg/day or placebo. This analysis assessed forced vital capacity (FVC) change from baseline measured using site spirometry (key secondary endpoint) and safety over 24 weeks by concomitant MMF use at randomization (pre-specified analysis) and/or previous corticosteroid use (post hoc analysis). Results Overall, 253 patients were randomized, including 45 (17.8%) patients (pirfenidone, n = 23; placebo, n = 22) receiving concomitant MMF with/without previous corticosteroids (MMF subgroup); 79 (31.2%) patients (pirfenidone, n = 44; placebo, n = 35) receiving previous corticosteroids without MMF (corticosteroids/no-MMF subgroup); and 129 (51.0%) patients (pirfenidone, n = 60; placebo, n = 69) not receiving concomitant MMF or previous corticosteroids (no-corticosteroids/no-MMF subgroup). At 24 weeks, difference in mean (95% confidence interval) FVC change from baseline between pirfenidone and placebo was − 55.4 mL (− 206.7, 96.0; P = 0.4645) in the MMF subgroup; 128.4 mL (− 6.4, 263.3; P = 0.0617) in the corticosteroids/no-MMF subgroup; and 115.5 mL (35.1, 195.9; P = 0.0052) in the no-corticosteroids/no-MMF subgroup. All subgroups generally exhibited a similar pattern of treatment-emergent adverse events. Conclusion Although limited by design and small sample sizes, this analysis suggests pirfenidone may be less effective in patients with uILD receiving concomitant MMF, whereas a beneficial treatment effect was observed in patients not receiving concomitant MMF regardless of previous corticosteroid use. Pirfenidone was well tolerated regardless of MMF and/or corticosteroid use. Trial Registration Number ClinicalTrials.gov: NCT03099187.
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Affiliation(s)
- Michael Kreuter
- Department of Pulmonology and Critical Care Medicine, Center for Interstitial and Rare Lung Diseases, Thoraxklinik, University of Heidelberg, Roentgen Street 1, 69126, Heidelberg, Germany.
- German Center for Lung Research, Heidelberg, Germany.
| | - Toby M Maher
- Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK
- Fibrosis Research Group, National Heart and Lung Institute, Imperial College London, London, UK
- Hastings Center for Pulmonary Research and Division of Pulmonary, Critical Care and Sleep Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Tamera J Corte
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Medical School, University of Sydney, Camperdown, NSW, Australia
| | - Maria Molina-Molina
- ILD Unit, Respiratory Department, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), University Hospital of Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | | | | | | | - Vincent Cottin
- National Reference Coordinating Center for Rare Pulmonary Diseases (OrphaLung), Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
- IVPC, INRAE, Member of ERN-LUNG, University of Lyon, Lyon, France
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27
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Nagy A, Nagy T, Kolonics-Farkas AM, Eszes N, Vincze K, Barczi E, Tarnoki AD, Tarnoki DL, Nagy G, Kiss E, Maurovich-Horvat P, Bohacs A, Müller V. Autoimmune Progressive Fibrosing Interstitial Lung Disease: Predictors of Fast Decline. Front Pharmacol 2021; 12:778649. [PMID: 35002713 PMCID: PMC8727590 DOI: 10.3389/fphar.2021.778649] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 10/28/2021] [Indexed: 12/23/2022] Open
Abstract
A subset of interstitial lung diseases (ILDs) with autoimmune traits-including connective tissue disease-associated ILD (CTD-ILD) and interstitial pneumonia with autoimmune features (IPAF)-develops progressive fibrosing (PF)-ILD. The aim of our study was to evaluate the clinical characteristics and predictors of longitudinal lung function (LF) changes in autoimmune PF-ILD patients in a real-world setting. All ILD cases with confirmed or suspected autoimmunity discussed by a multidisciplinary team (MDT) between January 2017 and June 2019 (n = 511) were reviewed, including 63 CTD-ILD and 44 IPAF patients. Detailed medical history, LF test, diffusing capacity of the lung for carbon monoxide (DLCO), 6-min walk test (6MWT), blood gas analysis (BGA), and high-resolution computer tomography (HRCT) were performed. Longitudinal follow-up for functional parameters was at least 2 years. Women were overrepresented (70.1%), and the age of the IPAF group was significantly higher as compared to the CTD-ILD group (p < 0.001). Dyspnea, crackles, and weight loss were significantly more common in the IPAF group as compared to the CTD-ILD group (84.1% vs. 58.7%, p = 0.006; 72.7% vs. 49.2%, p = 0.017; 29.6% vs. 4.8%, p = 0.001). Forced vital capacity (FVC) yearly decline was more pronounced in IPAF (53.1 ± 0.3 vs. 16.7 ± 0.2 ml; p = 0.294), while the majority of patients (IPAF: 68% and CTD-ILD 82%) did not deteriorate. Factors influencing progression included malignancy as a comorbidity, anti-SS-A antibodies, and post-exercise pulse increase at 6MWT. Antifibrotic therapy was administered significantly more often in IPAF as compared to CTD-ILD patients (n = 13, 29.5% vs. n = 5, 7.9%; p = 0.007), and importantly, this treatment reduced lung function decline when compared to non-treated patients. Majority of patients improved or were stable regarding lung function, and autoimmune-associated PF-ILD was more common in patients having IPAF. Functional decline predictors were anti-SS-A antibodies and marked post-exercise pulse increase at 6MWT. Antifibrotic treatments reduced progression in progressive fibrosing CTD-ILD and IPAF, emphasizing the need for guidelines including optimal treatment start and combination therapies in this special patient group.
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Affiliation(s)
- Alexandra Nagy
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
| | - Tamas Nagy
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
| | | | - Noemi Eszes
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
| | - Krisztina Vincze
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
| | - Eniko Barczi
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
| | | | | | - György Nagy
- Department of Genetics, Cell- and Immunobiology, Semmelweis University, Budapest, Hungary
- Department of Rheumatology and Clinical Immunology, Semmelweis University, Budapest, Hungary
| | - Emese Kiss
- Department of Clinical Immunology, Adult and Pediatric Rheumatology, National Institute of Locomotor Diseases and Disabilities, Budapest, Hungary
- 3rd Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | | | - Aniko Bohacs
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
| | - Veronika Müller
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
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28
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Kypreos M, Barbera T, Newton CA, Glazer CS, Adams TN. Addition of antifibrotic therapy to immunosuppression in hypersensitivity pneumonitis: A case series. Respir Med Case Rep 2021; 34:101562. [PMID: 34926143 PMCID: PMC8649083 DOI: 10.1016/j.rmcr.2021.101562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 10/26/2021] [Accepted: 11/28/2021] [Indexed: 11/28/2022] Open
Abstract
Hypersensitivity pneumonitis has historically been treated with immunosuppression, but recently nintedanib was approved for the treatment of progressive fibrotic HP. One limitation of INBUILD is that the only immunosuppression (IS) permitted at the time of enrollment was glucocorticoids at a dose of less than 20mg per day, so the additive effect of antifibrotic (AF) therapy to IS in HP remains unclear. We present 5 cases of patients with HP for whom AF therapy was added to IS. Trends observed in the cohort include reduced decline in FVC, oxygen requirement, and symptoms in the year after adding AF to IS in 4 of the 5 patients. All 5 patients (100%) in our series demonstrated progression in the year prior to initiation of antifibrotic based on criteria outlined in the INBUILD trial, but only 1 of 5 (20%) progressed in the year after AF. There was a significant decrease in the rate of relative decline in % predicted FVC in the 12 months after initiation of antifibrotic compared to the 12 months prior to antifibrotic (0.4% ±7.6 vs -17.5% ±7.6, p = 0.0495). Compared to the 12 months prior to antifibrotic therapy, fewer patients met criteria for progression in the 12 months after initiating antifibrotic therapy (p = 0.048). Similarly, fewer patients met criteria for progression in the 6 months after initiating antifibrotic therapy compared to the 6 months prior (p = 0.048). A larger study with control groups on IS alone and AF alone is needed to confirm the role of AF therapy in combination with IS in patients with HP.
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Affiliation(s)
- Margaret Kypreos
- University of Texas Southwestern Medical Center, Division of Pulmonary and Critical Care Medicine, USA
| | - Tyonn Barbera
- University of Texas Southwestern Medical Center, Division of Pulmonary and Critical Care Medicine, USA
| | - Chad A Newton
- University of Texas Southwestern Medical Center, Division of Pulmonary and Critical Care Medicine, USA
| | - Craig S Glazer
- University of Texas Southwestern Medical Center, Division of Pulmonary and Critical Care Medicine, USA
| | - Traci N Adams
- University of Texas Southwestern Medical Center, Division of Pulmonary and Critical Care Medicine, USA
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29
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Wilfong EM, Aggarwal R. Role of antifibrotics in the management of idiopathic inflammatory myopathy associated interstitial lung disease. Ther Adv Musculoskelet Dis 2021; 13:1759720X211060907. [PMID: 34917177 PMCID: PMC8669869 DOI: 10.1177/1759720x211060907] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 10/30/2021] [Indexed: 01/13/2023] Open
Abstract
The antifibrotic therapies nintedanib and pirfenidone were first approved by the United States for the treatment of idiopathic pulmonary fibrosis in 2014. In 2020, nintedanib received U.S. Food and Drug Administration (FDA) approval for the treatment of all progressive fibrosing interstitial lung disease (ILD). Given that a major cause of mortality and morbidity in the idiopathic inflammatory myopathies (IIM) is progressive interstitial lung disease and respiratory failure, antifibrotic therapies may be useful as adjuvant to traditional immunosuppression. However, randomized controlled trials of antifibrotic therapies in IIM are lacking. The purpose of this review is to (1) summarize the mechanism of action of nintedanib and pirfenidone in ILD with possible role in IIM-ILD, (2) review the clinical data supporting their use in interstitial lung disease in general, and more specifically in connective tissue disease associated ILD, and (3) discuss the evidence and remaining challenges for using antifibrotic therapies in IIM-ILD.
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Affiliation(s)
- Erin M. Wilfong
- Divisions of Rheumatology and Immunology & Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232 USA
| | - Rohit Aggarwal
- Division of Rheumatology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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30
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Nathan SD, Tapson VF, Elwing J, Rischard F, Mehta J, Shapiro S, Shen E, Deng C, Smith P, Waxman A. Efficacy of Inhaled Treprostinil on Multiple Disease Progression Events in Patients with Pulmonary Hypertension Due to Parenchymal Lung Disease in the INCREASE Trial. Am J Respir Crit Care Med 2021; 205:198-207. [PMID: 34767495 PMCID: PMC8787243 DOI: 10.1164/rccm.202107-1766oc] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Rationale The INCREASE study of inhaled treprostinil met its primary endpoint of change in 6-minute-walk distance at Week 16. In addition, there were significantly fewer clinical worsening events in patients receiving inhaled treprostinil. However, the incidence of multiple events in the same patient is unknown. Objectives This post hoc analysis evaluated the effect of continued treatment with inhaled treprostinil on the frequency and impact of multiple disease progression events. Methods Patients enrolled in INCREASE were analyzed for disease progression events, defined as at least 15% decline in 6-minute-walk distance, exacerbation of underlying lung disease, cardiopulmonary hospitalization, lung transplantation, at least 10% decline in forced vital capacity, or death during the duration of the 16-week study. Measurements and Main Results In total, 147 disease progression events occurred in the inhaled treprostinil group (89/163 patients, 55%) compared with 215 events (109/163 patients, 67%) in the placebo group (P = 0.018). There was a lower incidence of each disease progression component in the inhaled treprostinil group: 6-minute-walk distance decline (45 vs. 64 events), lung disease exacerbation (48 vs. 72 events), FVC decline (19 vs. 33), cardiopulmonary hospitalization (23 vs. 33 events), and death (10 vs. 12). Fewer patients receiving inhaled treprostinil had multiple progression events compared with those receiving the placebo (35 vs. 58, 22% vs. 36%; P = 0.005). Conclusions Patients who received inhaled treprostinil were significantly less likely to experience further disease progression events after an initial event compared with patients receiving placebo. These results support the continuation of inhaled treprostinil despite the occurrence of disease progression in clinical practice.
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Affiliation(s)
- Steven D Nathan
- Inova Fairfax Hospital, 23146, Advanced Lung Disease and Transplant Program, Falls Church, Virginia, United States;
| | - Victor F Tapson
- Cedars Sinai Medical Center, Medicine - Pulmonary, Beverely Hills, California, United States
| | - Jean Elwing
- University of Cincinnati, 2514, Pulmonary, Critical Care, and Sleep Medicine, Cincinnati, Ohio, United States
| | - Franz Rischard
- University of Arizona, Division of Pulmonary and Critical Care Medicine, Tuscon, Arizona, United States
| | - Jinesh Mehta
- Cleveland Clinic Florida, Department of Pulmonary & Critical Care Medicine, Weston, Florida, United States
| | - Shelley Shapiro
- UCLA Medical Center, 21767, Los Angeles, California, United States
| | - Eric Shen
- United Therapeutics Corp, 17909, Silver Spring, Maryland, United States
| | - Chunqin Deng
- United Therapeutics Corp, 17909, Silver Spring, Maryland, United States
| | - Peter Smith
- United Therapeutics Corp, 17909, Silver Spring, Maryland, United States
| | - Aaron Waxman
- Brigham and Women's Hospital, 1861, Pulmonary and Critical Care, Boston, Massachusetts, United States
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31
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Albera C, Verri G, Sciarrone F, Sitia E, Mangiapia M, Solidoro P. Progressive Fibrosing Interstitial Lung Diseases: A Current Perspective. Biomedicines 2021; 9:biomedicines9091237. [PMID: 34572422 PMCID: PMC8465039 DOI: 10.3390/biomedicines9091237] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/09/2021] [Accepted: 09/13/2021] [Indexed: 12/20/2022] Open
Abstract
Interstitial lung diseases (ILDs) are a large and diverse group of rare and chronic respiratory disorders, with idiopathic pulmonary fibrosis (IPF) being the most common and best-studied member. Increasing interest in fibrosis as a therapeutic target and the appreciation that fibrotic mechanisms may be a treatable target of IPF prompted the development and subsequent approval of the antifibrotics, pirfenidone and nintedanib. The management of ILDs has changed considerably following an understanding that IPF and some ILDs share similar disease behavior of progressive fibrosis, termed “progressive fibrosing phenotype”. Indeed, antifibrotic treatment has shown to be beneficial in ILDs characterized by the progressive fibrosing phenotype. This narrative review summarizes current knowledge in the field of progressive fibrosing ILDs. Here, we discuss the clinical characteristics and pathogenesis of lung fibrosis and highlight relevant literature concerning the mechanisms underlying progressive fibrosing ILDs. We also summarize current diagnostic approaches and the available treatments of progressive fibrosing ILDs and address the optimization of treating progressive fibrosing ILDs with antifibrotics in clinical practice.
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Affiliation(s)
- Carlo Albera
- Department of Medical Sciences, School of Medicine, University of Turin, SC Pneumologia U, 10124 Turin, Italy; (F.S.); (E.S.); (P.S.)
- Correspondence: or carlo.albera.@yahoo.it; Tel.: +39-3356376598
| | - Giulia Verri
- Ciità della Salute e della Scienza, Molinette Hospital, SC Pneumologia U, 10124 Turin, Italy; (G.V.); (M.M.)
| | - Federico Sciarrone
- Department of Medical Sciences, School of Medicine, University of Turin, SC Pneumologia U, 10124 Turin, Italy; (F.S.); (E.S.); (P.S.)
| | - Elena Sitia
- Department of Medical Sciences, School of Medicine, University of Turin, SC Pneumologia U, 10124 Turin, Italy; (F.S.); (E.S.); (P.S.)
| | - Mauro Mangiapia
- Ciità della Salute e della Scienza, Molinette Hospital, SC Pneumologia U, 10124 Turin, Italy; (G.V.); (M.M.)
| | - Paolo Solidoro
- Department of Medical Sciences, School of Medicine, University of Turin, SC Pneumologia U, 10124 Turin, Italy; (F.S.); (E.S.); (P.S.)
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Chiu YH, Spierings J, de Jong PA, Hoesein FM, Grutters JC, van Laar JM, Voortman M. Predictors for progressive fibrosis in patients with connective tissue disease associated interstitial lung diseases. Respir Med 2021; 187:106579. [PMID: 34438351 DOI: 10.1016/j.rmed.2021.106579] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 08/11/2021] [Accepted: 08/16/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Connective tissue disease associated interstitial lung disease (CTD-ILD) is associated with decreased quality of life and high mortality risk. Outcome and treatment response is unpredictable. This study aimed to identify clinical predictors for CTD-ILD with poor outcome. METHODS We performed a retrospective single centre cohort study in outpatients with CTD-ILD seen between 2004 and 2018. Clinical and biochemical data, pulmonary function tests (PFT) and high-resolution computed tomography (HRCT) results were analysed. Overall survival and progressive fibrosing ILD (PF-ILD, defined as a significant deterioration of PFT or HRCT) after two years of follow-up were assessed. RESULTS In total, 150 patients with CTD-ILD were included. Thirty (20%) deaths occurred during a median follow-up of 40 months (IQR 27.3-60.8), which were attributed to pulmonary infection in six (4%), respiratory failure due to PF-ILD in ten (7%) and due to other causes in fourteen patients. PF-ILD occurred in 76 (50.7%) patients and was associated with poor overall survival (adjusted HR 5.73, 95%CI 1.17-28.11). Age, smoking, C-reactive protein, and steroid-use were independently associated with increased mortality risk as well. Furthermore, patients with diabetes mellitus (adjusted OR 4.52, 95%CI 1.10-18.51), steroid-use (adjusted OR 2.26, 95%CI 1.04-4.93), and a fibrotic HRCT pattern at baseline (adjusted OR 3.11, 95%CI 1.15-8.38) had a higher risk of PF-ILD. CONCLUSION PF-ILD is associated with increased mortality in patients with CTD-ILD. Patients with a fibrotic HRCT pattern at baseline, diabetes mellitus and steroid-use have a higher risk of developing PF-ILD.
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Affiliation(s)
- Yu-Hsiang Chiu
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht, the Netherlands; Division of Rheumatology/Immunology/Allergy, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Julia Spierings
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Pim A de Jong
- Department of Radiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | | | - Jan C Grutters
- Department of Pulmonology, University Medical Centre Utrecht, Utrecht, the Netherlands; Department of Pulmonology, ILD Center of Excellence, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Jacob M van Laar
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Mareye Voortman
- Department of Pulmonology, University Medical Centre Utrecht, Utrecht, the Netherlands.
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