Nintedanib in patients with progressive fibrosing interstitial lung diseases-subgroup analyses by interstitial lung disease diagnosis in the INBUILD trial: a randomised, double-blind, placebo-controlled, parallel-group trial

BACKGROUND

The INBUILD trial investigated the efficacy and safety of nintedanib versus placebo in patients with progressive fibrosing interstitial lung diseases (ILDs) other than idiopathic pulmonary fibrosis (IPF). We aimed to establish the effects of nintedanib in subgroups based on ILD diagnosis.

METHODS

The INBUILD trial was a randomised, double-blind, placebo-controlled, parallel group trial done at 153 sites in 15 countries. Participants had an investigator-diagnosed fibrosing ILD other than IPF, with chest imaging features of fibrosis of more than 10% extent on high resolution CT (HRCT), forced vital capacity (FVC) of 45% or more predicted, and diffusing capacity of the lung for carbon monoxide (DLco) of at least 30% and less than 80% predicted. Participants fulfilled protocol-defined criteria for ILD progression in the 24 months before screening, despite management considered appropriate in clinical practice for the individual ILD. Participants were randomly assigned 1:1 by means of a pseudo-random number generator to receive nintedanib 150 mg twice daily or placebo for at least 52 weeks. Participants, investigators, and other personnel involved in the trial and analysis were masked to treatment assignment until after database lock. In this subgroup analysis, we assessed the rate of decline in FVC (mL/year) over 52 weeks in patients who received at least one dose of nintedanib or placebo in five prespecified subgroups based on the ILD diagnoses documented by the investigators: hypersensitivity pneumonitis, autoimmune ILDs, idiopathic non-specific interstitial pneumonia, unclassifiable idiopathic interstitial pneumonia, and other ILDs. The trial has been completed and is registered with ClinicalTrials.gov, number NCT02999178.

FINDINGS

Participants were recruited between Feb 23, 2017, and April 27, 2018. Of 663 participants who received at least one dose of nintedanib or placebo, 173 (26%) had chronic hypersensitivity pneumonitis, 170 (26%) an autoimmune ILD, 125 (19%) idiopathic non-specific interstitial pneumonia, 114 (17%) unclassifiable idiopathic interstitial pneumonia, and 81 (12%) other ILDs. The effect of nintedanib versus placebo on reducing the rate of FVC decline (mL/year) was consistent across the five subgroups by ILD diagnosis in the overall population (hypersensitivity pneumonitis 73·1 [95% CI -8·6 to 154·8]; autoimmune ILDs 104·0 [21·1 to 186·9]; idiopathic non-specific interstitial pneumonia 141·6 [46·0 to 237·2]; unclassifiable idiopathic interstitial pneumonia 68·3 [-31·4 to 168·1]; and other ILDs 197·1 [77·6 to 316·7]; p=0·41 for treatment by subgroup by time interaction). Adverse events reported in the subgroups were consistent with those reported in the overall population.

INTERPRETATION

The INBUILD trial was not designed or powered to provide evidence for a benefit of nintedanib in specific diagnostic subgroups. However, its results suggest that nintedanib reduces the rate of ILD progression, as measured by FVC decline, in patients who have a chronic fibrosing ILD and progressive phenotype, irrespective of the underlying ILD diagnosis.

FUNDING

Boehringer Ingelheim.

Motivational interviewing to enhance adolescent mental health treatment engagement: a randomized clinical trial

BACKGROUND

The prevalence of anxiety and mood disorders in adolescents is a growing public health concern worldwide. Given the high rates of drop-out and limited resources available in psychiatric settings, the importance of engaging adolescents in evidence-based treatments cannot be understated. The aim of the study was to determine the efficacy of motivational interviewing (MI), as a brief pre-treatment intervention, to enhance treatment engagement in a standard therapy setting (group cognitive behavioral therapy; gCBT) for adolescents with anxiety and mood disorders.

METHOD

Ninety-six adolescents (13-18 years) with a principal diagnosis of an anxiety or mood disorder participated in a trial conducted at two publicly funded outpatient services. Participants were randomly assigned to individual MI for treatment engagement prior to gCBT (MI + gCBT), or to an individually administered active control (befriending) prior to gCBT (befriending + gCBT). Eight pairs of gCBT were run in parallel. Outcome measures were the mean number of gCBT sessions attended, treatment initiation, and ratings of readiness for treatment.

RESULTS

Participants randomized to MI as a pretreatment intervention attended significantly more group therapy sessions compared to those in the active control condition. The MI group also demonstrated greater treatment initiation, and ratings of treatment readiness were significantly higher for those randomized to MI.

CONCLUSIONS

MI, used as a pre-treatment intervention, enhanced group treatment engagement in adolescents diagnosed with anxiety and mood disorders compared to the active control condition. MI is a promising intervention to facilitate engagement in adolescent mental health settings.

Cosmetic breast augmentation and eating disorders

AIMS

To comment on the relation between eating disorders and requests for cosmetic surgery in some women.

METHODS

We report two cases of women who were accepted for cosmetic breast augmentation while suffering from current anorexia and bulimia nervosa.

RESULTS

For both women, the motivation for seeking cosmetic surgery was directly related to the body image distortion and dissatisfaction which were an inherent part of the eating disorder.

CONCLUSION

It is our contention that women with eating disorders require treatment to address the distortion in body image, and the belief that cosmetic surgery will result in satisfaction with their bodies. Screening for eating disorders and body image disturbance should be a routine part of assessment for cosmetic surgery.

Changing patterns of referral to an eating disorders clinic

A decline in overall referrals was noted at the eating disorders clinic, Manawaroa centre for psychological medicine in 1987. At the same time a proportional increase in referrals for bulimia was observed. To gather more information on these apparent changes, data on the clinic's referral pattern were collected and general practitioners in the area health board district were surveyed. The results suggested a relatively stable referral rate from 1983-9, with an average of 31 referrals per year. However, there appears to have been a decrease in anorexia nervosa, from over 50% of referrals in 1983 to approximately 5% of referrals in 1988-9, and a corresponding rise in bulimia from 8% in 1983 to 49% in 1988 and 35% in 1989. Responses were received from 61 general practitioners, 78% of those surveyed. Most general practitioners indicated that they perceived a need for an eating disorders clinic, but only 40% had referred to the clinic. The main reasons given for not referring were: no appropriate patients (33%), the general practitioner was unaware of the clinic (29%), and the patient was being maintained by the general practitioner (25%).

Reduction of rapid eating by normal adults

Three normal adults, who considered their eating habits socially unacceptable, were trained in the family home to eat at normal pace by gradually increasing their meal duration. Additional food, descriptive praise, and self-approval were made contingent upon a step-wise increasing criterion of meal duration. During maintenance, the additional food component was withdrawn. A multiple baseline experimental analysis showed that the treatment package was successful in decreasing rapid eating to normal rates, as measured by the subjects' self-monitoring of their meal durations. In addition, the increased durations were maintained when the food component was withdrawn from the treatment package in a subsequent phase.