1251
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Could prominent airway-centered fibroblast foci in lung biopsies predict underlying chronic microaspiration in idiopathic pulmonary fibrosis patients? Hum Pathol 2016; 53:1-7. [DOI: 10.1016/j.humpath.2016.02.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 01/26/2016] [Accepted: 02/04/2016] [Indexed: 11/23/2022]
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1252
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Baddini-Martinez J, Baldi BG, Costa CHD, Jezler S, Lima MS, Rufino R. Update on diagnosis and treatment of idiopathic pulmonary fibrosis. J Bras Pneumol 2016; 41:454-66. [PMID: 26578138 PMCID: PMC4635093 DOI: 10.1590/s1806-37132015000000152] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 08/06/2015] [Indexed: 11/24/2022] Open
Abstract
Idiopathic pulmonary fibrosis is a type of chronic fibrosing interstitial pneumonia, of unknown etiology, which is associated with a progressive decrease in pulmonary function and with high mortality rates. Interest in and knowledge of this disorder have grown substantially in recent years. In this review article, we broadly discuss distinct aspects related to the diagnosis and treatment of idiopathic pulmonary fibrosis. We list the current diagnostic criteria and describe the therapeutic approaches currently available, symptomatic treatments, the action of new drugs that are effective in slowing the decline in pulmonary function, and indications for lung transplantation.
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Affiliation(s)
- José Baddini-Martinez
- Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brasil
| | - Bruno Guedes Baldi
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | | | | | | | - Rogério Rufino
- Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brasil
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1253
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Karampitsakos T, Woolard T, Bouros D, Tzouvelekis A. Toll-like receptors in the pathogenesis of pulmonary fibrosis. Eur J Pharmacol 2016; 808:35-43. [PMID: 27364757 DOI: 10.1016/j.ejphar.2016.06.045] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 03/26/2016] [Accepted: 06/27/2016] [Indexed: 02/08/2023]
Abstract
Pulmonary fibrosis (PF) constitutes the end stage of a broad range of heterogeneous interstitial lung diseases, characterized by the destruction of the pulmonary parenchyma, deposition of extracellular matrix and dramatic changes in the phenotype of both fibroblasts and alveolar epithelial cells. More than 200 causes of pulmonary fibrosis have been identified so far, yet the most common form is idiopathic pulmonary fibrosis (IPF). IPF is a lethal lung disorder of unknown etiology with a gradually increasing worldwide incidence and a median survival of 3-5 years from the time of diagnosis. Despite intense research efforts, the pathogenesis remains elusive and no effective treatment is available. Accumulating body of evidence suggests an abnormal wound healing response followed by extracellular matrix deposition, destruction of lung architecture, ultimately leading to respiratory failure. The contribution of immune system in lung fibrogenesis had been largely underscored due to the absence of response to immunosuppressive agents; however, the premise that lung fibrosis has an immunologic background has been recently revived. Toll-like receptors (TLRs) are pattern recognition receptors (PRRs), which link innate and adaptive immune response and regulate wound healing. TLRs promote tissue repair or fibrosis in many disease settings including lung fibrosis, albeit with profound differences depending on the cellular microenvironment. This review summarizes the current state of knowledge regarding the mechanistic implications between TLRs and lung fibrosis and highlights the therapeutic potential of targeting TLR signaling at the ligand or receptor level.
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Affiliation(s)
- Theodoros Karampitsakos
- Academic Department of Pneumonology, Hospital for Diseases of the Chest, "Sotiria", Medical School, University of Athens, Messogion Avenue 152, Athens 11527, Greece
| | - Tony Woolard
- Department of Internal Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, P.O. Box 208057 New Haven, CT, USA
| | - Demosthenes Bouros
- Academic Department of Pneumonology, Hospital for Diseases of the Chest, "Sotiria", Medical School, University of Athens, Messogion Avenue 152, Athens 11527, Greece
| | - Argyris Tzouvelekis
- Department of Internal Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, P.O. Box 208057 New Haven, CT, USA.
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1254
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Wuyts WA, Bonella F, Costabel U, Cottin V, Kreuter M, Poletti V, Spagnolo P. An Important Step Forward, but Still a Way to Go. Am J Respir Crit Care Med 2016; 193:340-1. [PMID: 26829426 DOI: 10.1164/rccm.201509-1763le] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Wim A Wuyts
- 1 University Hospitals Leuven Leuven, Belgium
| | | | | | | | | | | | - Paolo Spagnolo
- 6 Canton Hospital Baselland Basel, Switzerland and.,7 University of Basel Liestal, Switzerland
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1255
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Acetylcysteine in IPF: the knockout blow? THE LANCET RESPIRATORY MEDICINE 2016; 4:420-1. [DOI: 10.1016/s2213-2600(16)30085-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 04/19/2016] [Indexed: 11/22/2022]
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1256
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Idiopathic pulmonary fibrosis: combating on a new turf. THE LANCET RESPIRATORY MEDICINE 2016; 4:430-2. [DOI: 10.1016/s2213-2600(16)30106-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 04/28/2016] [Indexed: 11/21/2022]
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Abstract
Despite major research efforts leading to the recent approval of pirfenidone and nintedanib, the dismal prognosis of idiopathic pulmonary fibrosis (IPF) remains unchanged. The elaboration of international diagnostic criteria and disease stratification models based on clinical, physiological, radiological, and histopathological features has improved the accuracy of IPF diagnosis and prediction of mortality risk. Nevertheless, given the marked heterogeneity in clinical phenotype and the considerable overlap of IPF with other fibrotic interstitial lung diseases (ILDs), about 10% of cases of pulmonary fibrosis remain unclassifiable. Moreover, currently available tools fail to detect early IPF, predict the highly variable course of the disease, and assess response to antifibrotic drugs. Recent advances in understanding the multiple interrelated pathogenic pathways underlying IPF have identified various molecular phenotypes resulting from complex interactions among genetic, epigenetic, transcriptional, post-transcriptional, metabolic, and environmental factors. These different disease endotypes appear to confer variable susceptibility to the condition, differing risks of rapid progression, and, possibly, altered responses to therapy. The development and validation of diagnostic and prognostic biomarkers are necessary to enable a more precise and earlier diagnosis of IPF and to improve prediction of future disease behaviour. The availability of approved antifibrotic therapies together with potential new drugs currently under evaluation also highlights the need for biomarkers able to predict and assess treatment responsiveness, thereby allowing individualised treatment based on risk of progression and drug response. This approach of disease stratification and personalised medicine is already used in the routine management of many cancers and provides a potential road map for guiding clinical care in IPF.
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Affiliation(s)
- Cécile Daccord
- Interstitial Lung Disease Unit, Royal Brompton and Harefield NHS Foundation Trust, London, UK; Respiratory Medicine Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Toby M Maher
- Interstitial Lung Disease Unit, Royal Brompton and Harefield NHS Foundation Trust, London, UK; NIHR Respiratory Biomedical Research Unit, Royal Brompton Hospital, London, UK; Fibrosis Research Group, Imperial College, London, UK
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1258
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Tossier C, Dupin C, Plantier L, Leger J, Flament T, Favelle O, Lecomte T, Diot P, Marchand-Adam S. Hiatal hernia on thoracic computed tomography in pulmonary fibrosis. Eur Respir J 2016; 48:833-42. [PMID: 27174889 DOI: 10.1183/13993003.01796-2015] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 04/03/2016] [Indexed: 11/12/2022]
Abstract
Gastro-oesophageal reflux has long been suspected of implication in the genesis and progression of idiopathic pulmonary fibrosis (IPF). We hypothesised that hiatal hernia may be more frequent in IPF than in other interstitial lung disease (ILD), and that hiatal hernia may be associated with more severe clinical characteristics in IPF.We retrospectively compared the prevalence of hiatal hernia on computed tomographic (CT) scans in 79 patients with IPF and 103 patients with other ILD (17 scleroderma, 54 other connective tissue diseases and 32 chronic hypersensitivity pneumonitis). In the IPF group, we compared the clinical, biological, functional, CT scan characteristics and mortality of patients with hiatal hernia (n=42) and without hiatal hernia (n=37).The prevalence of hiatal hernia on CT scan at IPF diagnosis was 53%, similar to ILD associated with scleroderma, but significantly higher than in the two other ILD groups. The size of the hiatal hernia was not linked to either fibrosis CT scan scores, or reduction in lung function in any group. Mortality from respiratory causes was significantly higher among IPF patients with hiatal hernia than among those without hiatal hernia (p=0.009).Hiatal hernia might have a specific role in IPF genesis, possibly due to pathological gastro-oesophageal reflux.
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Affiliation(s)
| | | | - Laurent Plantier
- Service de Pneumologie, CHRU Tours, Tours, France Université François Rabelais, UMR 1100, Tours, France INSERM, Centre d'Etude des Pathologies Respiratoires, UMR 1100/EA6305, Tours, France
| | | | | | | | - Thierry Lecomte
- Service d'Hepato-gastro-enterologie Tours, CHRU Tours, Hôpital Bretonneau, Tours, France
| | - Patrice Diot
- Service de Pneumologie, CHRU Tours, Tours, France Université François Rabelais, UMR 1100, Tours, France INSERM, Centre d'Etude des Pathologies Respiratoires, UMR 1100/EA6305, Tours, France
| | - Sylvain Marchand-Adam
- Service de Pneumologie, CHRU Tours, Tours, France Université François Rabelais, UMR 1100, Tours, France INSERM, Centre d'Etude des Pathologies Respiratoires, UMR 1100/EA6305, Tours, France
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1259
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Multidisciplinary discussions and interstitial lung disease diagnosis: how useful is a meeting of the minds? THE LANCET RESPIRATORY MEDICINE 2016; 4:529-531. [PMID: 27180020 DOI: 10.1016/s2213-2600(16)30065-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 04/12/2016] [Indexed: 01/21/2023]
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1260
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Behr J, Bendstrup E, Crestani B, Günther A, Olschewski H, Sköld CM, Wells A, Wuyts W, Koschel D, Kreuter M, Wallaert B, Lin CY, Beck J, Albera C. Safety and tolerability of acetylcysteine and pirfenidone combination therapy in idiopathic pulmonary fibrosis: a randomised, double-blind, placebo-controlled, phase 2 trial. THE LANCET RESPIRATORY MEDICINE 2016; 4:445-53. [PMID: 27161257 DOI: 10.1016/s2213-2600(16)30044-3] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 03/30/2016] [Accepted: 04/05/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Oral acetylcysteine (also known as N-acetylcysteine) is used with pirfenidone to treat idiopathic pulmonary fibrosis (IPF) in Europe. However, no randomised studies have investigated the safety and tolerability of this combination. The PANORAMA study assessed the safety and tolerability of acetylcysteine combined with pirfenidone in patients with IPF. Exploratory efficacy endpoints were also assessed. METHODS We did a double-blind randomised trial at 48 sites in eight countries. Patients with IPF aged 40-80 years and established on pirfenidone (at least 1602 mg/day for 8 weeks or longer) were randomly assigned in a 1:1 ratio by interactive voice response system to receive concomitant oral acetylcysteine (600 mg, three times daily) or placebo for 24 weeks. A stratified blocked randomisation scheme was used with a block size of 4. Randomisation was stratified by dose of pirfenidone (2403 mg/day [the maximum dose] or <2403 mg/day). Patients, physicians, study staff and the sponsor were masked to treatment group allocation. The primary endpoint was assessment of adverse events, which were collected at each visit and for 28 days after the last dose of study drug. Exploratory efficacy measurements included forced vital capacity (FVC), carbon monoxide diffusing capacity, and 6 min walk distance. Analyses were done in the modified intention-to-treat population, which included all patients who were randomised and received at least one dose of study medication. This study is registered with the European Clinical Trials Database (EudraCT number 2012-000564-14) and has been completed. FINDINGS 123 patients participated in the study between June 28, 2013, and Feb 24, 2015. 61 were assigned to the acetylcysteine group (60 received study medication and included in analysis) and 62 were assigned to the placebo group (all included in analysis). The occurrence of at least one adverse event (46 [77%] patients receiving acetylcysteine vs 50 [81%] receiving placebo), adverse events related to study treatment (17 [28%] vs 16 [26%]), and the number of patients experiencing severe adverse events (three [5%] vs two [3%]), life-threatening adverse events (one [2%] vs one [2%]), or death (one [2%] vs three [5%]) was similar between treatment groups. One case of diarrhoea in the acetylcysteine group was considered severe and related to study treatment. Nine serious adverse events were reported by seven patients: dyspnoea, headache, hypertension, intervertebral disc protrusion, and malignant lung neoplasm in the acetylcysteine group, and aortic aneurysm, contusion, forearm fracture, and worsening IPF in the placebo group. The most common adverse events were cough, nasopharyngitis, and diarrhoea. Photosensitivity occurred more frequently with acetylcysteine (eight [13%] patients) than placebo (one [2%] patient; difference 11·7%; 95% CI 2·6-20·9; p=0·016]), and was not attributable to differences in location, season, or concomitant medication. Four (7%) patients receiving acetylcysteine and three (5%) receiving placebo discontinued study treatment due to adverse events. In the exploratory analysis, change in FVC indicated that clinical benefit from addition of acetylcysteine to pirfenidone is unlikely, with the possibility of a harmful effect in patients with IPF (adjusted rate of decline 125·6 mL/6 months for acetylcysteine vs 34·3 mL/6 months for placebo; difference -91·3 mL; 95% CI -174·4 to -8·3; p=0·031). INTERPRETATION Findings from the PANORAMA study suggest that addition of acetylcysteine to pirfenidone does not substantially alter the tolerability profile of pirfenidone, and is unlikely to be beneficial in IPF. FUNDING InterMune International AG (Roche).
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Affiliation(s)
- Jürgen Behr
- Department of Internal Medicine V, Ludwig-Maximilian University of Munich, Munich, Germany; Asklepios Clinic Gauting, Member of the German Center for Lung Research, Germany.
| | - Elisabeth Bendstrup
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | - Bruno Crestani
- AP-HP, Hôpital Bichat, Service de Pneumologie A, DHU FIRE, Université Paris Diderot, Paris, France
| | - Andreas Günther
- University of Giessen, Agaplesion Lung Clinic Greifenstein, Member of the German Center for Lung Research, Giessen, Germany
| | - Horst Olschewski
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria
| | - C Magnus Sköld
- Department of Medicine, Karolinska University Hospital Solna, and Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Athol Wells
- Interstitial Lung Disease Unit, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Wim Wuyts
- Department of Respiratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Dirk Koschel
- Department of Internal Medicine/Pulmonology, Fachkrankenhaus Coswig, Coswig, Germany
| | - Michael Kreuter
- Pneumology and Respiratory Critical Care Medicine, Center for Interstitial and Rare Lung Diseases, Thoraxklinik, University of Heidelberg, Member of the German Center for Lung Research, Heidelberg, Germany
| | - Benoît Wallaert
- CHU, Service de Pneumologie et Immuno-allergologie, Hôpital Albert Calmette, Lille, France
| | | | - Jürgen Beck
- InterMune International AG, Muttenz, Switzerland
| | - Carlo Albera
- Department of Clinical and Biological Sciences, Interstitial and Rare Diseases Unit, University of Turin, Turin, Italy
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1261
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Kreuter M, Wuyts W, Renzoni E, Koschel D, Maher TM, Kolb M, Weycker D, Spagnolo P, Kirchgaessler KU, Herth FJF, Costabel U. Antacid therapy and disease outcomes in idiopathic pulmonary fibrosis: a pooled analysis. THE LANCET. RESPIRATORY MEDICINE 2016; 4:381-9. [PMID: 27050871 DOI: 10.1016/s2213-2600(16)00067-9] [Citation(s) in RCA: 160] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 02/11/2016] [Accepted: 02/16/2016] [Indexed: 01/05/2023]
Abstract
BACKGROUND Gastro-oesophageal reflux disease is a potential risk factor for the development and progression of idiopathic pulmonary fibrosis (IPF). We aimed to investigate the effect of antacid therapy on disease progression in patients randomly assigned to placebo through analysis of three large, phase 3 trials of pirfenidone in IPF. METHODS Patients with IPF from the placebo groups of three trials of pirfenidone (CAPACITY 004, CAPACITY 006, and ASCEND) were included in this post-hoc analysis. We analysed effects of antacid therapy use from baseline for pulmonary function, exercise tolerance, survival, hospital admission, and adverse events for 52 weeks with and without adjustment for potential confounders. The primary endpoint, disease progression by 1 year, was defined as a decrease in predicted forced vital capacity (FVC) by 10% or more, a decrease in 6 min walk distance (6MWD) by 50 m or more, or death. We did survival analyses with the Kaplan-Meier estimator and evaluated using the log-rank test. FINDINGS Of 624 patients, 291 (47%) received antacid therapy and 333 (53%) did not. At 52 weeks, we noted no significant difference between groups for disease progression (114 [39%] for antacid therapy vs 141 [42%] for no antacid therapy, p=0·4844). Rates also did not differ for all-cause mortality (20 [7%] vs 22 [7%], p=0·8947), IPF-related mortality (11 [4%] vs 17 [5%]; p=0·4251), absolute FVC decrease by 10% or more (49 [17%] vs 64 [19%]; p=0·4411), or mean observed change in FVC (% predicted -4·9% [SD 6·4] vs -5·5% [7·2], p=0·3355; observed volume -0·2 L [0·3] vs -0·2 L [0·3], p=0·4238). The rate of hospital admission was non-significantly higher in the antacid therapy group (65 [22%] vs 54 [16%]; p=0·0522). When stratified by baseline FVC (<70% or ≥70%), disease progression, mortality, FVC, 6MWD, and hospital admission did not differ between groups. Adverse events were similar between treatment and no treatment groups; however, overall infections (107 [74%] vs 101 [62%]; p=0·0174) and pulmonary infections (20 [14%] vs 10 [6%]; p=0·0214) were higher in patients with advanced IPF (ie, FVC <70%) who were treated with antacids than not treated with antacids. INTERPRETATION Antacid therapy did not improve outcomes in patients with IPF and might potentially be associated with an increased risk of infection in those with advanced disease. FUNDING F Hoffmann-La Roche.
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Affiliation(s)
- Michael Kreuter
- Center for Interstitial and Rare Lung Diseases, Pneumology and Respiratory Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany; Translational Lung Research Center Heidelberg, German Center for Lung Research, Heidelberg, Germany.
| | - Wim Wuyts
- Unit for Interstitial Lung Diseases, Department of Respiratory Medicine, University Hospitals, Leuven, Belgium
| | - Elisabetta Renzoni
- National Institute for Health Biomedical Research Unit, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Dirk Koschel
- Department of Pulmonary Diseases, Fachkrankenhaus Coswig, Centre for Pulmonary Diseases and Thoracic Surgery, Coswig, Germany
| | - Toby M Maher
- National Institute for Health Biomedical Research Unit, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Martin Kolb
- Firestone Institute for Respiratory Health, Department of Medicine, Pathology & Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Derek Weycker
- Policy Analysis Inc, MINERVA Health Economics Network, Brookline, MA, USA
| | - Paolo Spagnolo
- Medical University Clinic, Kanton Hospital Baselland and University of Basel, Liestal, Switzerland
| | | | - Felix J F Herth
- Center for Interstitial and Rare Lung Diseases, Pneumology and Respiratory Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany; Translational Lung Research Center Heidelberg, German Center for Lung Research, Heidelberg, Germany
| | - Ulrich Costabel
- Interstitial and Rare Lung Disease Unit, Ruhrlandklinik, University Hospital, University of Duisburg-Essen, Essen, Germany
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1262
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Nathan SD. Antacid therapy and idiopathic pulmonary fibrosis: cause for heartburn? THE LANCET RESPIRATORY MEDICINE 2016; 4:340-1. [DOI: 10.1016/s2213-2600(16)00102-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 03/08/2016] [Indexed: 12/23/2022]
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Agrawal A, Verma I, Shah V, Agarwal A, Sikachi RR. Cardiac manifestations of idiopathic pulmonary fibrosis. Intractable Rare Dis Res 2016; 5:70-5. [PMID: 27195188 PMCID: PMC4869585 DOI: 10.5582/irdr.2016.01023] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive, parenchymal disease of the lung with an estimated prevalence of 14-43 per 100,000. Patient usually presents with coughing and exertional dyspnea, which can lead to acute respiratory failure. IPF has been associated with various co-morbidities such as lung cancer, emphysema, obstructive sleep apnea (OSA), GERD and multiple cardiovascular consequences. The cardiovascular manifestations of IPF include pulmonary hypertension, heart failure, coronary artery disease, cardiac arrhythmias & cardiac manifestations of drugs used to treat IPF. This review will outline evidence of the association between IPF and cardiovascular conditions and attempt to provide insights into the underlying pathophysiology. We also discuss the impact of these cardiovascular diseases on patients with IPF including increased morbidity and mortality.
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Affiliation(s)
- Abhinav Agrawal
- Department of Medicine, Monmouth Medical Center, Long Branch, New Jersey, USA
- Address correspondence to: Dr. Abhinav Agrawal, Department of Medicine, Monmouth Medical Center, Long Branch, New Jersey, USA 07740. E-mail: ,
| | - Isha Verma
- Department of Medicine, Monmouth Medical Center, Long Branch, New Jersey, USA
| | - Varun Shah
- Department of Medicine, University of Miami/JFK Medical Center Palm Beach Regional GME Consortium, Atlantis, Florida, USA
| | - Abhishek Agarwal
- Department of Medicine, Cooper University Hospital, Camden, New Jersey, USA
| | - Rutuja R Sikachi
- Department of Anesthesiology, Lilavati Hospital & Research Center, Mumbai, India
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1265
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Nair GB, Matela A, Kurbanov D, Raghu G. Newer developments in idiopathic pulmonary fibrosis in the era of anti-fibrotic medications. Expert Rev Respir Med 2016; 10:699-711. [PMID: 27094006 DOI: 10.1080/17476348.2016.1177461] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Idiopathic pulmonary fibrosis (IPF) is the most common interstitial lung disease with a fatal prognosis. Over the last decade, the concepts in pathobiology of pulmonary fibrosis have shifted from a model of chronic inflammation to dysregulated fibroproliferative repair in genetically predisposed patients. Although new breakthrough treatments are now available that slow the progression of the disease, several newer anti-inflammatory and anti-fibrotic drugs are under investigation. Patients with IPF often have coexistent conditions; prompt detection and interventions of which may improve the overall outcome of patients with IPF. Here, we summarize the present understanding of pathogenesis of IPF and treatment options for IPF in the current landscape of new anti-fibrotic treatment options.
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Affiliation(s)
- Girish B Nair
- a Division of Pulmonary & Critical Care Medicine , Winthrop-University Hospital , Mineola , NY , USA.,b Department of Medicine , SUNY Stony Brook School of Medicine , NY , USA
| | - Ajsza Matela
- a Division of Pulmonary & Critical Care Medicine , Winthrop-University Hospital , Mineola , NY , USA
| | - Daniel Kurbanov
- a Division of Pulmonary & Critical Care Medicine , Winthrop-University Hospital , Mineola , NY , USA
| | - Ganesh Raghu
- c Department of Medicine & Lab Medicine (Adjunct), Division of Pulmonary & Critical Care Medicine , University of Washington , Seattle , WA , USA
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1266
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Bando M. Pirfenidone: Clinical trials and clinical practice in patients with idiopathic pulmonary fibrosis. Respir Investig 2016; 54:298-304. [PMID: 27566376 DOI: 10.1016/j.resinv.2016.03.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 03/18/2016] [Accepted: 03/22/2016] [Indexed: 11/30/2022]
Abstract
Pirfenidone is an oral drug that exerts not only anti-fibrotic activity but also pleiotropic effects, such as anti-inflammatory and anti-oxidative effects. Because it suppresses reduction in vital capacity and improves progression-free survival, it was approved in October 2008 in Japan for the first time in the world as an anti-fibrotic agent for treatment of idiopathic pulmonary fibrosis (IPF). In October 2014, the agent was approved in the U.S., based on the results of the ASCEND study. Today, it is commercially available in 38 countries worldwide. In clinical practice, it is important to pay attention to the balance between the effectiveness and adverse events (such as gastrointestinal symptoms and photosensitivity reactions, among others) of treatment with pirfenidone. It is important to investigate pirfenidone׳s most cost-effective usage, and the ideal time of treatment initiation, the condition in which treatment should be initiated, and duration of treatment.
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Affiliation(s)
- Masashi Bando
- Division of Pulmonary Medicine, Department of Medicine, Jichi Medical University, Tochigi, Japan.
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1267
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Kreuter M, Wijsenbeek MS, Vasakova M, Spagnolo P, Kolb M, Costabel U, Weycker D, Kirchgaessler KU, Maher TM. Unfavourable effects of medically indicated oral anticoagulants on survival in idiopathic pulmonary fibrosis. Eur Respir J 2016; 47:1776-84. [PMID: 27103382 DOI: 10.1183/13993003.02087-2015] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 01/25/2016] [Indexed: 11/05/2022]
Abstract
Procoagulant and antifibrinolytic activity has been associated with idiopathic pulmonary fibrosis (IPF); however, investigation of anticoagulant therapy in IPF has suggested deleterious effects. This post hoc analysis evaluated the effect of medically indicated anticoagulation on mortality and other clinical outcomes in IPF.Patients randomised to placebo (n=624) from three controlled trials in IPF were analysed by oral anticoagulant use. End-points included all-cause and IPF-related mortality, disease progression, hospitalisation, and adverse events, over 1 year.At baseline, 32 (5.1%) patients randomised to placebo were prescribed anticoagulants for non-IPF indications, 29 (90.6%) of whom received warfarin. Unadjusted analyses demonstrated significantly higher all-cause and IPF-related mortality at 1 year in baseline anticoagulant users versus nonusers (15.6% versus 6.3%, p=0.039 and 15.6% versus 3.9%, p=0.002, respectively). In multivariate analyses, baseline use of anticoagulants was an independent predictor of IPF-related mortality (hazard ratio 4.7, p=0.034), but not other end-points. Rates of bleeding and cardiac events did not differ significantly between groups. In an exploratory analysis, anticoagulant use at any time during the study was an independent predictor of all end-points.This post hoc analysis suggests that anticoagulants used for non-IPF indications may have unfavourable effects in IPF patients. Future studies are needed to explore this relationship further.
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Affiliation(s)
- Michael Kreuter
- Center for Interstitial and Rare Lung Diseases, Pneumology and Respiratory Critical Care Medicine, Thoraxklinik, University of Heidelberg, and Translational Lung Research Center Heidelberg (TLRCH), Heidelberg, Germany; Member of the German Center for Lung Research (DZL), Germany
| | - Marlies S Wijsenbeek
- Dept of Pulmonary Medicine, Erasmus Medical Center, University Hospital Rotterdam, Rotterdam, The Netherlands
| | - Martina Vasakova
- Dept of Respiratory Medicine, Thomayer Hospital, Prague, Czech Republic
| | - Paolo Spagnolo
- Medical University Clinic, Canton Hospital Baselland and University of Basel, Liestal, Switzerland
| | - Martin Kolb
- Firestone Institute for Respiratory Health, Dept of Medicine, Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Ulrich Costabel
- Interstitial and Rare Lung Disease Unit, Ruhrlandklinik, University Hospital, University of Duisburg-Essen, Essen, Germany
| | | | | | - Toby M Maher
- National Institute for Health Research Biomedical Research Unit, Royal Brompton Hospital and Fibrosis Research Group, National Heart and Lung Institute, Imperial College, London, UK
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1268
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Williams K, Roman J. Studying human respiratory disease in animals--role of induced and naturally occurring models. J Pathol 2016; 238:220-32. [PMID: 26467890 DOI: 10.1002/path.4658] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 10/09/2015] [Accepted: 10/09/2015] [Indexed: 01/12/2023]
Abstract
Respiratory disorders like asthma, emphysema, and pulmonary fibrosis affect millions of Americans and many more worldwide. Despite advancements in medical research that have led to improved understanding of the pathophysiology of these conditions and sometimes to new therapeutic interventions, these disorders are for the most part chronic and progressive; current interventions are not curative and do not halt disease progression. A major obstacle to further advancements relates to the absence of animal models that exactly resemble the human condition, which delays the elucidation of relevant mechanisms of action, the unveiling of biomarkers of disease progression, and identification of new targets for intervention in patients. There are currently many induced animal models of human respiratory disease available for study, and even though they mimic features of human disease, discoveries in these models have not always translated into safe and effective treatments in humans. A major obstacle relates to the genetic, anatomical, and functional variations amongst species, which represents the major challenge to overcome when searching for appropriate models of respiratory disease. Nevertheless, rodents, in particular mice, have become the most common species used for experimentation, due to their relatively low cost, size, and adequate understanding of murine genetics, among other advantages. Less well known is the fact that domestic animals also suffer from respiratory illnesses similar to those found in humans. Asthma, bronchitis, pneumonia, and pulmonary fibrosis are among the many disorders occurring naturally in dogs, cats, and horses, among other species. These models might better resemble the human condition and are emphasized here, but further investigations are needed to determine their relevance.
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Affiliation(s)
- Kurt Williams
- Department of Pathobiology and Diagnostic Investigation, College of Veterinary Medicine, Michigan State University, East Lansing, Michigan, USA
| | - Jesse Roman
- Departments of Medicine and Pharmacology & Toxicology, Division of Pulmonary, Critical Care & Sleep Medicine, University of Louisville Health Sciences Center and Robley Rex Veterans Affairs Medical Center, Louisville, Kentucky, USA
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1269
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Hagmeyer L, Treml M, Priegnitz C, Randerath WJ. Successful Concomitant Therapy with Pirfenidone and Nintedanib in Idiopathic Pulmonary Fibrosis: A Case Report. Respiration 2016; 91:327-32. [PMID: 27073887 DOI: 10.1159/000444690] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Accepted: 02/05/2016] [Indexed: 11/19/2022] Open
Abstract
Pirfenidone and nintedanib are both pleiotropic anti-fibrotic agents approved for the treatment of idiopathic pulmonary fibrosis (IPF) as monotherapy. To date, evidence supporting their efficacy as concomitant therapy has not been reported. Here, we present the first case of a Caucasian male patient with IPF treated with both pirfenidone and nintedanib following 2 years of treatment with pirfenidone monotherapy. Over a 24-month period, there was a clear decline in the patient's forced vital capacity from 3.5 liter before initiation of treatment to 2.5 liter after 24 months. Concomitant nintedanib treatment was initiated in March 2015. Lung function stabilized, and the two treatments were well tolerated. Treatment with pirfenidone and nintedanib has currently been ongoing for nearly 12 months. This is the first report of a successful long-term treatment with pirfenidone and nintedanib and suggests that in selected cases, concomitant anti-fibrotic therapy may represent a safe and therapeutically valuable escalation option after pirfenidone monotherapy.
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Affiliation(s)
- Lars Hagmeyer
- Clinic for Pneumology and Allergology, Center of Sleep Medicine and Respiratory Care, Bethanien Hospital, Solingen, Germany
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1270
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Borie R, Justet A, Beltramo G, Manali ED, Pradère P, Spagnolo P, Crestani B. Pharmacological management of IPF. Respirology 2016; 21:615-25. [PMID: 27072575 DOI: 10.1111/resp.12778] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 01/17/2016] [Accepted: 01/18/2016] [Indexed: 12/23/2022]
Abstract
Idiopathic pulmonary fibrosis (IPF) is a deadly disease with a median survival of approximately three years in historical cohorts. Despite increased knowledge of disease pathophysiology and selection of more targeted therapy, main clinical trials yielded negative results. However, two agents, pirfenidone and nintedanib, were recently shown to be effective in IPF and received marketing authorization worldwide. Both drugs significantly reduce functional decline and disease progression with an acceptable safety profile. Yet, none of these drugs actually improves or even stabilizes the disease or the symptoms perceived by the patient. Several other treatments and combinations are currently tested, and many more are ready for clinical trials. Their completion is critical for achieving the ultimate goal of curing patients with IPF.
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Affiliation(s)
- Raphael Borie
- APHP, Bichat Hospital, Department of Pneumology A, Centre de competence des maladies pulmonaires rares, DHU Fire, Paris, France.,INSERM, Paris, France.,Paris Diderot University, Paris, France
| | - Aurelien Justet
- APHP, Bichat Hospital, Department of Pneumology A, Centre de competence des maladies pulmonaires rares, DHU Fire, Paris, France.,INSERM, Paris, France.,Paris Diderot University, Paris, France
| | - Guillaume Beltramo
- APHP, Bichat Hospital, Department of Pneumology A, Centre de competence des maladies pulmonaires rares, DHU Fire, Paris, France.,INSERM, Paris, France.,Paris Diderot University, Paris, France
| | - Effrosyni D Manali
- 2nd Respiratory Medicine Department, 'Attikon' University Hospital, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Pauline Pradère
- APHP, Bichat Hospital, Department of Pneumology A, Centre de competence des maladies pulmonaires rares, DHU Fire, Paris, France.,INSERM, Paris, France.,Paris Diderot University, Paris, France
| | - Paolo Spagnolo
- Clinica di Malattie dell'Apparato Respiratorio, Università degli Studi di Padova, Padova, Italy
| | - Bruno Crestani
- APHP, Bichat Hospital, Department of Pneumology A, Centre de competence des maladies pulmonaires rares, DHU Fire, Paris, France.,INSERM, Paris, France.,Paris Diderot University, Paris, France
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1271
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Trawinska MA, Rupesinghe RD, Hart SP. Patient considerations and drug selection in the treatment of idiopathic pulmonary fibrosis. Ther Clin Risk Manag 2016; 12:563-74. [PMID: 27114711 PMCID: PMC4833375 DOI: 10.2147/tcrm.s81144] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) is a progressive interstitial lung disease of unknown cause. Approximately 5,000 people are diagnosed with IPF in the UK every year. People with IPF suffer significant morbidity and, without any curative treatment at present, survival rates remain poor with a median survival of 3 years. While treatment remains largely supportive, many drug therapies have been trialed in IPF over the years. Pirfenidone and nintedanib are newly licensed treatments for IPF and the first drugs to have shown convincing evidence of slowing disease progression. In addition to evaluating clinical evidence, we also discuss elements affecting drug choice from the viewpoint of patients and health care professionals. We discuss pharmacological and nonpharmacological aspects of providing best supportive care for patients with IPF. However, few good quality studies exist focusing on controlling symptoms specifically in patients with IPF, and recommendations are often extrapolated from evidence in other chronic diseases. In covering these topics, we hope to provide readers with a comprehensive review of the available evidence pertaining to all aspects of care for patients suffering with IPF.
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Affiliation(s)
- Maria A Trawinska
- Hull and East Yorkshire Hospitals NHS Trust, Cottingham, East Yorkshire, UK
| | | | - Simon P Hart
- Hull and East Yorkshire Hospitals NHS Trust, Cottingham, East Yorkshire, UK
- Hull York Medical School, Academic Respiratory Medicine, Castle Hill Hospital, Cottingham, East Yorkshire, UK
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1272
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Jones MG, Walsh SL, Jones KD, Richeldi L. Idiopathic pulmonary fibrosis: securing a confident diagnosis for every patient. Eur Respir J 2016; 47:1057-9. [DOI: 10.1183/13993003.00265-2016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 02/04/2016] [Indexed: 11/05/2022]
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1273
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Rochwerg B, Raghu G. Reply: Can Warfarin Be Used in the Treatment of Pulmonary Embolism in Idiopathic Pulmonary Fibrosis? Am J Respir Crit Care Med 2016; 193:811. [DOI: 10.1164/rccm.201601-0078le] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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1274
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Margaritopoulos GA, Antoniou KM. Can Warfarin Be Used in the Treatment of Pulmonary Embolism in Idiopathic Pulmonary Fibrosis? Am J Respir Crit Care Med 2016; 193:810-1. [DOI: 10.1164/rccm.201511-2267le] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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1275
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Kreuter M, Ehlers-Tenenbaum S, Palmowski K, Bruhwyler J, Oltmanns U, Muley T, Heussel CP, Warth A, Kolb M, Herth FJF. Impact of Comorbidities on Mortality in Patients with Idiopathic Pulmonary Fibrosis. PLoS One 2016; 11:e0151425. [PMID: 27023440 PMCID: PMC4811578 DOI: 10.1371/journal.pone.0151425] [Citation(s) in RCA: 191] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 02/29/2016] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Comorbidities significantly influence the clinical course of idiopathic pulmonary fibrosis (IPF). However, their prognostic impact is not fully understood. We therefore aimed to determine the impact of comorbidities, as individual and as whole, on survival in IPF. METHODS The database of a tertiary referral centre for interstitial lung diseases was reviewed for comorbidities, their treatments, their frequency and survival in IPF patients. RESULTS 272 patients were identified of which 12% had no, 58% 1-3 and 30% 4-7 comorbidities, mainly cardiovascular, pulmonary and oncologic comorbidities. Median survival according to the frequency of comorbidities differed significantly with 66 months for patients without comorbidities, 48 months when 1-3 comorbidities were reported and 35 months when 4-7 comorbidities were prevalent (p = 0.004). A multivariate Cox proportional hazard analyses identified other cardiac diseases and lung cancer as significant predictors of death, gastro-oesophageal reflux disease (GERD) and diastolic dysfunction had a significant positive impact on survival. A significant impact of comorbidities associated therapies on survival was not discovered. This included the use of proton pump inhibitors at baseline, which was not associated with a survival benefit (p = 0.718). We also established a predictive tool for highly prevalent comorbidities, termed IPF comorbidome which demonstrates a new relationship of IPF and comorbidities. CONCLUSION Comorbidities are frequent in IPF patients. Some comorbidities, especially lung cancer, mainly influence survival in IPF, while others such as GERD may inherit a more favourable effect. Moreover, their cumulative incidence impacts survival.
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Affiliation(s)
- Michael Kreuter
- Centre for Interstitial and Rare Lung Diseases, Pneumology and Respiratory Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
- Member of the German Center for Lung Research, Translational Lung Research Centre, Heidelberg, Germany
| | - Svenja Ehlers-Tenenbaum
- Centre for Interstitial and Rare Lung Diseases, Pneumology and Respiratory Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
| | - Karin Palmowski
- Centre for Interstitial and Rare Lung Diseases, Pneumology and Respiratory Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
| | | | - Ute Oltmanns
- Centre for Interstitial and Rare Lung Diseases, Pneumology and Respiratory Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
| | - Thomas Muley
- Department of Translational Research, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
- Member of the German Center for Lung Research, Translational Lung Research Centre, Heidelberg, Germany
| | - Claus Peter Heussel
- Diagnostic and Interventional Radiology, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
- Department of Radiology, University of Heidelberg, Heidelberg, Germany
- Member of the German Center for Lung Research, Translational Lung Research Centre, Heidelberg, Germany
| | - Arne Warth
- Institute of Pathology, University of Heidelberg, Heidelberg, Germany
- Member of the German Center for Lung Research, Translational Lung Research Centre, Heidelberg, Germany
| | | | - Felix J. F. Herth
- Centre for Interstitial and Rare Lung Diseases, Pneumology and Respiratory Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
- Member of the German Center for Lung Research, Translational Lung Research Centre, Heidelberg, Germany
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1276
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Ekström M, Bornefalk-Hermansson A. Cardiovascular and antacid treatment and mortality in oxygen-dependent pulmonary fibrosis: A population-based longitudinal study. Respirology 2016; 21:705-11. [PMID: 27009834 DOI: 10.1111/resp.12781] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 09/19/2015] [Accepted: 02/23/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND OBJECTIVE Severe idiopathic pulmonary fibrosis is associated with an increased risk of cardiovascular disease and gastro-oesophageal reflux, which may influence prognosis. We evaluated associations between cardiovascular and antacid medications, and mortality, in oxygen-dependent pulmonary fibrosis (PF) of unknown cause. METHODS Prospective population-based study of adults starting long-term oxygen therapy (LTOT) for PF in Sweden 2005-2009. PF of unknown cause was defined by excluding patients with known or probable secondary PF. Time-dependent associations between medications and all-cause mortality were analysed using extended Cox regression, adjusting for potential confounders including age, sex, vital capacity, blood gases, body mass index, performance status, comorbidity and concurrent medications. RESULTS Of 462 included patients, 329 (71%) died under observation. No patient was lost to follow-up. Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEI/ARB) were associated with reduced adjusted mortality (HR 0.63; 0.47-0.85) and antiplatelet drugs with increased mortality (HR 1.49; 1.11-2.00), largely driven by higher mortality in women. There were no associations with mortality for antacid treatments, β-blockers, diuretics or statins. CONCLUSION In oxygen-dependent PF, treatment with ACEI/ARB was associated with improved survival, antiplatelet drugs with decreased survival, whereas there was no association between antacid, β-blocker, diuretic or statin treatment and survival.
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Affiliation(s)
- Magnus Ekström
- Department of Clinical Sciences, Division of Respiratory Medicine & Allergology, Lund University, Lund, Sweden
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1277
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Chen YC, Chen BC, Yu CC, Lin SH, Lin CH. miR-19a, -19b, and -26b Mediate CTGF Expression and Pulmonary Fibroblast Differentiation. J Cell Physiol 2016; 231:2236-48. [PMID: 26873752 DOI: 10.1002/jcp.25341] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 02/10/2016] [Indexed: 01/01/2023]
Abstract
Although microRNA (miRNA) dysregulation with intracellular signaling cascade disruption has been demonstrated in the pathophysiology of pulmonary fibrosis, the relationship between miRNAs and intracellular signaling cascades in pulmonary fibrosis remains unclear. Using the human embryonic lung fibroblast cell line WI-38, we observed endothelin-1 (ET-1)- and thrombin-induced expression of the differentiation markers α-smooth muscle actin (α-SMA) and vimentin along with increased connective tissue growth factor (CTGF) protein expression. Decreased CTGF protein expression by CTGF siRNA significantly blocked ET-1- and thrombin-induced α-SMA and vimentin expression in WI-38 cells. Activation of the mitogen-activated protein kinases (MAPKs) extracellular signal-regulated kinase ERK, c-Jun N-terminal kinase (JNK), and p38 contributed to ET-1- and thrombin-induced CTGF, α-SMA, and vimentin expression in WI-38 cells. TargetScan Human, miRanda, and PicTar prediction algorithms were used to predict miRNAs with binding sites in the 3' untranslated region (UTR) of CTGF mRNA. miR-19a, -19b, and -26b were candidate miRNAs of CTGF. Direct binding of the candidate miRNAs to the 3'-UTR of CTGF mRNA was verified through luciferase assay by using SV40-promoter-IRES-driven luciferase containing the 3'-UTR of CTGF mRNA as a reporter plasmid. ET-1 and thrombin reduced candidate miRNA levels. Candidate miRNA overexpression significantly suppressed ET-1- and thrombin-induced CTGF expression and reduced α-SMA and vimentin expression in the WI-38 cells. Furthermore, candidate miRNA levels were decreased in the lung tissues of mice with bleomycin-induced pulmonary fibrosis, and intratracheal application of miR-19a, -19b, and 26b reduced the pulmonary fibrotic severity induced by bleomycin. This study is the first to demonstrate crosstalk between MAPK activation and reduction in miR-19a, -19b, and -26b expression leading to lung fibroblast differentiation. J. Cell. Physiol. 231: 2236-2248, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Yen-Chou Chen
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Cancer Research Center and Orthopedics Research Center, Taipei Medical University Hospital, Taipei, Taiwan
| | - Bing-Chang Chen
- School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chung-Chi Yu
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Shin-Hua Lin
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chien-Huang Lin
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, Taiwan
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1278
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Costabel U, Bonella F. How to handle IPF--the new Portuguese consensus document. REVISTA PORTUGUESA DE PNEUMOLOGIA 2016; 22:70-72. [PMID: 27056483 DOI: 10.1016/j.rppnen.2016.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Indexed: 06/05/2023] Open
Affiliation(s)
- Ulrich Costabel
- Interstitial and Rare Lung Disease Unit, Ruhrlandklinik, University Hospital, University of Duisburg-Essen, Essen, Germany.
| | - Francesco Bonella
- Interstitial and Rare Lung Disease Unit, Ruhrlandklinik, University Hospital, University of Duisburg-Essen, Essen, Germany
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1279
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Rangarajan S, Locy ML, Luckhardt TR, Thannickal VJ. Targeted Therapy for Idiopathic Pulmonary Fibrosis: Where To Now? Drugs 2016; 76:291-300. [PMID: 26729185 PMCID: PMC4939080 DOI: 10.1007/s40265-015-0523-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Idiopathic pulmonary fibrosis (IPF) is an aging-associated, recalcitrant lung disease with historically limited therapeutic options. The recent approval of two drugs, pirfenidone and nintedanib, by the US Food and Drug Administration in 2014 has heralded a new era in its management. Both drugs have demonstrated efficacy in phase III clinical trials by retarding the rate of progression of IPF; neither drug appears to be able to completely arrest disease progression. Advances in the understanding of IPF pathobiology have led to an unprecedented expansion in the number of potential therapeutic targets. Drugs targeting several of these are under investigation in various stages of clinical development. Here, we provide a brief overview of the drugs that are currently approved and others in phase II clinical trials. Future therapeutic opportunities that target novel pathways, including some that are associated with the biology of aging, are examined. A multi-targeted approach, potentially with combination therapies, and identification of individual patients (or subsets of patients) who may respond more favourably to specific agents are likely to be more effective.
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Affiliation(s)
- Sunad Rangarajan
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, 1900 University Blvd THT 422, Birmingham, AL, 35294-2180, USA
| | - Morgan L Locy
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, 1900 University Blvd THT 422, Birmingham, AL, 35294-2180, USA
| | - Tracy R Luckhardt
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, 1900 University Blvd THT 422, Birmingham, AL, 35294-2180, USA
| | - Victor J Thannickal
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, 1900 University Blvd THT 422, Birmingham, AL, 35294-2180, USA.
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1280
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Puglisi S, Torrisi SE, Vindigni V, Giuliano R, Palmucci S, Mulè M, Vancheri C. New perspectives on management of idiopathic pulmonary fibrosis. Ther Adv Chronic Dis 2016; 7:108-20. [PMID: 26977280 PMCID: PMC4772343 DOI: 10.1177/2040622315624276] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive parenchymal lung disease characterized by a median survival of 3-5 years following diagnosis. The diagnosis is based on clinical, radiological and histopathological evaluation. Therefore, a multidisciplinary team is needed to reach the correct diagnosis. For a long time, supportive care and lung transplantation in selected cases, have been considered the only possible treatments for IPF. In the last decade many studies have investigated IPF pathogenesis, leading to an improved knowledge of the mechanisms underlying the disease and to the approval of two new drugs for IPF treatment (pirfenidone and nintedanib). The therapeutic approach of IPF cannot be limited to the administration of antifibrotic drugs, but it is necessary for improving the quality of life of patients and for facilitating, as far as possible, the performance of normal daily activities and relationships. IPF patients are also afflicted by disease-related complications such as gastroesophageal reflux, pulmonary hypertension, acute exacerbations and an increased risk of developing lung cancer. The clinician who treats IPF patients, should also treat these possible complications to slow disease progression, thus maintaining the possibility of a pulmonary transplantation.
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Affiliation(s)
- Silvia Puglisi
- Regional Centre for Interstitial and Rare Lung Diseases, Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78 Catania, 95123, Italy
| | - Sebastiano Emanuele Torrisi
- Regional Centre for Interstitial and Rare Lung Diseases, Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78 Catania, 95123, Italy
| | - Virginia Vindigni
- Regional Centre for Interstitial and Rare Lung Diseases, Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78 Catania, 95123, Italy
| | - Riccardo Giuliano
- Regional Centre for Interstitial and Rare Lung Diseases, Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78 Catania, 95123, Italy
| | - Stefano Palmucci
- Radiodiagnostic and Radiotherapy Unit-University Hospital “Policlinico-Vittorio Emanuele” Via Santa Sofia 78, Catania 95123-Italy
| | - Massimiliano Mulè
- University of Catania - Division of Cardiology Ferrarotto Hospital, Catania, Italy
| | - Carlo Vancheri
- Regional Centre for Interstitial and Rare Lung Diseases, Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78 Catania, 95123, Italy
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1281
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Moerer O, Quintel M. Bridge or Abyss: Extracorporeal Membrane Oxygenation for Acute Respiratory Failure in Interstitial Lung Disease. Am J Respir Crit Care Med 2016; 193:474-6. [DOI: 10.1164/rccm.201511-2184ed] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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1282
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Consensus document for the diagnosis and treatment of idiopathic pulmonary fibrosis: Joint Consensus of Sociedade Portuguesa de Pneumologia, Sociedade Portuguesa de Radiologia e Medicina Nuclear e Sociedade Portuguesa de Anatomia Patológica. REVISTA PORTUGUESA DE PNEUMOLOGIA 2016; 22:112-22. [PMID: 26906287 DOI: 10.1016/j.rppnen.2016.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Indexed: 12/15/2022] Open
Abstract
Idiopathic pulmonary fibrosis is a rare interstitial lung disease included in the Idiopathic Interstitial Pneumonias group. Although several potential risk factors have been described, it is a progressive fibrosing disease of unknown cause affecting mainly adults over 50 years and associated with a poor prognosis, reflected in a median survival of 2-3 years after diagnosis. The concept of a multidisciplinary working group for the diagnosis of idiopathic pulmonary fibrosis is based on the need to have experienced pulmonologists, radiologists and pathologists in the evaluation and correct treatment of the disease, and requires the use of all available data about individual patients, standardized (largely through High Resolution Computed Tomography and pathology when needed) as well as non-standardized data (laboratory, serology and biomarkers). This approach helps to increase diagnostic accuracy and is an internationally accepted recommendation. In regard to therapy, the situation has changed radically since the publication of the ATS/ERS/JRS/ALAT 2011 guidelines on the diagnosis and management of idiopathic pulmonary fibrosis where it was stressed that no proven therapy exists for this disease. Currently besides non-pharmacological treatment, therapy of complications and comorbidities and palliative care, nintedanib and pirfenidone, two compounds with pleiotropic mechanisms of action, are to date, the two drugs with confirmed efficacy in slowing functional decline and disease progression in idiopathic pulmonary fibrosis patients.
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1283
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Sgalla G, Cocconcelli E, Tonelli R, Richeldi L. Novel drug targets for idiopathic pulmonary fibrosis. Expert Rev Respir Med 2016; 10:393-405. [PMID: 26854382 DOI: 10.1586/17476348.2016.1152186] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Idiopathic Pulmonary Fibrosis (IPF) is a progressive, fatal lung disorder of unknown cause with a highly variable and unpredictable clinical course. The advances made in deciphering IPF pathobiology over the last decades have led to the approval of two anti-fibrotic molecules, pirfenidone and nintedanib, that showed to be effective in significantly reducing the rate of progression of the disease. Such pharmacological breakthroughs represent a dramatic change in the management of these patients and are reflected in updated international guidelines. However, the need to find a cure for this devastating disease remains unmet and the development of novel therapeutic agents remains hurdled by several factors. Here, we review the latest insights into therapeutic approaches for IPF and the available evidence for the most promising novel compounds currently under development, and discuss the challenges and evolution of IPF clinical research over the next few years.
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Affiliation(s)
- Giacomo Sgalla
- a Southampton NIHR Respiratory Biomedical Research Unit , University Hospital Southampton , Southampton , UK
| | - Elisabetta Cocconcelli
- b Department of Cardiologic, Thoracic and Vascular Sciences, Section of Respiratory Diseases , University of Padova , Padova , Italy
| | - Roberto Tonelli
- c Department of Respiratory Diseases , University Hospital of Modena , Modena , Italy
| | - Luca Richeldi
- a Southampton NIHR Respiratory Biomedical Research Unit , University Hospital Southampton , Southampton , UK.,d Academic Unit of Clinical and Experimental Sciences, Faculty of Medicine , University Hospital Southampton , Southampton , UK
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1284
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Abstract
The lung is a common site of complications of systemic connective tissue disease (CTD), and lung involvement can present in several ways. Interstitial lung disease (ILD) and pulmonary hypertension are the most common lung manifestations in CTD. Although it is generally thought that interstitial lung disease develops later on in CTD it is often the initial presentation ("lung dominant" CTD). ILD can be present in most types of CTD, including rheumatoid arthritis, scleroderma, systemic lupus erythematosus, polymyositis or dermatomyositis, Sjögren's syndrome, and mixed connective tissue disease. Despite similarities in clinical and pathologic presentation, the prognosis and treatment of CTD associated ILD (CTD-ILD) can differ greatly from that of other forms of ILD, such as idiopathic pulmonary fibrosis. Pulmonary hypertension (PH) can present as a primary vasculopathy in pulmonary arterial hypertension or in association with ILD (PH-ILD). Therefore, detailed history, physical examination, targeted serologic testing, and, occasionally, lung biopsy are needed to diagnose CTD-ILD, whereas both non-invasive and invasive assessments of pulmonary hemodynamics are needed to diagnose pulmonary hypertension. Immunosuppression is the mainstay of treatment for ILD, although data from randomized controlled trials (RCTs) to support specific treatments are lacking. Furthermore, treatment strategies vary according to the clinical situation-for example, the treatment of a patient newly diagnosed as having CTD-ILD differs from that of someone with an acute exacerbation of the disease. Immunosuppression is indicated only in select cases of pulmonary arterial hypertension related to CTD; more commonly, selective pulmonary vasodilators are used. For both diseases, comorbidities such as sleep disordered breathing, symptoms of dyspnea, and cough should be evaluated and treated. Lung transplantation should be considered in patients with advanced disease but is not always feasible because of other manifestations of CTD and comorbidities. Clinical trials of novel therapies including immunosuppressive therapies are needed to inform best treatment strategies.
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Affiliation(s)
- Stephen C Mathai
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sonye K Danoff
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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1285
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Jo HE, Corte TJ, Wort SJ, Eves ND, Piper A, Wainwright C. Year in review 2015: Interstitial lung disease, pulmonary vascular disease, pulmonary function, sleep and ventilation, cystic fibrosis and paediatric lung disease. Respirology 2016; 21:556-66. [DOI: 10.1111/resp.12749] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 01/20/2016] [Indexed: 12/16/2022]
Affiliation(s)
- Helen E. Jo
- Department of Respiratory and Sleep Medicine; Royal Prince Alfred Hospital; Sydney New South Wales Australia
- University of Sydney; Sydney New South Wales Australia
| | - Tamera J. Corte
- Department of Respiratory and Sleep Medicine; Royal Prince Alfred Hospital; Sydney New South Wales Australia
- University of Sydney; Sydney New South Wales Australia
| | - Stephen J. Wort
- Department of Pulmonary Hypertension; Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London; London UK
| | - Neil D. Eves
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, Faculty of Health and Social Development; University of British Columbia; Kelowna British Columbia Canada
| | - Amanda Piper
- Department of Respiratory and Sleep Medicine; Royal Prince Alfred Hospital; Sydney New South Wales Australia
- Woolcock Institute of Medical Research; University of Sydney; Sydney New South Wales Australia
| | - Claire Wainwright
- Lady Cilento Children's Hospital, School of Medicine; University of Queensland; Brisbane Queensland Australia
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1286
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The Protective Effect of Naringin against Bleomycin-Induced Pulmonary Fibrosis in Wistar Rats. Pulm Med 2016; 2016:7601393. [PMID: 26977316 PMCID: PMC4764747 DOI: 10.1155/2016/7601393] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 12/23/2015] [Accepted: 01/14/2016] [Indexed: 12/22/2022] Open
Abstract
The aim of the current study was to investigate the protective effect of naringin on bleomycin-induced pulmonary fibrosis in rats. Twenty-four Wistar rats randomly divided into four groups (control, bleomycin alone, bleomycin + naringin 40, and bleomycin + naringin 80) were used. Rats were administered a single dose of bleomycin (5 mg/kg; via the tracheal cannula) alone or followed by either naringin 40 mg/kg (orally) or naringin 80 mg/kg (orally) or water (1 mL, orally) for 14 days. Rats and lung tissue were weighed to determine the lung index. TNF-α and IL-1β levels, hydroxyproline content, and malondialdehyde (MDA) levels were assayed. Glutathione peroxidase (GSH-Px) and superoxide dismutase (SOD) activities were determined. Tissue sections were stained with hematoxylin-eosin, Masson's trichrome, and 0.1% toluidine blue. TNF-α, IL-1β, and MDA levels and hydroxyproline content significantly increased (p < 0.01) and GPx and SOD activities significantly decreased in bleomycin group (p < 0.01). Naringin at a dose of 80 mg/kg body weight significantly decreased TNF-α and IL-1β activity, hydroxyproline content, and MDA level (p < 0.01) and increased GPx and SOD activities (p < 0.05). Histological evidence supported the results. These results show that naringin has the potential of reducing the toxic effects of bleomycin and may provide supportive therapy for conventional treatment methods for idiopathic pulmonary fibrosis.
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1287
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Behr J. Guidelines or guidance for better idiopathic pulmonary fibrosis management? BMC Med 2016; 14:24. [PMID: 26860906 PMCID: PMC4748484 DOI: 10.1186/s12916-016-0567-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 01/25/2016] [Indexed: 12/03/2022] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) is a rare fibrotic interstitial lung disease with a relentlessly progressive course and fatal outcome. Guidelines summarizing the current evidence and providing evidence-based recommendations for the treatment of rare diseases such as IPF are important since individual physicians often have limited experience. Nevertheless, the available evidence is often scarce and, therefore, evidence-based recommendations are prone to being vague or with low confidence, thus creating uncertainty instead of guidance. Moreover, the effect of guidelines themselves on clinical practice has not been sufficiently evaluated. On the other hand, expert opinion may be biased and lead to the misinterpretation of evidence, resulting in misleading recommendations and a potential harm to patients. This editorial focuses on the advantages and disadvantages of evidence-based guidelines and professional experience in the context of a rare disease such as IPF and tries to assess the optimum combination of both approaches.Please see related commentary articles: http://dx.doi.org/10.1186/s12916-016-0562-1 and http://dx.doi.org/10.1186/s12916-016-0563-0.
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Affiliation(s)
- Jürgen Behr
- Department of Internal Medicine V University of Munich and Asklepios Clinic München-Gauting, Comprehensive Pneumology Center Munich, Member of the German Centre for Lung Research, München, Germany.
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1288
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Rochwerg B, Schünemann HJ, Raghu G. Idiopathic pulmonary fibrosis - clinical management guided by the evidence-based GRADE approach: what arguments can be made against transparency in guideline development? BMC Med 2016; 14:22. [PMID: 26860831 PMCID: PMC4748604 DOI: 10.1186/s12916-016-0563-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 09/17/2015] [Indexed: 01/13/2023] Open
Abstract
Evidence-based guidelines have undergone an incredible transformation over the last number of years. Significant advances include explicit linkages of systematic evidence summaries to the strength and direction of recommendations, consideration of all patient-important factors, transparent reporting of the recommendation generation process including conflict of interest management strategies and the production of clinical practice guidelines which use simple and clear language. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology provides a framework for guideline development and was employed to produce the recently published ATS/ERS/JRS/ALAT update on treatment for idiopathic pulmonary fibrosis (IPF). Herein we discuss the advantages of using an evidence-based approach for guideline development using the IPF process and resultant document as an example.
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Affiliation(s)
- Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, ON, Canada. .,Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada.
| | - Holger J Schünemann
- Department of Medicine, McMaster University, Hamilton, ON, Canada. .,Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada.
| | - Ganesh Raghu
- Department of Medicine (Division of Pulmonary and Critical Care Medicine), University of Washington, Seattle, WA, USA. .,Center for Interstitial lung Diseases, UW Medical Center, Seattle, WA, USA.
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1289
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Rochwerg B, Neupane B, Zhang Y, Garcia CC, Raghu G, Richeldi L, Brozek J, Beyene J, Schünemann H. Treatment of idiopathic pulmonary fibrosis: a network meta-analysis. BMC Med 2016; 14:18. [PMID: 26843176 PMCID: PMC4741055 DOI: 10.1186/s12916-016-0558-x] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 01/15/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Idiopathic pulmonary fibrosis (IPF) is an interstitial lung disease associated with high morbidity and mortality. Effective treatments for IPF are limited. Several recent studies have investigated novel therapeutic agents for IPF, but very few have addressed their comparative benefits and harms. METHODS We performed a Bayesian network meta-analysis (NMA) to assess the effects of different treatments for IPF on mortality and serious adverse events (SAEs). We searched MEDLINE and EMBASE for randomized controlled trials (RCTs) up to August 2015. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach served to assess the certainty in the evidence of direct and indirect estimates. We calculated the surface under the cumulative ranking curve (SUCRA) for each treatment. We included parallel group RCTs, including factorial designs, but excluded quasi-randomized and cross-over trials. Studies were only included if they involved adult (≥18 years of age) patients with IPF as defined by the 2011 criteria and examined one of the 10 interventions of interest (ambrisentan, bosentan, imatinib, macitentan, N-acetylcysteine, nintedanib, pirfenidone, sildenafil, prednisone/azathioprine/N-acetylcysteine triple therapy, and vitamin K antagonist). RESULTS A total of 19 RCTs (5,694 patients) comparing 10 different interventions with placebo and an average follow-up period of 1 year fulfilled the inclusion criteria. SUCRA analysis suggests nintedanib, pirfenidone, and sildenafil are the three treatments with the highest probability of reducing mortality in IPF. Indirect comparison showed no significant difference in mortality between pirfenidone and nintedanib (NMA OR, 1.05; 95% CrI, 0.45-2.78, moderate certainty of evidence), pirenidone and sildenafil (NMA OR, 2.26; 95% CrI, 0.44-13.17, low certainty of evidence), or nintedanib and sildenafil (NMA OR 2.40; 95% CrI, 0.47-14.66, low certainty of evidence). Sildenafil, pirfenidone, and nintedanib were ranked second, fourth, and sixth out of 10 for SAEs. CONCLUSION In the absence of direct comparisons between treatment interventions, this NMA suggests that treatment with nintedanib, pirfenidone, and sildenafil extends survival in patients with IPF. The SAEs of these agents are similar to the other interventions and include mostly dermatologic and gastrointestinal manifestations. Head-to-head comparisons need to confirm these findings.
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Affiliation(s)
- Bram Rochwerg
- Department of Medicine, Division of Critical Care, McMaster University, 1200 Main St W, L8S 4L8, Hamilton, ON, Canada. .,Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada. .,MacGRADE Centre, McMaster University, Hamilton, ON, Canada.
| | - Binod Neupane
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada.
| | - Yuan Zhang
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada. .,MacGRADE Centre, McMaster University, Hamilton, ON, Canada.
| | - Carlos Cuello Garcia
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada. .,MacGRADE Centre, McMaster University, Hamilton, ON, Canada. .,Tecnologico de Monterrey, School of Medicine, Monterrey, Mexico.
| | - Ganesh Raghu
- Department of Medicine (Division of Pulmonary and Critical Care Medicine), University of Washington Seattle, Seattle, WA, USA.
| | - Luca Richeldi
- National Institute for Health Research Southampton Respiratory Biomedical Research Unit and Clinical and Experimental Sciences, University of Southampton, Southampton, UK.
| | - Jan Brozek
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada. .,MacGRADE Centre, McMaster University, Hamilton, ON, Canada.
| | - Joseph Beyene
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada.
| | - Holger Schünemann
- Department of Medicine, Division of Critical Care, McMaster University, 1200 Main St W, L8S 4L8, Hamilton, ON, Canada. .,Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada. .,MacGRADE Centre, McMaster University, Hamilton, ON, Canada.
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1290
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Boland JW, Reigada C, Yorke J, Hart SP, Bajwah S, Ross J, Wells A, Papadopoulos A, Currow DC, Grande G, Macleod U, Johnson MJ. The Adaptation, Face, and Content Validation of a Needs Assessment Tool: Progressive Disease for People with Interstitial Lung Disease. J Palliat Med 2016; 19:549-55. [PMID: 26840603 PMCID: PMC4860674 DOI: 10.1089/jpm.2015.0355] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Irrreversible interstitial lung disease (ILD) is associated with high morbidity and mortality. Palliative care needs of patients and caregivers are not routinely assessed; there is no tool to identify needs and triage support in clinical practice. OBJECTIVE The study objective was to adapt and face/content validate a palliative needs assessment tool for people with ILD. METHODS The Needs Assessment Tool: Progressive Disease-Cancer (NAT:PD-C) was adapted to reflect the palliative care needs identified from the ILD literature and patient/caregiver interviews. Face and content validity of the NAT:PD-ILD was tested using patient/caregiver focus groups and an expert consensus group. Participants in the study were two English tertiary health care trusts' outpatients clinics. There were four focus groups: two patient (n = 7; n = 4); one caregiver (n = 3); and one clinician (n = 8). There was a single caregiver interview, and an expert consensus group-academics (n = 3), clinicians (n = 9), patients (n = 4), and caregivers (n = 2). Each item in the tool was revised as agreed by the groups. Expert consensus was reached. RESULTS Overall, the tool reflected participants' experience of ILD. Each domain was considered relevant. Adaptations were needed to represent the burden of ILD: respiratory symptoms (especially cough) and concerns about sexual activity were highlighted. All emphasized assessment of caregiver need as critical, and the role of caregivers in clinical consultations. CONCLUSIONS The NAT:PD-ILD appears to have face and content validity. The inclusion of the family caregiver in the consultation as someone with their own needs as well as a source of information was welcomed. Reliability testing and construct validation of the tool are ongoing.
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Affiliation(s)
- Jason W Boland
- 1 Hull York Medical School, University of Hull , Yorkshire, United Kingdom
| | - Carla Reigada
- 1 Hull York Medical School, University of Hull , Yorkshire, United Kingdom
| | - Janelle Yorke
- 2 School of Nursing, Midwifery and Social Work, University of Manchester , Manchester, United Kingdom
| | - Simon P Hart
- 1 Hull York Medical School, University of Hull , Yorkshire, United Kingdom .,3 Hull and East Yorkshire Hospitals NHS Trust , Hull, United Kingdom
| | - Sabrina Bajwah
- 4 King's College Hospital NHS Foundation Trust and, London , United Kingdom .,5 Cicely Saunders Institute, London, United Kingdom
| | - Joy Ross
- 6 Royal and Harefield Trust Fundation , London, United Kingdom
| | - Athol Wells
- 6 Royal and Harefield Trust Fundation , London, United Kingdom
| | - Athanasios Papadopoulos
- 7 School of Business, Management and Economics, University of Sussex , Brighton, United Kingdom
| | - David C Currow
- 8 Palliative and Supportive Services, Flinders University , Adelaide, Australia
| | - Gunn Grande
- 2 School of Nursing, Midwifery and Social Work, University of Manchester , Manchester, United Kingdom
| | - Una Macleod
- 1 Hull York Medical School, University of Hull , Yorkshire, United Kingdom
| | - Miriam J Johnson
- 1 Hull York Medical School, University of Hull , Yorkshire, United Kingdom
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1291
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Abstract
Idiopathic pulmonary fibrosis (IPF) is characterised by progressive accumulation of scar tissue in the lung and is associated with a median life expectancy of 2-4 years. Until recently, treatment options were limited, focusing on ineffective anti-inflammatory therapy, palliation, transplant or trial recruitment. Significant recent advances in the field have led to two novel anti-fibrotic agents, pirfenidone and nintedanib, which have been shown to significantly slow disease progression in IPF. This article outlines the approach to management of IPF, the role of specialist centres and specialist interstitial lung disease multidisciplinary review, and explores both the trial evidence and practical considerations in the use of these anti-fibrotic agents.
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Affiliation(s)
- Emily Fraser
- Oxford Interstitial Lung Disease Service, Churchill Hospital, Oxford, UK
| | - Rachel K Hoyles
- Oxford Interstitial Lung Disease Service, Churchill Hospital, Oxford, UK
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1292
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Jo HE, Corte TJ, Moodley Y, Levin K, Westall G, Hopkins P, Chambers D, Glaspole I. Evaluating the interstitial lung disease multidisciplinary meeting: a survey of expert centres. BMC Pulm Med 2016; 16:22. [PMID: 26831722 PMCID: PMC4736654 DOI: 10.1186/s12890-016-0179-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 01/13/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Multidisciplinary meetings (MDM) are the current "gold standard" in interstitial lung disease (ILD) diagnosis and comprise inter-disciplinary discussion of multiple forms of information to provide diagnostic and management outputs. Although bias could be potentially inserted at any step in the discussion process, to date there has been no consensus regarding the appropriate constitution and governance of MDM. We sought to determine the features of ILD MDMs based within ILD centres of excellence around the world. METHODS An internet based questionnaire was sent to twelve expert centres in Europe, North America, and Australia seeking information regarding the structure and governance of their MDM. Data was analysed for consistent themes and points of contrast. RESULTS Responses were received from 10 out of 12 centres. Similarities were demonstrated with regards to contributing attendees, meeting frequency and case numbers reviewed. Significant heterogeneity in attendee speciality group type, quantity and method of data presentation, approach to diagnosis formulation and documentation, and information provision was apparent. CONCLUSIONS The constitution of ILD MDMs differs considerably between expert centres. Such differences may result in discordant outcomes, and emphasise the need for further evidence regarding the appropriate constitution and governance of ILD MDMs.
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Affiliation(s)
- Helen E Jo
- Royal Prince Alfred Hospital, Sydney, Australia. .,University of Sydney, Sydney, Australia.
| | - Tamera J Corte
- Royal Prince Alfred Hospital, Sydney, Australia. .,University of Sydney, Sydney, Australia.
| | - Yuben Moodley
- University of Western Australia, Perth, Australia. .,Fiona Stanley Hospital, Perth, Australia. .,Respiratory Health Institute, Perth, Australia.
| | - Kovi Levin
- The Alfred Hospital, Melbourne, Australia.
| | - Glen Westall
- The Alfred Hospital, Melbourne, Australia. .,Monash University, Melbourne, Australia.
| | - Peter Hopkins
- Prince Charles Hospital, Brisbane, Australia. .,University of Queensland, Brisbane, Australia.
| | - Daniel Chambers
- Prince Charles Hospital, Brisbane, Australia. .,University of Queensland, Brisbane, Australia.
| | - Ian Glaspole
- The Alfred Hospital, Melbourne, Australia. .,Monash University, Melbourne, Australia.
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1293
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Wilson KC. Reply to “An Important Step Forward, but Still a Way to Go”. Am J Respir Crit Care Med 2016; 193:342. [DOI: 10.1164/rccm.201510-2010le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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1294
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Fahim A, Crooks MG, Morice AH, Hart SP. Idiopathic Pulmonary Fibrosis and Prothrombotic State. Am J Respir Crit Care Med 2016; 193:341-2. [DOI: 10.1164/rccm.201509-1835le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Ahmed Fahim
- New Cross HospitalWolverhampton, United Kingdom
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1295
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Rochwerg B, Schunemann H, Raghu G. Reply to “An Important Step Forward, but Still a Way to Go” and “Idiopathic Pulmonary Fibrosis and Prothrombotic State”. Am J Respir Crit Care Med 2016; 193:343. [DOI: 10.1164/rccm.201510-2049le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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1296
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Canestaro WJ, Forrester SH, Raghu G, Ho L, Devine BE. Drug Treatment of Idiopathic Pulmonary Fibrosis: Systematic Review and Network Meta-Analysis. Chest 2016; 149:756-66. [PMID: 26836914 DOI: 10.1016/j.chest.2015.11.013] [Citation(s) in RCA: 118] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 10/16/2015] [Accepted: 11/02/2015] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Idiopathic pulmonary fibrosis (IPF) is a form of chronic progressive fibrosing interstitial lung disease of unknown origin. Recently, nintedanib and pirfenidone demonstrated efficacy in slowing disease progression and were approved by the US Food and Drug Administration. Although numerous treatments have been evaluated in IPF, none have shown significant decreases in mortality. The objective of this study was to identify all pharmacologic treatments evaluated for IPF and analyze their efficacy via Bayesian network meta-analysis and pairwise indirect treatment comparisons. This review did not evaluate the effect of steroid therapy. METHODS We searched MEDLINE, Embase, and the Cochrane Library for studies published on or before August 2014. Studies were required to contain a randomized evaluation of nonsteroidal drug therapy for treatment of IPF and be published in English. Key outcomes of interest for this analysis were pulmonary function as measured by FVC as well as all-cause and respiratory-specific death. All outcomes were analyzed via a Bayesian framework. RESULTS Our review identified 30 eligible studies that evaluated 16 unique treatments. Under both the fixed-effect and random-effect models for respiratory-specific mortality, no treatments performed better than placebo. For all-cause mortality, pirfenidone and nintedanib had effects approaching significance with credible intervals slightly crossing the null under a fixed-effect model. Notably, for respiratory-specific mortality, all-cause mortality, and decline in percent predicted FVC, nintedanib and pirfenidone were virtually indistinguishable and no clear advantage was detected. CONCLUSIONS Although two treatments have been approved for IPF on the basis of reduced decline in pulmonary function, neither one has a clear advantage on mortality outcomes.
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Affiliation(s)
- William J Canestaro
- Pharmaceutical Outcomes Research and Policy Program, University of Washington School of Pharmacy, Seattle, WA
| | | | - Ganesh Raghu
- Division of Pulmonary and Critical Care Medicine, Center for Interstitial Lung Disease, University of Washington School of Medicine, Seattle, WA
| | - Lawrence Ho
- Division of Pulmonary and Critical Care Medicine, Center for Interstitial Lung Disease, University of Washington School of Medicine, Seattle, WA
| | - Beth E Devine
- Pharmaceutical Outcomes Research and Policy Program, University of Washington School of Pharmacy, Seattle, WA.
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1297
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Wuyts WA, Collard HR. Gastroesophageal Reflux in Idiopathic Pulmonary Fibrosis: More than a Gut Feeling? Respiration 2016; 91:1-2. [PMID: 26727600 DOI: 10.1159/000443183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Wim A Wuyts
- Department of Respiratory Medicine, University Hospitals Leuven, Leuven, Belgium
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1298
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Abstract
Idiopathic pulmonary fibrosis (IPF) is a severe lung disease, with death occurring within 2-5 years after its onset. IPF affects people in the second half of life. Its causes are unknown. Before 1999, IPF was out from the group of idiopathic interstitial lung diseases as a separate nosological entity. Practitioners very often (80%) make diagnostic errors in IPF and prescribe antibiotics, anti-inflammatory drugs, which worsen the course of this disease. The distinctive feature of the pathogenesis of IPF is the absence of inflammation, which is clinically manifested by the inefficacy of glucocorticosteroids and other anti-inflammatory drugs. Pharmacological agents for the treatment of IPF have been designed since 2000. One of them has been registered and permitted for use in the Russian Federation. This paper is a review of an update on the problem of IPF, which should facilitate the appropriate orientation of physicians in diagnosing and treating this severe disease.
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Affiliation(s)
- E I Shmelev
- Central Research Institute of Tuberculosis, Moscow, Russia
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1299
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Muramatsu Y, Sugino K, Ishida F, Tatebe J, Morita T, Homma S. Effect of inhaled N-acetylcysteine monotherapy on lung function and redox balance in idiopathic pulmonary fibrosis. Respir Investig 2015; 54:170-8. [PMID: 27108012 DOI: 10.1016/j.resinv.2015.11.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 08/14/2015] [Accepted: 11/09/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND An oxidant-antioxidant imbalance is considered to be involved in the pathogenesis of idiopathic pulmonary fibrosis (IPF). Therefore, administration of antioxidants, such as N-acetylcysteine (NAC), may represent a potential treatment option for IPF patients. METHODS The aim of this study was to evaluate the effect of inhaled NAC monotherapy on lung function and redox balance in patients with IPF. A retrospective observational study was done, involving 22 patients with untreated early IPF (19 men; mean [±S.D.] age, 71.8 [±6.3]y). At baseline and at 6 and 12 months after initiating inhaled NAC monotherapy, we assessed forced vital capacity (FVC) and measured the levels of total glutathione, oxidized glutathione (GSSG), and the ratio of reduced to oxidized glutathione in whole blood (hereafter referred to as the ratio), and of 8-hydroxy-2'-deoxyguanosine in urine. To evaluate response to treatment, we defined disease progression as a decrease in FVC of ≥5% from baseline and stable disease as a decrease in FVC of <5%, over a period of 6 months. RESULTS Change in FVC in the stable group at 6 and 12 months were 95±170mL and -70±120mL, while those in the progressive group at 6 and 12 months were -210±80mL, -320±350mL, respectively. The serial mean change in GSSG from baseline decreased as the ratio of reduced to oxidized glutathione increased in patients with stable disease, while it increased as this ratio decreased in patients with progressive disease. Receiver operating characteristic curve analysis revealed that a baseline GSSG level of ≥1.579μM was optimal for identifying treatment responders. CONCLUSION Inhaled NAC monotherapy was associated with improved redox imbalance in patients with early IPF.
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Affiliation(s)
- Yoko Muramatsu
- Department of Respiratory Medicine, Toho University School of Medicine (Omori), Omori-nishi 6-11-1, Ota-ku, Tokyo 143-8541, Japan.
| | - Keishi Sugino
- Department of Respiratory Medicine, Toho University School of Medicine (Omori), Omori-nishi 6-11-1, Ota-ku, Tokyo 143-8541, Japan.
| | - Fumiaki Ishida
- Department of Respiratory Medicine, Toho University School of Medicine (Omori), Omori-nishi 6-11-1, Ota-ku, Tokyo 143-8541, Japan.
| | - Junko Tatebe
- Department of Clinical Laboratory Medicine, Toho University School of Medicine (Omori), Omori-nishi 6-11-1, Ota-ku, Tokyo 143-8541, Japan.
| | - Toshisuke Morita
- Department of Clinical Laboratory Medicine, Toho University School of Medicine (Omori), Omori-nishi 6-11-1, Ota-ku, Tokyo 143-8541, Japan.
| | - Sakae Homma
- Department of Respiratory Medicine, Toho University School of Medicine (Omori), Omori-nishi 6-11-1, Ota-ku, Tokyo 143-8541, Japan.
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Reichmann WM, Yu YF, Macaulay D, Wu EQ, Nathan SD. Change in forced vital capacity and associated subsequent outcomes in patients with newly diagnosed idiopathic pulmonary fibrosis. BMC Pulm Med 2015; 15:167. [PMID: 26714746 PMCID: PMC4696269 DOI: 10.1186/s12890-015-0161-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 12/14/2015] [Indexed: 12/02/2022] Open
Abstract
Background Idiopathic pulmonary fibrosis (IPF) is a rare and serious disease characterized by progressive lung-function loss. Limited evidence has been published on the impact of lung-function loss on subsequent patient outcomes. This study examined change in forced vital capacity (FVC) across IPF patients in the 6 months after diagnosis and its association with clinical and healthcare resource utilization (HRU) outcomes in a real-world setting in the U.S. Methods A retrospective chart review was conducted of patients diagnosed with IPF by U.S. pulmonologists. Patient eligibility criteria included: 1) 40 years or older with a confirmed date of first IPF diagnosis with high-resolution computed tomography and/or lung biopsy between 01/2011 and 06/2013; 2) FVC results recorded at first diagnosis (±1 month) and at 6 months (±3 months) following diagnosis. Based on relative change in FVC percent predicted (FVC%), patients were categorized as stable (decline <5 %), marginal decline (decline ≥5 % and <10 %), or significant decline (decline ≥10 %). Physician-reported clinical and HRU outcomes were assessed from ~6 months post-diagnosis until the last contact date with the physician and compared between FVC% change groups. Multivariable Cox proportional-hazards models were constructed to assess risk of mortality, suspected acute exacerbation (AEx), and hospitalization post-FVC% change. Generalized estimating equations were used to account for multiple patients contributed by individual physicians. Results The sample included 490 IPF patients contributed by 168 pulmonologists. The mean (SD) age was 61 (11) years, 68 % were male, and the mean (SD) baseline FVC% was 60 % (26 %). 250 (51 %) patients were categorized as stable, 98 (20 %) as marginal decline, and 142 (29 %) as significant decline. The mean (SD) observation time was 583 (287) days. In both unadjusted analysis and multivariable models, significantly worse clinical outcomes and increased HRU were observed with greater lung-function decline. Conclusions These findings suggest that nearly half of IPF patients experienced decline in FVC% within ~6 months following IPF diagnosis. Greater FVC% decline was associated with an increased risk of further IPF progression, suspected AEx, mortality, and higher rate of HRU. Management options that slow FVC decline may help improve future health outcomes in IPF.
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Affiliation(s)
| | - Yanni F Yu
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA.
| | | | - Eric Q Wu
- Analysis Group, Inc., Boston, MA, USA.
| | - Steven D Nathan
- Advanced Lung Disease and Transplant Program, Department of Medicine, Inova Fairfax Hospital, Falls Church, VA, USA.
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