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Kou M, Jiao Y, Li Z, Wei B, Li Y, Cai Y, Wei W. Real-world safety and effectiveness of pirfenidone and nintedanib in the treatment of idiopathic pulmonary fibrosis: a systematic review and meta-analysis. Eur J Clin Pharmacol 2024:10.1007/s00228-024-03720-7. [PMID: 38963453 DOI: 10.1007/s00228-024-03720-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 06/23/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND AND OBJECTIVE Multiple randomized controlled studies have shown that pirfenidone and nintedanib are effective and safe for treating idiopathic pulmonary fibrosis. This study aimed to evaluate their efficacy, safety, and tolerability in a real-world setting. METHODS We searched PubMed, Embase, Cochrane Library, and ClinicalTrials.gov databases for real-world studies published up to March 3, 2023, on pirfenidone and nintedanib for idiopathic pulmonary fibrosis. RESULTS A total of 74 studies with 23,119 participants were included. After 12 months of treatment, the change from baseline in percent predicted FVC (%FVC) was - 0.75% for pirfenidone and - 1.43% for nintedanib. The change from baseline in percent predicted DLCO (%DCLO) was - 2.32% for pirfenidone and - 3.95% for nintedanib. The incidence of acute exacerbation of idiopathic pulmonary fibrosis (AE-IPF) was 12.5% for pirfenidone and 14.4% for nintedanib. The IPF-related mortality rates of pirfenidone and nintedanib were 13.4% and 7.2%, respectively. The all-cause mortality was 20.1% for pirfenidone and 16.6% for nintedanib. In the pirfenidone group, 16.6% of patients discontinued treatment because of adverse events, and in the nintedanib group, 16.2% of patients discontinued treatment because of adverse events. The incidence of adverse events was 56.4% and 69.7% for pirfenidone and nintedanib, respectively. CONCLUSION The results of this study indicate that pirfenidone and nintedanib are both effective in slowing down the decline of lung function in IPF patients in real-world settings. The incidence of adverse events with pirfenidone is lower than that with nintedanib, but both are below the clinical trial data, and no new major adverse events have been observed. The discontinuation rates due to adverse reactions of the two drugs are consistent with clinical trial data, indicating good tolerability. However, the mortality rates and AE-IPF incidence rates of these two drugs in real-world settings are higher than those in previous clinical trials, with pirfenidone patients showing a higher mortality rate. Further large-sample studies are needed to investigate the risks of these drugs in these aspects. Additionally, we recommend that future real-world studies pay more attention to patients' subjective symptoms and conduct stratified analyses of the efficacy and safety of pirfenidone and nintedanib based on factors such as patients' baseline lung function, comorbidities, and age, in order to provide more personalized medication advice for IPF patients in clinical practice.
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Affiliation(s)
- Mengjia Kou
- Graduate School, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Yang Jiao
- Department of Respiration, Dongfang Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, 100078, China
| | - Zhipeng Li
- Graduate School, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Bin Wei
- Graduate School, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Yang Li
- Graduate School, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Yaodong Cai
- Graduate School, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Wan Wei
- Department of Respiration, Dongfang Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, 100078, China.
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Taherian M, Bayati P, Mojtabavi N. Stem cell-based therapy for fibrotic diseases: mechanisms and pathways. Stem Cell Res Ther 2024; 15:170. [PMID: 38886859 PMCID: PMC11184790 DOI: 10.1186/s13287-024-03782-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 06/04/2024] [Indexed: 06/20/2024] Open
Abstract
Fibrosis is a pathological process, that could result in permanent scarring and impairment of the physiological function of the affected organ; this condition which is categorized under the term organ failure could affect various organs in different situations. The involvement of the major organs, such as the lungs, liver, kidney, heart, and skin, is associated with a high rate of morbidity and mortality across the world. Fibrotic disorders encompass a broad range of complications and could be traced to various illnesses and impairments; these could range from simple skin scars with beauty issues to severe rheumatologic or inflammatory disorders such as systemic sclerosis as well as idiopathic pulmonary fibrosis. Besides, the overactivation of immune responses during any inflammatory condition causing tissue damage could contribute to the pathogenic fibrotic events accompanying the healing response; for instance, the inflammation resulting from tissue engraftment could cause the formation of fibrotic scars in the grafted tissue, even in cases where the immune system deals with hard to clear infections, fibrotic scars could follow and cause severe adverse effects. A good example of such a complication is post-Covid19 lung fibrosis which could impair the life of the affected individuals with extensive lung involvement. However, effective therapies that halt or slow down the progression of fibrosis are missing in the current clinical settings. Considering the immunomodulatory and regenerative potential of distinct stem cell types, their application as an anti-fibrotic agent, capable of attenuating tissue fibrosis has been investigated by many researchers. Although the majority of the studies addressing the anti-fibrotic effects of stem cells indicated their potent capabilities, the underlying mechanisms, and pathways by which these cells could impact fibrotic processes remain poorly understood. Here, we first, review the properties of various stem cell types utilized so far as anti-fibrotic treatments and discuss the challenges and limitations associated with their applications in clinical settings; then, we will summarize the general and organ-specific mechanisms and pathways contributing to tissue fibrosis; finally, we will describe the mechanisms and pathways considered to be employed by distinct stem cell types for exerting anti-fibrotic events.
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Affiliation(s)
- Marjan Taherian
- Department of Immunology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
- Immunology Research Center, Institute of Immunology and Infectious Diseases, Iran University of Medical Sciences, Tehran, Iran
| | - Paria Bayati
- Department of Immunology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
- Immunology Research Center, Institute of Immunology and Infectious Diseases, Iran University of Medical Sciences, Tehran, Iran
| | - Nazanin Mojtabavi
- Department of Immunology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
- Immunology Research Center, Institute of Immunology and Infectious Diseases, Iran University of Medical Sciences, Tehran, Iran.
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Zhang Q, Li G, Zhao G, Yan C, Lv H, Fu Y, Li Y, Zhao Z. Preparation and evaluation of inhalable S-allylmercapto-N-acetylcysteine and nintedanib co-loaded liposomes for pulmonary fibrosis. Eur J Pharm Sci 2024; 197:106779. [PMID: 38670294 DOI: 10.1016/j.ejps.2024.106779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 04/22/2024] [Accepted: 04/23/2024] [Indexed: 04/28/2024]
Abstract
Orally marketed products nintedanib (NDNB) and pirfenidone (PFD) for pulmonary fibrosis (PF) are administered in high doses and have been shown to have serious toxic and side effects. NDNB can cause the elevation of galectin-3, which activates the NF-κB signaling pathway and causes the inflammatory response. S-allylmercapto-N-acetylcysteine (ASSNAC) can alleviate the inflammation response by inhibiting the TLR-4/NF-κB signaling pathway. Therefore, we designed and prepared inhalable ASSNAC and NDNB co-loaded liposomes for the treatment of pulmonary fibrosis. The yellow, spheroidal co-loaded liposomes with a particle size of 98.32±1.98 nm and zeta potential of -22.5 ± 1.58 mV were produced. The aerodynamic fine particle fraction (FPF) and mass median aerodynamic diameter (MMAD) of NDNB were >50 % (81.14 %±0.22 %) and <5 μm (1.79 μm±0.06 μm) in the nebulized liposome solution, respectively. The results showed that inhalation improved the lung deposition and retention times of both drugs. DSPE-PEG 2000 in the liposome formulation enhanced the mucus permeability and reduced phagocytic efflux mediated by macrophages. ASSNAC reduced the mRNA over-expressions of TLR-4, MyD88 and NF-κB caused by NDNB, which could reduce the NDNB's side effects. The Masson's trichrome staining of lung tissues and the levels of CAT, TGF-β1, HYP, collagen III and mRNA expressions of Collagen I, Collagen III and α-SMA in lung tissues revealed that NDNB/Lip inhalation was more beneficial to alleviate fibrosis than oral NDNB. Although the dose of NDNB/Lip was 30 times lower than that in the oral group, the inhaled NDNB/Lip group had better or comparable anti-fibrotic effects to those in the oral group. According to the expressions of Collagen I, Collagen III and α-SMA in vivo and in vitro, the combination of ASSNAC and NDNB was more effective than the single drugs for pulmonary fibrosis. Therefore, this study provided a new scheme for the treatment of pulmonary fibrosis.
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Affiliation(s)
- Qinxiu Zhang
- Department of Pharmaceutics, Key Laboratory of Chemical Biology of Ministry of Education, School of Pharmaceutical Sciences, Cheelloo College of Medicine, Shandong University, 44 West Wenhua Road, Jinan, Shandong 250012, China; Laboratory of Drug Discovery and Design, School of Pharmacy, Liaocheng University, Liaocheng, Shandong 252000, China; Key University Laboratory of Pharmaceutics & Drug Delivery Systems of Shandong Province, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, 44 West Wenhua Road, Jinan, Shandong 250012, China
| | - Genju Li
- Department of Pharmaceutics, Key Laboratory of Chemical Biology of Ministry of Education, School of Pharmaceutical Sciences, Cheelloo College of Medicine, Shandong University, 44 West Wenhua Road, Jinan, Shandong 250012, China; Key University Laboratory of Pharmaceutics & Drug Delivery Systems of Shandong Province, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, 44 West Wenhua Road, Jinan, Shandong 250012, China
| | - Guozhi Zhao
- Department of Pharmaceutics, Key Laboratory of Chemical Biology of Ministry of Education, School of Pharmaceutical Sciences, Cheelloo College of Medicine, Shandong University, 44 West Wenhua Road, Jinan, Shandong 250012, China; Key University Laboratory of Pharmaceutics & Drug Delivery Systems of Shandong Province, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, 44 West Wenhua Road, Jinan, Shandong 250012, China
| | - Chongzheng Yan
- Department of Pharmaceutics, Key Laboratory of Chemical Biology of Ministry of Education, School of Pharmaceutical Sciences, Cheelloo College of Medicine, Shandong University, 44 West Wenhua Road, Jinan, Shandong 250012, China; Key University Laboratory of Pharmaceutics & Drug Delivery Systems of Shandong Province, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, 44 West Wenhua Road, Jinan, Shandong 250012, China
| | - Huaiyou Lv
- Department of Pharmaceutics, Key Laboratory of Chemical Biology of Ministry of Education, School of Pharmaceutical Sciences, Cheelloo College of Medicine, Shandong University, 44 West Wenhua Road, Jinan, Shandong 250012, China; Key University Laboratory of Pharmaceutics & Drug Delivery Systems of Shandong Province, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, 44 West Wenhua Road, Jinan, Shandong 250012, China
| | - Yaqing Fu
- Department of Pharmaceutics, Key Laboratory of Chemical Biology of Ministry of Education, School of Pharmaceutical Sciences, Cheelloo College of Medicine, Shandong University, 44 West Wenhua Road, Jinan, Shandong 250012, China; Key University Laboratory of Pharmaceutics & Drug Delivery Systems of Shandong Province, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, 44 West Wenhua Road, Jinan, Shandong 250012, China
| | - Yuhan Li
- Department of Pharmaceutics, Key Laboratory of Chemical Biology of Ministry of Education, School of Pharmaceutical Sciences, Cheelloo College of Medicine, Shandong University, 44 West Wenhua Road, Jinan, Shandong 250012, China; Key University Laboratory of Pharmaceutics & Drug Delivery Systems of Shandong Province, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, 44 West Wenhua Road, Jinan, Shandong 250012, China
| | - Zhongxi Zhao
- Department of Pharmaceutics, Key Laboratory of Chemical Biology of Ministry of Education, School of Pharmaceutical Sciences, Cheelloo College of Medicine, Shandong University, 44 West Wenhua Road, Jinan, Shandong 250012, China; Key University Laboratory of Pharmaceutics & Drug Delivery Systems of Shandong Province, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, 44 West Wenhua Road, Jinan, Shandong 250012, China; Pediatric Pharmaceutical Engineering Laboratory of Shandong Province, Shandong Dyne Marine Biopharmaceutical Company Limited, Rongcheng, Shandong 264300, China; Chemical Immunopharmaceutical Engineering Laboratory of Shandong Province, Shandong Xili Pharmaceutical Company Limited, Heze, Shandong 274300, China.
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Chianese M, Screm G, Salton F, Confalonieri P, Trotta L, Barbieri M, Ruggero L, Mari M, Reccardini N, Geri P, Hughes M, Lerda S, Confalonieri M, Mondini L, Ruaro B. Pirfenidone and Nintedanib in Pulmonary Fibrosis: Lights and Shadows. Pharmaceuticals (Basel) 2024; 17:709. [PMID: 38931376 PMCID: PMC11206515 DOI: 10.3390/ph17060709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Revised: 05/22/2024] [Accepted: 05/27/2024] [Indexed: 06/28/2024] Open
Abstract
Pirfenidone and Nintedanib are specific drugs used against idiopathic pulmonary fibrosis (IPF) that showed efficacy in non-IPF fibrosing interstitial lung diseases (ILD). Both drugs have side effects that affect patients in different ways and have different levels of severity, making treatment even more challenging for patients and clinicians. The present review aims to assess the effectiveness and potential complications of Pirfenidone and Nintedanib treatment regimens across various ILD diseases. A detailed search was performed in relevant articles published between 2018 and 2023 listed in PubMed, UpToDate, Google Scholar, and ResearchGate, supplemented with manual research. The following keywords were searched in the databases in all possible combinations: Nintedanib; Pirfenidone, interstitial lung disease, and idiopathic pulmonary fibrosis. The most widely accepted method for evaluating the progression of ILD is through the decline in forced vital capacity (FVC), as determined by respiratory function tests. Specifically, a decrease in FVC over a 6-12-month period correlates directly with increased mortality rates. Antifibrotic drugs Pirfenidone and Nintedanib have been extensively validated; however, some patients reported several side effects, predominantly gastrointestinal symptoms (such as diarrhea, dyspepsia, and vomiting), as well as photosensitivity and skin rashes, particularly associated with Pirfenidone. In cases where the side effects are extremely severe and are more threatening than the disease itself, the treatment has to be discontinued. However, further research is needed to optimize the use of antifibrotic agents in patients with PF-ILDs, which could slow disease progression and decrease all-cause mortality. Finally, other studies are requested to establish the treatments that can stop ILD progression.
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Affiliation(s)
- Maria Chianese
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University of Trieste, Hospital of Cattinara, 34149 Trieste, Italy; (M.C.)
| | - Gianluca Screm
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University of Trieste, Hospital of Cattinara, 34149 Trieste, Italy; (M.C.)
| | - Francesco Salton
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University of Trieste, Hospital of Cattinara, 34149 Trieste, Italy; (M.C.)
| | - Paola Confalonieri
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University of Trieste, Hospital of Cattinara, 34149 Trieste, Italy; (M.C.)
| | - Liliana Trotta
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University of Trieste, Hospital of Cattinara, 34149 Trieste, Italy; (M.C.)
| | - Mariangela Barbieri
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University of Trieste, Hospital of Cattinara, 34149 Trieste, Italy; (M.C.)
| | - Luca Ruggero
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University of Trieste, Hospital of Cattinara, 34149 Trieste, Italy; (M.C.)
| | - Marco Mari
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University of Trieste, Hospital of Cattinara, 34149 Trieste, Italy; (M.C.)
| | - Nicolò Reccardini
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University of Trieste, Hospital of Cattinara, 34149 Trieste, Italy; (M.C.)
| | - Pietro Geri
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University of Trieste, Hospital of Cattinara, 34149 Trieste, Italy; (M.C.)
| | - Michael Hughes
- Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester & Salford Royal NHS Foundation Trust, Manchester M6 8HD, UK
| | - Selene Lerda
- Graduate School, University of Milan, 20149 Milano, Italy
| | - Marco Confalonieri
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University of Trieste, Hospital of Cattinara, 34149 Trieste, Italy; (M.C.)
| | - Lucrezia Mondini
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University of Trieste, Hospital of Cattinara, 34149 Trieste, Italy; (M.C.)
| | - Barbara Ruaro
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University of Trieste, Hospital of Cattinara, 34149 Trieste, Italy; (M.C.)
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Huang CW, Lee SY, Du CX, Wu ST, Kuo YH, Ku HC. Caffeic acid ethanolamide induces antifibrosis, anti-inflammatory, and antioxidant effects protects against bleomycin-induced pulmonary fibrosis. Biomed Pharmacother 2024; 173:116298. [PMID: 38394850 DOI: 10.1016/j.biopha.2024.116298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 02/04/2024] [Accepted: 02/17/2024] [Indexed: 02/25/2024] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) is a chronic and progressive interstitial lung disease; its cause is unknown, and it leads to notable health problems. Currently, only two drugs are recommended for IPF treatment. Although these drugs can mitigate lung function decline, neither can improve nor stabilize IPF or the symptoms perceived by patients. Therefore, the development of novel treatment options for pulmonary fibrosis is required. The present study investigated the effects of a novel compound, caffeic acid ethanolamide (CAEA), on human pulmonary fibroblasts and evaluated its potential to mitigate bleomycin-induced pulmonary fibrosis in mice. CAEA inhibited TGF-β-induced α-SMA and collagen expression in human pulmonary fibroblasts, indicating that CAEA prevents fibroblasts from differentiating into myofibroblasts following TGF-β exposure. In animal studies, CAEA treatment efficiently suppressed immune cell infiltration and the elevation of TNF-α and IL-6 in bronchoalveolar lavage fluid in mice with bleomycin-induced pulmonary fibrosis. Additionally, CAEA exerted antioxidant effects by recovering the enzymatic activities of oxidant scavengers. CAEA directly inhibited activation of TGF-β receptors and protected against bleomycin-induced pulmonary fibrosis through inhibition of the TGF-β/SMAD/CTGF signaling pathway. The protective effect of CAEA was comparable to that of pirfenidone, a clinically available drug. Our findings support the potential of CAEA as a viable method for preventing the progression of pulmonary fibrosis.
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Affiliation(s)
- Cheng-Wei Huang
- Department of Life Science, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Shih-Yi Lee
- Division of Pulmonary and Critical Care Medicine, MacKay Memorial Hospital, Taipei, Taiwan; MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
| | - Chen-Xuan Du
- Department of Life Science, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Shao-Tung Wu
- Department of Life Science, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Yueh-Hsiung Kuo
- Department of Chinese Pharmaceutical Sciences and Chinese Medicine Resources, China Medical University, Taichung, Taiwan; Department of Biotechnology, Asia University, Taichung, Taiwan
| | - Hui-Chun Ku
- Department of Life Science, Fu Jen Catholic University, New Taipei City, Taiwan.
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Ren C, Wang Q, Fan S, Mi T, Zhang Z, He D. Toll-Like Receptor 9 Aggravates Pulmonary Fibrosis by Promoting NLRP3-Mediated Pyroptosis of Alveolar Epithelial Cells. Inflammation 2024:10.1007/s10753-024-02006-5. [PMID: 38498270 DOI: 10.1007/s10753-024-02006-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 03/13/2024] [Accepted: 03/13/2024] [Indexed: 03/20/2024]
Abstract
The apoptosis-prone property of alveolar epithelial cells plays a crucial role in pulmonary fibrosis(PF), but the role of pyroptosis in it is still unclear. Toll-like receptor 9(TLR9) has been reported to play a vital role in the pathogenesis of many diseases. However, the effect of TLR9 on alveolar epithelial cells in PF has not been fully elucidated. Gene expression microarray related to Idiopathic pulmonary fibrosis(IPF) was obtained from the Gene Expression Omnibus(GEO) database. In the mouse model of bleomycin-induced PF, adeno-associated virus(AAV6) was used to interfere with TLR9 to construct TLR9 knockdown mice to study the role of TLR9 in PF, and the specific mechanism was studied by intratracheal instillation of NLR family pyrin domain containing 3(NLRP3) activator. In vitro experiments were performed using A549 cells. Bleomycin-induced pyroptosis in the lung tissue of PF mice increased, and TLR9 protein levels also increased, especially in alveolar epithelial cells. The levels of fibrosis and pyroptosis in lung tissue of TLR9 knockdown mice were improved. We found that TLR9 can bind to the NLRP3, thereby increasing the activation of the NLRP3/caspase-1 inflammasome pathway. When we use the NLRP3 activator, the levels of fibrosis and pyroptosis in lung tissue of TLR9 knockout mice can be counteracted. Pyroptosis of alveolar epithelial cells plays a vital role in PF, and TLR9 can promote NLRP3-mediated pyroptosis of alveolar epithelial cells to aggravate the progression of PF and may become a feasible target for the prevention and treatment of PF.
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Affiliation(s)
- Chunnian Ren
- Department of Urology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child development and Disorders, China International Science and Technology Cooperation base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, People's Republic of China
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University , National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, People's Republic of China
| | - Quan Wang
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University , National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, People's Republic of China
| | - Shulei Fan
- Department of Respiratory Medicine, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Tao Mi
- Department of Urology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child development and Disorders, China International Science and Technology Cooperation base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, People's Republic of China
| | - Zhaoxia Zhang
- Department of Urology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child development and Disorders, China International Science and Technology Cooperation base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, People's Republic of China
| | - Dawei He
- Department of Urology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child development and Disorders, China International Science and Technology Cooperation base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, People's Republic of China.
- Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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Aydin P, Aksakalli-Magden ZB, Civelek MS, Karabulut-Uzuncakmak S, Mokhtare B, Ozkaraca M, Alper F, Halici Z. The melatonin agonist ramelteon attenuates bleomycin-induced lung fibrosis by suppressing the NLRP3/TGF-Β1/HMGB1 signaling pathway. Adv Med Sci 2023; 68:322-331. [PMID: 37716182 DOI: 10.1016/j.advms.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 03/10/2023] [Accepted: 09/06/2023] [Indexed: 09/18/2023]
Abstract
PURPOSE The possible effects of ramelteon, a melatonin receptor agonist on bleomycin-induced lung fibrosis were analyzed via transforming growth factor β1 (TGF-β1), the high mobility group box 1 (HMGB1) and Nod-like receptor pyrin domain-containing 3 (NLRP3) which are related to the fibrosis process. MATERIALS AND METHODS Bleomycin (0.1 mL of 5 mg/kg) was administered by intratracheal instillation to induce pulmonary fibrosis (PF). Starting 24 h after bleomycin administration, a single dose of ramelteon was administered by oral gavage to the healthy groups, i.e. PF + RM2 (pulmonary fibrosis model with bleomycin + ramelteon at 2 mg/kg) and PF + RM4 (pulmonary fibrosis model with bleomycin + ramelteon at 4 mg/kg) at 2 and 4 mg/kg doses, respectively. Real-time polymerase chain reaction (real-time PCR) analyses, histopathological, and immunohistochemical staining were performed on lung tissues. Lung tomography images of the rats were also examined. RESULTS The levels of TGF-β1, HMGB1, NLRP3, and interleukin 1 beta (IL-1β) mRNA expressions increased as a result of PF and subsequently decreased with both ramelteon doses (p < 0.0001). Both doses of ramelteon partially ameliorated the reduction in the peribronchovascular thickening, ground-glass appearances, and reticulations, and the loss of lung volume. CONCLUSIONS The severity of fibrosis decreased with ramelteon application. These effects of ramelteon may be associated with NLRP3 inflammation cascade.
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Affiliation(s)
- Pelin Aydin
- Department of Pharmacology, Faculty of Medicine, Ataturk University, Erzurum, Turkey.
| | | | - Maide S Civelek
- Department of Pharmacology, Faculty of Medicine, Ataturk University, Erzurum, Turkey
| | | | - Behzad Mokhtare
- Department of Pathology, Faculty of Veterinary Medicine, Ataturk University, Erzurum, Turkey
| | - Mustafa Ozkaraca
- Department of Pathology, Faculty of Veterinary Medicine, Cumhurıyet University, Sıvas, Turkey
| | - Fatih Alper
- Department of Radiology, Faculty of Medicine, Atatürk University, Erzurum, Turkey
| | - Zekai Halici
- Department of Pharmacology, Faculty of Medicine, Ataturk University, Erzurum, Turkey; Clinical Research, Development and Design Application and Research Center, Atatürk University, Erzurum, Turkey
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Podolanczuk AJ, Cottin V. A Narrative Review of Real-World Data on the Safety of Nintedanib in Patients with Idiopathic Pulmonary Fibrosis. Adv Ther 2023; 40:2038-2050. [PMID: 36928494 PMCID: PMC10129989 DOI: 10.1007/s12325-023-02454-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/06/2023] [Indexed: 03/18/2023]
Abstract
Nintedanib is a tyrosine kinase inhibitor approved for the treatment of idiopathic pulmonary fibrosis (IPF) and other progressive fibrosing interstitial lung diseases. Placebo-controlled trials showed that the adverse event profile of nintedanib was characterised mainly by gastrointestinal events, particularly diarrhoea. We review the data from all published real-world studies of the safety of nintedanib in patients with IPF. These real-world data were consistent with the safety profile observed in clinical trials and described in the product label. The most common adverse events were diarrhoea, nausea and vomiting, but these infrequently led to permanent treatment discontinuation. Liver enzyme elevations were observed, supporting the recommendation for regular monitoring of liver enzymes, particularly in the first few months of treatment. Bleeding and cardiovascular adverse events were rarely reported. As in clinical trials, in real-world studies, reductions of the nintedanib dose, treatment interruptions and use of anti-diarrhoeal medications were frequently employed to manage adverse events. Few data are available on the use of nintedanib in patients who are elderly or have advanced disease, but there are some data to suggest a greater rate of treatment discontinuation in these patients. Effective management of adverse events associated with nintedanib is important to minimise their impact.
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Affiliation(s)
| | - Vincent Cottin
- Coordinating Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, University of Lyon, INRAE, Lyon, France
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Xu R, Wu M, Wang Y, Li C, Zeng L, Wang Y, Xiao M, Chen X, Geng S, Lai P, Du X, Weng J. Mesenchymal stem cells reversibly de-differentiate myofibroblasts to fibroblast-like cells by inhibiting the TGF-β-SMAD2/3 pathway. Mol Med 2023; 29:59. [PMID: 37098464 PMCID: PMC10131436 DOI: 10.1186/s10020-023-00630-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/07/2023] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND Myofibroblasts (MFB), one of the major effectors of pathologic fibrosis, mainly derived from the activation of fibroblast to myofibroblast transition (FMT). Although MFBs were historically considered terminally differentiated cells, their potential for de-differentiation was recently recognized and implied with therapeutic value in treating fibrotic diseases, for instance, idiopathic pulmonary fibrosis (IPF) and post allogeneic hematopoietic stem cell transplantation bronchiolitis obliterans (BO). During the past decade, several methods were reported to block or reverse MFB differentiation, among which mesenchymal stem cells (MSC) have demonstrated potential but undetermined therapeutic values. However, the MSC-mediated regulation of FMT and underlying mechanisms remained largely undefined. METHOD By identifying TGF-β1 hypertension as the pivotal landmark during the pro-fibrotic FMT, TGF-β1-induced MFB and MSC co-culture models were established and utilized to investigate regulations by MSC on FMT in vitro. Methods including RNA sequencing (RNA-seq), Western blot, qPCR and flow cytometry were used. RESULT Our data revealed that TGF-β1 readily induced invasive signatures identified in fibrotic tissues and initiated MFB differentiation in normal FB. MSC reversibly de-differentiated MFB into a group of FB-like cells by selectively inhibiting the TGF-β-SMAD2/3 signaling. Importantly, these proliferation-boosted FB-like cells remained sensitive to TGF-β1 and could be re-induced into MFB. CONCLUSION Our findings highlighted the reversibility of MSC-mediated de-differentiation of MFB through TGF-β-SMAD2/3 signaling, which may explain MSC's inconsistent clinical efficacies in treating BO and other fibrotic diseases. These de-differentiated FB-like cells are still sensitive to TGF-β1 and may further deteriorate MFB phenotypes unless the pro-fibrotic microenvironment is corrected.
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Affiliation(s)
- Ruohao Xu
- Department of Hematology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, 510080, People's Republic of China
| | - Miao Wu
- Department of Hematology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, 510080, People's Republic of China
| | - Yawen Wang
- Department of Hematology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, 510080, People's Republic of China
| | - Chao Li
- Department of Hematology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, 510080, People's Republic of China
| | - Lingji Zeng
- Department of Hematology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, 510080, People's Republic of China
| | - Yulian Wang
- Department of Hematology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, 510080, People's Republic of China
| | - Maozhi Xiao
- Department of Hematology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, 510080, People's Republic of China
| | - Xiaomei Chen
- Department of Hematology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, 510080, People's Republic of China
| | - Suxia Geng
- Department of Hematology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, 510080, People's Republic of China
| | - Peilong Lai
- Department of Hematology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, 510080, People's Republic of China
| | - Xin Du
- Department of Hematology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, 510080, People's Republic of China.
| | - Jianyu Weng
- Department of Hematology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, 510080, People's Republic of China.
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Khan MA, Ghamdi BA, Alhamadi M, Rajendram R, Alyami S, Al-Gamedi M, Al-Harbi A, Al-Jahdali H. A survival analysis of idiopathic pulmonary fibrosis in the context of antifibrotic therapy in Saudi Arabia. Ann Thorac Med 2023; 18:79-85. [PMID: 37323372 PMCID: PMC10263079 DOI: 10.4103/atm.atm_264_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 10/14/2022] [Accepted: 10/19/2022] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND The prognosis of idiopathic pulmonary fibrosis (IPF) can be predicted by the gender, age, and physiology (GAP) index. However, antifibrotic therapy (i.e., nintedanib and pirfenidone) may improve survival. AIMS This study aimed to compare the outcomes of antifibrotic-treated IPF with the survival predicted by the GAP index. METHODS A retrospective cohort study was conducted from March 2014 to January 2020. The electronic health-care records of all IPF patients treated with nintedanib or pirfenidone were reviewed. Besides standard demographic and mortality data, the variables required to calculate the GAP index were also extracted. RESULTS Eighty-one patients (male 55, 68%; age 71.4 ± 10.2 years) with IPF received antifibrotic therapy (nintedanib 44.4%; pirfenidone 55.6%; mean follow-up 35 ± 16.5 months). Cumulative mortality (whole cohort 3 years 12%; 4 years 26%; 5 years 33%) was significantly less than predicted by the GAP index. CONCLUSIONS The survival of antifibrotic-treated IPF is better than predicted by the GAP index. Novel systems for prognostication are required. The survival benefit from pirfenidone and nintedanib seem similar overall.
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Affiliation(s)
- Mohammed Ayaz Khan
- Department of Medicine, College of Medicine, King Saud University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia
- Department of Medicine, Division of Pulmonary, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Basma Al Ghamdi
- Department of Medicine, College of Medicine, King Saud University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia
| | - Mohammed Alhamadi
- Department of Medicine, College of Medicine, King Saud University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia
| | - Rajkumar Rajendram
- Department of Medicine, College of Medicine, King Saud University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia
- Department of Medicine, Internal Medicine Division, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Sami Alyami
- Department of Medicine, College of Medicine, King Saud University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia
- Department of Medicine, Internal Medicine Division, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Majed Al-Gamedi
- Department of Medicine, College of Medicine, King Saud University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia
- Department of Medicine, Division of Pulmonary, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Abdullah Al-Harbi
- Department of Medicine, College of Medicine, King Saud University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia
- Department of Medicine, Division of Pulmonary, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Hamdan Al-Jahdali
- Department of Medicine, College of Medicine, King Saud University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia
- Department of Medicine, Division of Pulmonary, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
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Fu C, Chen L, Cheng Y, Yang W, Zhu H, Wu X, Cai B. Identification of immune biomarkers associated with basement membranes in idiopathic pulmonary fibrosis and their pan-cancer analysis. Front Genet 2023; 14:1114601. [PMID: 36936416 PMCID: PMC10017543 DOI: 10.3389/fgene.2023.1114601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/20/2023] [Indexed: 03/06/2023] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) is a chronic progressive interstitial lung disease of unknown etiology, characterized by diffuse alveolitis and alveolar structural damage. Due to the short median survival time and poor prognosis of IPF, it is particularly urgent to find new IPF biomarkers. Previous studies have shown that basement membranes (BMs) are associated with the development of IPF and tumor metastasis. However, there is still a lack of research on BMs-related genes in IPF. Therefore, we investigated the expression level of BMs genes in IPF and control groups, and explored their potential as biomarkers for IPF diagnosis. In this study, the GSE32537 and GSE53845 datasets were used as training sets, while the GSE24206, GSE10667 and GSE101286 datasets were used as validation sets. In the training set, seven immune biomarkers related to BMs were selected by differential expression analysis, machine learning algorithm (LASSO, SVM-RFE, Randomforest) and ssGSEA analysis. Further ROC analysis confirmed that seven BMs-related genes played an important role in IPF. Finally, four immune-related Hub genes (COL14A1, COL17A1, ITGA10, MMP7) were screened out. Then we created a logistic regression model of immune-related hub genes (IHGs) and used a nomogram to predict IPF risk. The nomogram model was evaluated to have good reliability and validity, and ROC analysis showed that the AUC value of IHGs was 0.941 in the training set and 0.917 in the validation set. Pan-cancer analysis showed that IHGs were associated with prognosis, immune cell infiltration, TME, and drug sensitivity in 33 cancers, suggesting that IHGs may be potential targets for intervention in human diseases including IPF and cancer.
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Affiliation(s)
- Chenkun Fu
- Department of Respiratory and Critical Care Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Lina Chen
- Guiyang Public Health Clinical Center, Guiyang, China
- Guizhou Medical University, Guiyang, China
| | - Yiju Cheng
- Guizhou Medical University, Guiyang, China
- Department of Respiratory and Critical Care Medicine, The First People’s Hospital of Guiyang, Guiyang, China
- *Correspondence: Yiju Cheng, ; Wenting Yang,
| | - Wenting Yang
- Department of Respiratory and Critical Care Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
- *Correspondence: Yiju Cheng, ; Wenting Yang,
| | - Honglan Zhu
- Department of Respiratory and Critical Care Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Xiao Wu
- Department of Respiratory and Critical Care Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Banruo Cai
- Shanghai Institute of Technology, Shanghai, China
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12
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Long-Term Safety of Antifibrotic Drugs in IPF: A Real-World Experience. Biomedicines 2022; 10:biomedicines10123229. [PMID: 36551989 PMCID: PMC9775369 DOI: 10.3390/biomedicines10123229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 11/11/2022] [Accepted: 12/07/2022] [Indexed: 12/15/2022] Open
Abstract
Pirfenidone and nintedanib are the only two drugs approved for the treatment of idiopathic pulmonary fibrosis (IPF). Both proved to be safe and well-tolerated in clinical trials, but real-world data and direct comparisons are scarce. This real-life study explored the safety profile of pirfenidone and nintedanib with a prolonged follow-up. We retrospectively collected clinical status, adverse events (AEs), and treatment changes from IPF patients who had started an antifibrotic treatment at our centre from December 2011 to December 2020, including 192 patients treated with pirfenidone and 89 with nintedanib. The majority of patients in both groups experienced one or more AEs during the follow-up. A higher proportion of AEs in the nintedanib group were effectively treated with behavioural modifications or additional medications compared with the pirfenidone group (52.5% vs. 40.6%, p = 0.04). Overall, a difference in the impact of AEs due to nintedanib versus pirfenidone resulted in a lower permanent discontinuation of therapy (8.3% vs. 18.3%, p = 0.02), with the latter being associated with a higher risk of drug discontinuation at 48 months after initiation (OR = 2.52, p = 0.03). Our study confirms the safety profile of antifibrotic drugs in IPF but highlights that AEs due to nintedanib are usually easier to manage and lead to fewer cases of permanent discontinuation of therapy.
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13
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Cottin V, Bonniaud P, Cadranel J, Crestani B, Jouneau S, Marchand-Adam S, Nunes H, Wémeau-Stervinou L, Bergot E, Blanchard E, Borie R, Bourdin A, Chenivesse C, Clément A, Gomez E, Gondouin A, Hirschi S, Lebargy F, Marquette CH, Montani D, Prévot G, Quetant S, Reynaud-Gaubert M, Salaun M, Sanchez O, Trumbic B, Berkani K, Brillet PY, Campana M, Chalabreysse L, Chatté G, Debieuvre D, Ferretti G, Fourrier JM, Just N, Kambouchner M, Legrand B, Le Guillou F, Lhuillier JP, Mehdaoui A, Naccache JM, Paganon C, Rémy-Jardin M, Si-Mohamed S, Terrioux P. [French practical guidelines for the diagnosis and management of IPF - 2021 update, full version]. Rev Mal Respir 2022; 39:e35-e106. [PMID: 35752506 DOI: 10.1016/j.rmr.2022.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Since the previous French guidelines were published in 2017, substantial additional knowledge about idiopathic pulmonary fibrosis has accumulated. METHODS Under the auspices of the French-speaking Learned Society of Pulmonology and at the initiative of the coordinating reference center, practical guidelines for treatment of rare pulmonary diseases have been established. They were elaborated by groups of writers, reviewers and coordinators with the help of the OrphaLung network, as well as pulmonologists with varying practice modalities, radiologists, pathologists, a general practitioner, a head nurse, and a patients' association. The method was developed according to rules entitled "Good clinical practice" in the overall framework of the "Guidelines for clinical practice" of the official French health authority (HAS), taking into account the results of an online vote using a Likert scale. RESULTS After analysis of the literature, 54 recommendations were formulated, improved, and validated by the working groups. The recommendations covered a wide-ranging aspects of the disease and its treatment: epidemiology, diagnostic modalities, quality criteria and interpretation of chest CT, indication and modalities of lung biopsy, etiologic workup, approach to familial disease entailing indications and modalities of genetic testing, evaluation of possible functional impairments and prognosis, indications for and use of antifibrotic therapy, lung transplantation, symptom management, comorbidities and complications, treatment of chronic respiratory failure, diagnosis and management of acute exacerbations of fibrosis. CONCLUSION These evidence-based guidelines are aimed at guiding the diagnosis and the management in clinical practice of idiopathic pulmonary fibrosis.
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Affiliation(s)
- V Cottin
- Centre national coordonnateur de référence des maladies pulmonaires rares, service de pneumologie, hôpital Louis-Pradel, Hospices Civils de Lyon (HCL), Lyon, France; UMR 754, IVPC, INRAE, Université de Lyon, Université Claude-Bernard Lyon 1, Lyon, France; Membre d'OrphaLung, RespiFil, Radico-ILD2, et ERN-LUNG, Lyon, France.
| | - P Bonniaud
- Centre de référence constitutif des maladies pulmonaires rares, service de pneumologie et soins intensifs respiratoires, centre hospitalo-universitaire de Bourgogne et faculté de médecine et pharmacie, université de Bourgogne-Franche Comté, Dijon ; Inserm U123-1, Dijon, France
| | - J Cadranel
- Centre de référence constitutif des maladies pulmonaires rares, service de pneumologie et oncologie thoracique, Assistance publique-Hôpitaux de Paris (AP-HP), hôpital Tenon, Paris ; Sorbonne université GRC 04 Theranoscan, Paris, France
| | - B Crestani
- Centre de référence constitutif des maladies pulmonaires rares, service de pneumologie A, AP-HP, hôpital Bichat, Paris, France
| | - S Jouneau
- Centre de compétence pour les maladies pulmonaires rares de l'adulte, service de pneumologie, hôpital Pontchaillou, Rennes ; IRSET UMR1085, université de Rennes 1, Rennes, France
| | - S Marchand-Adam
- Centre de compétence pour les maladies pulmonaires rares de l'adulte, hôpital Bretonneau, service de pneumologie, CHRU, Tours, France
| | - H Nunes
- Centre de référence constitutif des maladies pulmonaires rares, service de pneumologie, AP-HP, hôpital Avicenne, Bobigny ; université Sorbonne Paris Nord, Bobigny, France
| | - L Wémeau-Stervinou
- Centre de référence constitutif des maladies pulmonaires rares, Institut Cœur-Poumon, service de pneumologie et immuno-allergologie, CHRU de Lille, Lille, France
| | - E Bergot
- Centre de compétence pour les maladies pulmonaires rares de l'adulte, service de pneumologie et oncologie thoracique, hôpital Côte de Nacre, CHU de Caen, Caen, France
| | - E Blanchard
- Centre de compétence pour les maladies pulmonaires rares de l'adulte, service de pneumologie, hôpital Haut Levêque, CHU de Bordeaux, Pessac, France
| | - R Borie
- Centre de référence constitutif des maladies pulmonaires rares, service de pneumologie A, AP-HP, hôpital Bichat, Paris, France
| | - A Bourdin
- Centre de compétence pour les maladies pulmonaires rares de l'adulte, département de pneumologie et addictologie, hôpital Arnaud-de-Villeneuve, CHU de Montpellier, Montpellier ; Inserm U1046, CNRS UMR 921, Montpellier, France
| | - C Chenivesse
- Centre de référence constitutif des maladies pulmonaires rares, service de pneumologie et d'immuno-allergologie, hôpital Albert Calmette ; CHRU de Lille, Lille ; centre d'infection et d'immunité de Lille U1019 - UMR 9017, Université de Lille, CHU Lille, CNRS, Inserm, Institut Pasteur de Lille, Lille, France
| | - A Clément
- Centre de ressources et de compétence de la mucoviscidose pédiatrique, centre de référence des maladies respiratoires rares (RespiRare), service de pneumologie pédiatrique, hôpital d'enfants Armand-Trousseau, CHU Paris Est, Paris ; Sorbonne université, Paris, France
| | - E Gomez
- Centre de compétence pour les maladies pulmonaires rares, département de pneumologie, hôpitaux de Brabois, CHRU de Nancy, Vandoeuvre-les Nancy, France
| | - A Gondouin
- Centre de compétence pour les maladies pulmonaires rares, service de pneumologie, CHU Jean-Minjoz, Besançon, France
| | - S Hirschi
- Centre de compétence pour les maladies pulmonaires rares, service de pneumologie, Nouvel Hôpital civil, Strasbourg, France
| | - F Lebargy
- Centre de compétence pour les maladies pulmonaires rares, service de pneumologie, CHU Maison Blanche, Reims, France
| | - C-H Marquette
- Centre de compétence pour les maladies pulmonaires rares, FHU OncoAge, département de pneumologie et oncologie thoracique, hôpital Pasteur, CHU de Nice, Nice cedex 1 ; Université Côte d'Azur, CNRS, Inserm, Institute of Research on Cancer and Aging (IRCAN), Nice, France
| | - D Montani
- Centre de compétence pour les maladies pulmonaires rares, centre national coordonnateur de référence de l'hypertension pulmonaire, service de pneumologie et soins intensifs pneumologiques, AP-HP, DMU 5 Thorinno, Inserm UMR S999, CHU Paris-Sud, hôpital de Bicêtre, Le Kremlin-Bicêtre ; Université Paris-Saclay, Faculté de médecine, Le Kremlin-Bicêtre, France
| | - G Prévot
- Centre de compétence pour les maladies pulmonaires rares, service de pneumologie, CHU Larrey, Toulouse, France
| | - S Quetant
- Centre de compétence pour les maladies pulmonaires rares, service de pneumologie et physiologie, CHU Grenoble Alpes, Grenoble, France
| | - M Reynaud-Gaubert
- Centre de compétence pour les maladies pulmonaires rares, service de pneumologie, AP-HM, CHU Nord, Marseille ; Aix Marseille Université, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France
| | - M Salaun
- Centre de compétence pour les maladies pulmonaires rares, service de pneumologie, oncologie thoracique et soins intensifs respiratoires & CIC 1404, hôpital Charles Nicole, CHU de Rouen, Rouen ; IRIB, laboratoire QuantiIF-LITIS, EA 4108, université de Rouen, Rouen, France
| | - O Sanchez
- Centre de compétence pour les maladies pulmonaires rares, service de pneumologie et soins intensifs, hôpital européen Georges-Pompidou, AP-HP, Paris, France
| | | | - K Berkani
- Clinique Pierre de Soleil, Vetraz Monthoux, France
| | - P-Y Brillet
- Université Paris 13, UPRES EA 2363, Bobigny ; service de radiologie, AP-HP, hôpital Avicenne, Bobigny, France
| | - M Campana
- Service de pneumologie et oncologie thoracique, CHR Orléans, Orléans, France
| | - L Chalabreysse
- Service d'anatomie-pathologique, groupement hospitalier est, HCL, Bron, France
| | - G Chatté
- Cabinet de pneumologie et infirmerie protestante, Caluire, France
| | - D Debieuvre
- Service de pneumologie, GHRMSA, hôpital Emile-Muller, Mulhouse, France
| | - G Ferretti
- Université Grenoble Alpes, Grenoble ; service de radiologie diagnostique et interventionnelle, CHU Grenoble Alpes, Grenoble, France
| | - J-M Fourrier
- Association Pierre-Enjalran Fibrose Pulmonaire Idiopathique (APEFPI), Meyzieu, France
| | - N Just
- Service de pneumologie, CH Victor-Provo, Roubaix, France
| | - M Kambouchner
- Service de pathologie, AP-HP, hôpital Avicenne, Bobigny, France
| | - B Legrand
- Cabinet médical de la Bourgogne, Tourcoing ; Université de Lille, CHU Lille, ULR 2694 METRICS, CERIM, Lille, France
| | - F Le Guillou
- Cabinet de pneumologie, pôle santé de l'Esquirol, Le Pradet, France
| | - J-P Lhuillier
- Cabinet de pneumologie, La Varenne Saint-Hilaire, France
| | - A Mehdaoui
- Service de pneumologie et oncologie thoracique, CH Eure-Seine, Évreux, France
| | - J-M Naccache
- Service de pneumologie, allergologie et oncologie thoracique, GH Paris Saint-Joseph, Paris, France
| | - C Paganon
- Centre national coordonnateur de référence des maladies pulmonaires rares, service de pneumologie, hôpital Louis-Pradel, Hospices Civils de Lyon (HCL), Lyon, France
| | - M Rémy-Jardin
- Institut Cœur-Poumon, service de radiologie et d'imagerie thoracique, CHRU de Lille, Lille, France
| | - S Si-Mohamed
- Département d'imagerie cardiovasculaire et thoracique, hôpital Louis-Pradel, HCL, Bron ; Université de Lyon, INSA-Lyon, Université Claude-Bernard Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, U1206, Villeurbanne, France
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Cameli P, Alonzi V, d’Alessandro M, Bergantini L, Pordon E, Guerrieri M, Refini RM, Sestini P, Bargagli E. The Effectiveness of Nintedanib in Patients with Idiopathic Pulmonary Fibrosis, Familial Pulmonary Fibrosis and Progressive Fibrosing Interstitial Lung Diseases: A Real-World Study. Biomedicines 2022; 10:biomedicines10081973. [PMID: 36009520 PMCID: PMC9405731 DOI: 10.3390/biomedicines10081973] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/09/2022] [Accepted: 08/11/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Nintedanib is an oral multitarget tyrosine kinase inhibitor approved for the treatment of patients with idiopathic pulmonary fibrosis (IPF). Recent evidence demonstrated that nintedanib reduced functional disease progression also in subjects with non-IPF progressive fibrosing interstitial lung disease (PF-ILD). However, real-life data on the effectiveness of nintedanib in PF-ILD and familial pulmonary fibrosis (FPF) are lacking. Methods: this retrospective monocentric study enrolled 197 patients affected with IPF, PF-ILD and FPF treated with nintedanib at the Referral Centre of Siena from 2014 to 2021. Pulmonary functional tests and survival data were collected throughout the observation period for the evaluation of mortality and disease progression outcomes. Results: nintedanib treatment significantly reduced the FVC decline rate in IPF and PF-ILD subgroups, but not in FPF subjects. No significant differences were observed among the subgroups in terms of survival, which appeared to be influenced by gender and impaired lung function (FVC < 70% of predicted value). Concerning disease progression rate, a diagnosis of FPF is associated with more pronounced FVC decline despite nintedanib treatment. Conclusions: our research studies the effectiveness and safety of nintedanib in reducing functional disease progression of IPF and PF-ILD. FPF appeared to be less responsive to nintedanib, even though no differences were observed in terms of survival.
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15
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French practical guidelines for the diagnosis and management of idiopathic pulmonary fibrosis - 2021 update. Full-length version. Respir Med Res 2022; 83:100948. [PMID: 36630775 DOI: 10.1016/j.resmer.2022.100948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Since the latest 2017 French guidelines, knowledge about idiopathic pulmonary fibrosis has evolved considerably. METHODS Practical guidelines were drafted on the initiative of the Coordinating Reference Center for Rare Pulmonary Diseases, led by the French Language Pulmonology Society (SPLF), by a coordinating group, a writing group, and a review group, with the involvement of the entire OrphaLung network, pulmonologists practicing in various settings, radiologists, pathologists, a general practitioner, a health manager, and a patient association. The method followed the "Clinical Practice Guidelines" process of the French National Authority for Health (HAS), including an online vote using a Likert scale. RESULTS After a literature review, 54 guidelines were formulated, improved, and then validated by the working groups. These guidelines addressed multiple aspects of the disease: epidemiology, diagnostic procedures, quality criteria and interpretation of chest CT scans, lung biopsy indication and procedures, etiological workup, methods and indications for family screening and genetic testing, assessment of the functional impairment and prognosis, indication and use of antifibrotic agents, lung transplantation, management of symptoms, comorbidities and complications, treatment of chronic respiratory failure, diagnosis and management of acute exacerbations of fibrosis. CONCLUSION These evidence-based guidelines are intended to guide the diagnosis and practical management of idiopathic pulmonary fibrosis.
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Glass DS, Grossfeld D, Renna HA, Agarwala P, Spiegler P, DeLeon J, Reiss AB. Idiopathic pulmonary fibrosis: Current and future treatment. THE CLINICAL RESPIRATORY JOURNAL 2022; 16:84-96. [PMID: 35001525 PMCID: PMC9060042 DOI: 10.1111/crj.13466] [Citation(s) in RCA: 87] [Impact Index Per Article: 43.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 10/21/2021] [Accepted: 11/25/2021] [Indexed: 12/12/2022]
Abstract
Objectives Idiopathic pulmonary fibrosis (IPF) is a chronic fibrotic lung disease characterized by dry cough, fatigue, and progressive exertional dyspnea. Lung parenchyma and architecture is destroyed, compliance is lost, and gas exchange is compromised in this debilitating condition that leads inexorably to respiratory failure and death within 3–5 years of diagnosis. This review discusses treatment approaches to IPF in current use and those that appear promising for future development. Data Source The data were obtained from the Randomized Controlled Trials and scientific studies published in English literature. We used search terms related to IPF, antifibrotic treatment, lung transplant, and management. Results Etiopathogenesis of IPF is not fully understood, and treatment options are limited. Pathological features of IPF include extracellular matrix remodeling, fibroblast activation and proliferation, immune dysregulation, cell senescence, and presence of aberrant basaloid cells. The mainstay therapies are the oral antifibrotic drugs pirfenidone and nintedanib, which can improve quality of life, attenuate symptoms, and slow disease progression. Unilateral or bilateral lung transplantation is the only treatment for IPF shown to increase life expectancy. Conclusion Clearly, there is an unmet need for accelerated research into IPF mechanisms so that progress can be made in therapeutics toward the goals of increasing life expectancy, alleviating symptoms, and improving well‐being.
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Affiliation(s)
- Daniel S Glass
- Department of Medicine and Biomedical Research Institute, NYU Long Island School of Medicine, Mineola, New York, USA
| | - David Grossfeld
- Department of Medicine and Biomedical Research Institute, NYU Long Island School of Medicine, Mineola, New York, USA
| | - Heather A Renna
- Department of Medicine and Biomedical Research Institute, NYU Long Island School of Medicine, Mineola, New York, USA
| | - Priya Agarwala
- Department of Medicine and Biomedical Research Institute, NYU Long Island School of Medicine, Mineola, New York, USA
| | - Peter Spiegler
- Department of Medicine and Biomedical Research Institute, NYU Long Island School of Medicine, Mineola, New York, USA
| | - Joshua DeLeon
- Department of Medicine and Biomedical Research Institute, NYU Long Island School of Medicine, Mineola, New York, USA
| | - Allison B Reiss
- Department of Medicine and Biomedical Research Institute, NYU Long Island School of Medicine, Mineola, New York, USA
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17
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Takehara K, Koga Y, Hachisu Y, Utsugi M, Sawada Y, Saito Y, Yoshimi S, Yatomi M, Shin Y, Wakamatsu I, Umetsu K, Kouno S, Nakagawa J, Sunaga N, Maeno T, Hisada T. Differential Discontinuation Profiles between Pirfenidone and Nintedanib in Patients with Idiopathic Pulmonary Fibrosis. Cells 2022; 11:cells11010143. [PMID: 35011705 PMCID: PMC8750555 DOI: 10.3390/cells11010143] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 12/17/2021] [Accepted: 12/29/2021] [Indexed: 12/18/2022] Open
Abstract
Antifibrotic agents have been widely used in patients with idiopathic pulmonary fibrosis (IPF). Long-term continuation of antifibrotic therapy is required for IPF treatment to prevent disease progression. However, antifibrotic treatment has considerable adverse events, and the continuation of treatment is uncertain in many cases. Therefore, we examined and compared the continuity of treatment between pirfenidone and nintedanib in patients with IPF. We retrospectively enrolled 261 consecutive IPF patients who received antifibrotic treatment from six core facilities in Gunma Prefecture from 2009 to 2018. Among them, 77 patients were excluded if the antifibrotic agent was switched or if the observation period was less than a year. In this study, 134 patients treated with pirfenidone and 50 treated with nintedanib were analyzed. There was no significant difference in patient background, discontinuation rate of antifibrotic treatment over time, and survival rate between the two groups. However, the discontinuation rate due to adverse events within one year of antifibrotic treatment was significantly higher in the nintedanib group than in the pirfenidone group (76% vs. 37%, p < 0.001). Furthermore, the discontinuation rate due to adverse events in nintedanib was higher than that of pirfenidone treatment throughout the observation period (70.6% vs. 31.2%, p = 0.016). The pirfenidone group tended to be discontinued due to acute exacerbation or transfer to another facility. The results of this study suggest that better management of adverse events with nintedanib leads to more continuous treatment that prevents disease progression and acute exacerbations, thus improving prognosis in patients with IPF.
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Affiliation(s)
- Kazutaka Takehara
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, 3-39-15, Showa-machi, Maebashi 371-8511, Japan; (K.T.); (Y.S.); (M.Y.); (Y.S.); (N.S.); (T.M.)
- Department of Respiratory Medicine, Public Tomioka General Hospital, 2073-1, Tomioka 370-2393, Japan
| | - Yasuhiko Koga
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, 3-39-15, Showa-machi, Maebashi 371-8511, Japan; (K.T.); (Y.S.); (M.Y.); (Y.S.); (N.S.); (T.M.)
- Correspondence:
| | - Yoshimasa Hachisu
- Department of Respiratory Medicine, Maebashi Red Cross Hospital, 389-1, Asakura-machi, Maebashi 371-0811, Japan;
| | - Mitsuyoshi Utsugi
- Department of Respiratory Medicine, Kiryu Kosei General Hospital, 6-3, Orihime-machi, Kiryu 376-0024, Japan;
| | - Yuri Sawada
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, 3-39-15, Showa-machi, Maebashi 371-8511, Japan; (K.T.); (Y.S.); (M.Y.); (Y.S.); (N.S.); (T.M.)
| | - Yasuyuki Saito
- Department of Respiratory Medicine, Isesaki Municipal Hospital, Tsunatorihonchou 12-1, Isesaki 372-0817, Japan;
| | - Seishi Yoshimi
- Department of Respiratory Medicine, Tone Central Hospital, 910-1, Numasu-machi, Numata 378-0012, Japan;
| | - Masakiyo Yatomi
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, 3-39-15, Showa-machi, Maebashi 371-8511, Japan; (K.T.); (Y.S.); (M.Y.); (Y.S.); (N.S.); (T.M.)
| | - Yuki Shin
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, 3-39-15, Showa-machi, Maebashi 371-8511, Japan; (K.T.); (Y.S.); (M.Y.); (Y.S.); (N.S.); (T.M.)
| | - Ikuo Wakamatsu
- Department of Respiratory Medicine, National Hospital Organization Takasaki General Medical Center, 36, Takamatsu-cho, Takasaki 370-0829, Japan; (I.W.); (J.N.)
| | - Kazue Umetsu
- Department of Respiratory Medicine, Fujioka General Hospital, 813-1, Nakakurisu, Fujioka 375-8503, Japan; (K.U.); (S.K.)
| | - Shunichi Kouno
- Department of Respiratory Medicine, Fujioka General Hospital, 813-1, Nakakurisu, Fujioka 375-8503, Japan; (K.U.); (S.K.)
| | - Junichi Nakagawa
- Department of Respiratory Medicine, National Hospital Organization Takasaki General Medical Center, 36, Takamatsu-cho, Takasaki 370-0829, Japan; (I.W.); (J.N.)
| | - Noriaki Sunaga
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, 3-39-15, Showa-machi, Maebashi 371-8511, Japan; (K.T.); (Y.S.); (M.Y.); (Y.S.); (N.S.); (T.M.)
| | - Toshitaka Maeno
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, 3-39-15, Showa-machi, Maebashi 371-8511, Japan; (K.T.); (Y.S.); (M.Y.); (Y.S.); (N.S.); (T.M.)
| | - Takeshi Hisada
- Graduate School of Health Sciences, Gunma University, 3-39-22, Showa-machi, Maebashi 371-8514, Japan;
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18
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Kawano-Dourado L, Glassberg MK, Assayag D, Borie R, Johannson KA. Sex and gender in interstitial lung diseases. Eur Respir Rev 2021; 30:30/162/210105. [PMID: 34789464 DOI: 10.1183/16000617.0105-2021] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 07/01/2021] [Indexed: 12/14/2022] Open
Abstract
Sex and gender differences influence key domains of research, lung health, healthcare access and healthcare delivery. In interstitial lung diseases (ILDs), mouse models of pulmonary fibrosis are clearly influenced by sex hormones. Additionally, short telomeres, a biomarker of telomere regulation gene mutations, are impacted by sex, while heritability unexplained by genetic variation may be attributable to gendered environmental factors that drive epigenetic control. Diseases like idiopathic pulmonary fibrosis, hypersensitivity pneumonitis, occupational ILDs, connective tissue-associated ILDs and lymphangioleiomyomatosis have different prevalence and prognosis between men and women. These differences arise from a complex interplay between biological sex and sociocultural gender influencing genetics, epigenomic modifiers, hormones, immune function, response to treatment and interaction with healthcare systems. Much work remains to be done to systematically integrate sex and gender analysis into relevant domains of science and clinical care in ILD, from strategic considerations for establishing research priorities to guidelines for establishing best clinical practices. Accounting for sex and gender in ILD is essential to the practice of individualised, patient-centred medicine.
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Affiliation(s)
- Leticia Kawano-Dourado
- HCor Research Institute, Hospital do Coracao, Sao Paulo, Brazil.,Pulmonary Division, Heart Institute (InCor), University of Sao Paulo, Sao Paulo, Brazil.,INSERM 1152, University of Paris, Paris, France
| | - Marilyn K Glassberg
- Pulmonary, Critical Care, and Sleep Medicine Division, Dept of Medicine, University of Arizona College of Medicine, Phoenix, AZ, USA
| | | | - Raphaël Borie
- Pulmonary Division, Hospital Bichat, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Kerri A Johannson
- Depts of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada .,Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, Canada
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19
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Cox IA, de Graaff B, Corte TJ, Glaspole I, Chambers DC, Moodley Y, Teoh A, Walters EH, Palmer AJ. Recent trends in pirfenidone and nintedanib use for idiopathic pulmonary fibrosis in Australia. AUST HEALTH REV 2021; 45:718-727. [PMID: 34706811 DOI: 10.1071/ah20337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 03/10/2021] [Indexed: 11/23/2022]
Abstract
ObjectivesIdiopathic pulmonary fibrosis (IPF) is one of the most common forms of interstitial lung disease presenting in people aged ≥50 years. There is currently no cure for IPF, but two medications (pirfenidone and nintedanib) have been shown to slow the functional decline of the lungs. In 2017, these two medications were listed on the Pharmaceutical Benefits Scheme (PBS) for subsidisation in Australia. This study evaluated local trends in the use of these two medications.MethodsPrescription data for this analysis were obtained from the PBS Item Reports for the period May 2017-May 2020. Population data were extracted from the Australian Bureau of Statistics data cubes. A descriptive approach was used to conduct and report the analysis to illustrate trends in the use of these two medications and associated costs.ResultsThere were 44 010 prescriptions processed for the treatment for IPF in the 3-year period. Nintedanib use was higher than pirfenidone use, accounting for 54% of prescriptions. New South Wales accounted for 35% of the total prescriptions but, when standardised against population size, the Australian Capital Territory accounted for the highest proportion of prescriptions (24%). Prescriptions for nintedanib and pirfenidone were associated with a total cost of A$131 377 951 over the period 2017-20.ConclusionThis study provides initial information on prescription rates, practices and expenditure for pirfenidone and nintedanib. In addition, we provide some insight into possible pharmacological and epidemiological trends based on jurisdictional differences. Together, the results from this study provide a platform for future research given the dearth of information on IPF in Australia.What is known about the topic?Data regarding trends in the utilisation of antifibrotics for the treatment of IPF in Australia are currently limited.What does this paper add?This study demonstrated that nintedanib use was slightly higher than pirfenidone use, and that there were variations in jurisdictional prescribing practices. The highest number of prescriptions and costs were attributable to New South Wales but, when standardised against population size, the Australian Capital Territory had the highest number of prescriptions and costs.What are the implications for practitioners?This study provides some insights into the use of pirfenidone and nintedanib, as well as pharmacoepidemiological trends, in Australia, which is useful for economic evaluation and modelling future health expenditure.
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Affiliation(s)
- Ingrid A Cox
- Menzies Institute for Medical Research, The University of Tasmania, Hobart, Tas., Australia. ; ; ; and National Health and Medical Research Council (NHMRC) Centre of Research Excellence for Pulmonary Fibrosis, Camperdown, NSW, Australia. ; ;
| | - Barbara de Graaff
- Menzies Institute for Medical Research, The University of Tasmania, Hobart, Tas., Australia. ; ; ; and National Health and Medical Research Council (NHMRC) Centre of Research Excellence for Pulmonary Fibrosis, Camperdown, NSW, Australia. ; ;
| | - Tamera J Corte
- National Health and Medical Research Council (NHMRC) Centre of Research Excellence for Pulmonary Fibrosis, Camperdown, NSW, Australia. ; ; ; and Central Clinical School, The University of Sydney, Camperdown, NSW, Australia; and Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Ian Glaspole
- National Health and Medical Research Council (NHMRC) Centre of Research Excellence for Pulmonary Fibrosis, Camperdown, NSW, Australia. ; ; ; and Interstitial Lung Disease Clinic, Alfred Hospital, Melbourne, Vic., Australia; and Central Clinical School, Monash University, Melbourne, Vic., Australia
| | - Daniel C Chambers
- National Health and Medical Research Council (NHMRC) Centre of Research Excellence for Pulmonary Fibrosis, Camperdown, NSW, Australia. ; ; ; and School of Clinical Medicine, The University of Queensland, Brisbane, Qld, Australia. ; and Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Qld, Australia
| | - Yuben Moodley
- National Health and Medical Research Council (NHMRC) Centre of Research Excellence for Pulmonary Fibrosis, Camperdown, NSW, Australia. ; ; ; and Faculty of Health and Medical Sciences, The University of Western Australia, Perth, WA, Australia. ; and Institute of Respiratory Health, The University of Western Australia, Perth, WA, Australia; and Department of Respiratory Medicine, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Alan Teoh
- National Health and Medical Research Council (NHMRC) Centre of Research Excellence for Pulmonary Fibrosis, Camperdown, NSW, Australia. ; ; ; and Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - E Haydn Walters
- Menzies Institute for Medical Research, The University of Tasmania, Hobart, Tas., Australia. ; ; ; and National Health and Medical Research Council (NHMRC) Centre of Research Excellence for Pulmonary Fibrosis, Camperdown, NSW, Australia. ; ;
| | - Andrew J Palmer
- Menzies Institute for Medical Research, The University of Tasmania, Hobart, Tas., Australia. ; ; ; and National Health and Medical Research Council (NHMRC) Centre of Research Excellence for Pulmonary Fibrosis, Camperdown, NSW, Australia. ; ; ; and Centre for Health Policy, School of Population and Global Health, The University of Melbourne, Melbourne, Vic., Australia; and Corresponding author.
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20
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Marijic P, Schwarzkopf L, Schwettmann L, Ruhnke T, Trudzinski F, Kreuter M. Pirfenidone vs. nintedanib in patients with idiopathic pulmonary fibrosis: a retrospective cohort study. Respir Res 2021; 22:268. [PMID: 34666765 PMCID: PMC8527681 DOI: 10.1186/s12931-021-01857-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/03/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Two antifibrotic drugs, pirfenidone and nintedanib, are licensed for the treatment of patients with idiopathic pulmonary fibrosis (IPF). However, there is neither evidence from prospective data nor a guideline recommendation, which drug should be preferred over the other. This study aimed to compare pirfenidone and nintedanib-treated patients regarding all-cause mortality, all-cause and respiratory-related hospitalizations, and overall as well as respiratory-related health care costs borne by the Statutory Health Insurance (SHI). METHODS A retrospective cohort study with SHI data was performed, including IPF patients treated either with pirfenidone or nintedanib. Stabilized inverse probability of treatment weighting (IPTW) based on propensity scores was applied to adjust for observed covariates. Weighted Cox models were estimated to analyze mortality and hospitalization. Weighted cost differences with bootstrapped 95% confidence intervals (CI) were applied for cost analysis. RESULTS We compared 840 patients treated with pirfenidone and 713 patients treated with nintedanib. Both groups were similar regarding two-year all-cause mortality (HR: 0.90 95% CI: 0.76; 1.07), one-year all cause (HR: 1.09, 95% CI: 0.95; 1.25) and respiratory-related hospitalization (HR: 0.89, 95% CI: 0.72; 1.08). No significant differences were observed regarding total (€- 807, 95% CI: €- 2977; €1220) and respiratory-related (€- 1282, 95% CI: €- 3423; €534) costs. CONCLUSION Our analyses suggest that the patient-related outcomes mortality, hospitalization, and costs do not differ between the two currently available antifibrotic drugs pirfenidone and nintedanib. Hence, the decision on treatment with pirfenidone versus treatment with nintedanib ought to be made case-by-case taking clinical characteristics, comorbidities, comedications, individual risk of side effects, and patients' preferences into account.
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Affiliation(s)
- Pavo Marijic
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München - German Research Center for Environmental Health (GmbH), Neuherberg, Germany. .,Pettenkoffer School of Public Health, Munich, Germany. .,Institute for Medical Information Processing, Biometry and Epidemiology - IBE, LMU Munich, Munich, Germany.
| | - Larissa Schwarzkopf
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München - German Research Center for Environmental Health (GmbH), Neuherberg, Germany.,Pettenkoffer School of Public Health, Munich, Germany.,Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany.,IFT-Institut Fuer Therapieforschung, Munich, Germany
| | - Lars Schwettmann
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München - German Research Center for Environmental Health (GmbH), Neuherberg, Germany.,Department of Economics, Martin Luther University Halle-Wittenberg, Halle, Germany
| | | | - Franziska Trudzinski
- Center for Interstitial and Rare Lung Diseases, Pneumology and Respiratory Critical Care Medicine, Thoraxklinik, University of Heidelberg, Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Michael Kreuter
- Center for Interstitial and Rare Lung Diseases, Pneumology and Respiratory Critical Care Medicine, Thoraxklinik, University of Heidelberg, Member of the German Center for Lung Research (DZL), Heidelberg, Germany
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21
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Campiani G, Cavella C, Osko JD, Brindisi M, Relitti N, Brogi S, Saraswati AP, Federico S, Chemi G, Maramai S, Carullo G, Jaeger B, Carleo A, Benedetti R, Sarno F, Lamponi S, Rottoli P, Bargagli E, Bertucci C, Tedesco D, Herp D, Senger J, Ruberti G, Saccoccia F, Saponara S, Gorelli B, Valoti M, Kennedy B, Sundaramurthi H, Butini S, Jung M, Roach KM, Altucci L, Bradding P, Christianson DW, Gemma S, Prasse A. Harnessing the Role of HDAC6 in Idiopathic Pulmonary Fibrosis: Design, Synthesis, Structural Analysis, and Biological Evaluation of Potent Inhibitors. J Med Chem 2021; 64:9960-9988. [PMID: 34251197 PMCID: PMC8300879 DOI: 10.1021/acs.jmedchem.1c00184] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Idiopathic pulmonary fibrosis (IPF) is an interstitial lung disease characterized by a progressive-fibrosing phenotype. IPF has been associated with aberrant HDAC activities confirmed by our immunohistochemistry studies on HDAC6 overexpression in IPF lung tissues. We herein developed a series of novel hHDAC6 inhibitors, having low inhibitory potency over hHDAC1 and hHDAC8, as potential pharmacological tools for IPF treatment. Their inhibitory potency was combined with low in vitro and in vivo toxicity. Structural analysis of 6h and structure-activity relationship studies contributed to the optimization of the binding mode of the new molecules. The best-performing analogues were tested for their efficacy in inhibiting fibrotic sphere formation and cell viability, proving their capability in reverting the IPF phenotype. The efficacy of analogue 6h was also determined in a validated human lung model of TGF-β1-dependent fibrogenesis. The results highlighted in this manuscript may pave the way for the identification of first-in-class molecules for the treatment of IPF.
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Affiliation(s)
- Giuseppe Campiani
- University of Siena, Department of Biotechnology, Chemistry and Pharmacy, DoE Department of Excellence 2018-2022, via Aldo Moro 2, 53100 Siena, Italy
| | - Caterina Cavella
- University of Siena, Department of Biotechnology, Chemistry and Pharmacy, DoE Department of Excellence 2018-2022, via Aldo Moro 2, 53100 Siena, Italy
| | - Jeremy D. Osko
- Roy and Diana Vagelos Laboratories, Department of Chemistry, University of Pennsylvania, Philadelphia, PA 19104-6323, United States
| | - Margherita Brindisi
- University of Siena, Department of Biotechnology, Chemistry and Pharmacy, DoE Department of Excellence 2018-2022, via Aldo Moro 2, 53100 Siena, Italy
| | - Nicola Relitti
- University of Siena, Department of Biotechnology, Chemistry and Pharmacy, DoE Department of Excellence 2018-2022, via Aldo Moro 2, 53100 Siena, Italy
| | - Simone Brogi
- Department of Pharmacy, University of Pisa, via Bonanno 6, 56126, Pisa, Italy
| | - A. Prasanth Saraswati
- University of Siena, Department of Biotechnology, Chemistry and Pharmacy, DoE Department of Excellence 2018-2022, via Aldo Moro 2, 53100 Siena, Italy
| | - Stefano Federico
- University of Siena, Department of Biotechnology, Chemistry and Pharmacy, DoE Department of Excellence 2018-2022, via Aldo Moro 2, 53100 Siena, Italy
| | - Giulia Chemi
- University of Siena, Department of Biotechnology, Chemistry and Pharmacy, DoE Department of Excellence 2018-2022, via Aldo Moro 2, 53100 Siena, Italy
| | - Samuele Maramai
- University of Siena, Department of Biotechnology, Chemistry and Pharmacy, DoE Department of Excellence 2018-2022, via Aldo Moro 2, 53100 Siena, Italy
| | - Gabriele Carullo
- University of Siena, Department of Biotechnology, Chemistry and Pharmacy, DoE Department of Excellence 2018-2022, via Aldo Moro 2, 53100 Siena, Italy
| | - Benedikt Jaeger
- Klinik für Pneumologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, Hannover, 30625, Germany
| | - Alfonso Carleo
- Klinik für Pneumologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, Hannover, 30625, Germany
| | - Rosaria Benedetti
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Vico L. de Crecchio 7, 80138, Naples, Italy
| | - Federica Sarno
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Vico L. de Crecchio 7, 80138, Naples, Italy
| | - Stefania Lamponi
- University of Siena, Department of Biotechnology, Chemistry and Pharmacy, DoE Department of Excellence 2018-2022, via Aldo Moro 2, 53100 Siena, Italy
| | - Paola Rottoli
- University of Siena, Specialization School of Respiratory Diseases, Department of Medical Sciences, Surgery and Neurosciences, Centro didattico Le Scotte, , 53100, Siena, Italy
| | - Elena Bargagli
- University of Siena, Department of Medical Sciences, Surgery and Neurosciences, Respiratory Diseases Unit, AOUS, Centro didattico Le Scotte, 53100, Siena, Italy
| | - Carlo Bertucci
- Department of Pharmacy and Biotechnology, University of Bologna, Via Belmeloro, 6, Bologna 40126, Italy
| | - Daniele Tedesco
- Department of Pharmacy and Biotechnology, University of Bologna, Via Belmeloro, 6, Bologna 40126, Italy
| | - Daniel Herp
- Institute of Pharmaceutical Sciences, Albert-Ludwigs-Universität Freiburg, Albertstraße 25, 79104, Freiburg, Germany
| | - Johanna Senger
- Institute of Pharmaceutical Sciences, Albert-Ludwigs-Universität Freiburg, Albertstraße 25, 79104, Freiburg, Germany
| | - Giovina Ruberti
- Institute of Biochemistry and Cell Biology (IBBC), National Research Council (CNR), via E. Ramarini 32, 00015 Monterotondo (Rome), Italy
| | - Fulvio Saccoccia
- Institute of Biochemistry and Cell Biology (IBBC), National Research Council (CNR), via E. Ramarini 32, 00015 Monterotondo (Rome), Italy
| | - Simona Saponara
- Department of Life Sciences, University of Siena, via Aldo Moro 2, I-53100 Siena, Italy
| | - Beatrice Gorelli
- Department of Life Sciences, University of Siena, via Aldo Moro 2, I-53100 Siena, Italy
| | - Massimo Valoti
- Department of Life Sciences, University of Siena, via Aldo Moro 2, I-53100 Siena, Italy
| | - Breándan Kennedy
- UCD School of Biomolecular and Biomedical Science, UCD Conway Institute, University College Dublin, D04 V1W8, Dublin, Ireland
| | - Husvinee Sundaramurthi
- UCD School of Biomolecular and Biomedical Science, UCD Conway Institute, University College Dublin, D04 V1W8, Dublin, Ireland
| | - Stefania Butini
- University of Siena, Department of Biotechnology, Chemistry and Pharmacy, DoE Department of Excellence 2018-2022, via Aldo Moro 2, 53100 Siena, Italy
| | - Manfred Jung
- Institute of Pharmaceutical Sciences, Albert-Ludwigs-Universität Freiburg, Albertstraße 25, 79104, Freiburg, Germany
| | - Katy M. Roach
- Department of Respiratory Sciences, University of Leicester, UK, Institute of Lung Health and NIHR Leicester BRC-Respiratory, LE5 4PW, Leicester, UK
| | - Lucia Altucci
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Vico L. de Crecchio 7, 80138, Naples, Italy
| | - Peter Bradding
- Department of Respiratory Sciences, University of Leicester, UK, Institute of Lung Health and NIHR Leicester BRC-Respiratory, LE5 4PW, Leicester, UK
| | - David W. Christianson
- Roy and Diana Vagelos Laboratories, Department of Chemistry, University of Pennsylvania, Philadelphia, PA 19104-6323, United States
| | - Sandra Gemma
- University of Siena, Department of Biotechnology, Chemistry and Pharmacy, DoE Department of Excellence 2018-2022, via Aldo Moro 2, 53100 Siena, Italy
| | - Antje Prasse
- Klinik für Pneumologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, Hannover, 30625, Germany
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22
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Ghumman M, Dhamecha D, Gonsalves A, Fortier L, Sorkhdini P, Zhou Y, Menon JU. Emerging drug delivery strategies for idiopathic pulmonary fibrosis treatment. Eur J Pharm Biopharm 2021; 164:1-12. [PMID: 33882301 PMCID: PMC8154728 DOI: 10.1016/j.ejpb.2021.03.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 03/03/2021] [Accepted: 03/29/2021] [Indexed: 12/18/2022]
Abstract
Idiopathic pulmonary fibrosis (IPF) is a debilitating and fatal condition that causes severe scarring of the lungs. While the pathogenesis of IPF continues to be extensively studied and several factors have been considered, an exact cause has yet to be established. With inadequate treatment options and no cure available, overall disease prognosis is still poor. Existing oral therapies, pirfenidone and nintedanib, may attempt to improve the patients' quality of life by mitigating symptoms and slowing disease progression, however chronic doses and systemic deliveries of these drugs can lead to severe side effects. The lack of effective treatment options calls for further investigation of restorative as well as additional palliative therapies for IPF. Nanoparticle-based sustained drug delivery strategies can be utilized to ensure targeted delivery for site-specific treatment as well as long-acting therapy, improving overall patient compliance. This review provides an update on promising strategies for the delivery of anti-fibrotic agents, along with an overview of key therapeutic targets as well as relevant emerging therapies currently being evaluated for IPF treatment.
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Affiliation(s)
- Moez Ghumman
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, Kingston, RI 02881, USA
| | - Dinesh Dhamecha
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, Kingston, RI 02881, USA
| | - Andrea Gonsalves
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, Kingston, RI 02881, USA
| | - Lauren Fortier
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, Kingston, RI 02881, USA
| | - Parand Sorkhdini
- Department of Molecular Microbiology and Immunology, Brown University, Providence, RI 02912, USA
| | - Yang Zhou
- Department of Molecular Microbiology and Immunology, Brown University, Providence, RI 02912, USA.
| | - Jyothi U Menon
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, Kingston, RI 02881, USA.
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Bergantini L, d'Alessandro M, Cameli P, Carleo A, Landi C, Vietri L, Lanzarone N, Pieroni M, Sestini P, Bargagli E. Antithrombin III as predictive indicator of survival in idiopathic pulmonary fibrosis (IPF) patients treated with nintedanib: a preliminary study. Intern Med J 2021; 51:705-711. [PMID: 32040256 DOI: 10.1111/imj.14768] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 01/20/2020] [Accepted: 02/03/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Idiopathic pulmonary fibrosis (IPF) is a progressive lung disease often managed with nintedanib, a tyrosine kinase inhibitor targeting several profibrotic pathways. Although clotting processes are involved in wound healing and repair in the lung, there are no data on the role of antithrombin III (ATIII) in IPF patients treated with nintedanib. A previous proteomic analysis of serum of IPF patients before and after 1 year of nintedanib treatment showed differential protein expression of ATIII. AIMS Here we used quantitative methods to evaluate differential ATIII concentrations in IPF patients before and after 1 year of nintedanib treatment and to assess the potential of ATIII as a prognostic biomarker in IPF patients. METHODS Serum levels of ATIII were measured by enzyme-linked immunosorbent assay in 14 IPF patients before and after 1 year of nintedanib treatment. RESULTS A statistically significant inverse correlation was found between serum ATIII concentrations and pulmonary function test parameters in all patients at baseline and follow up. Baseline serum ATIII and bronchoalveolar lavage (BAL) neutrophils proved to be reliable predictors of poor prognosis. A baseline ATIII threshold of 126.5 μg/mL discriminated survivors from non-survivors. CONCLUSIONS After 12 months of antifibrotic treatment, IPF patients with high serum ATIII concentrations and high BAL neutrophil percentages had a poor prognosis and increased survival risk. The results of this preliminary study suggest that ATIII has potential as a biomarker of IPF severity and in predicting response to nintedanib therapy. As a marker, ATIII showed several advantages over BAL neutrophil percentage.
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Affiliation(s)
- Laura Bergantini
- Department of Medical Sciences, Surgery and Neuroscience, Respiratory Disease and Lung Transplant Unit, Siena University, Siena, Italy
| | - Miriana d'Alessandro
- Department of Medical Sciences, Surgery and Neuroscience, Respiratory Disease and Lung Transplant Unit, Siena University, Siena, Italy
| | - Paolo Cameli
- Department of Medical Sciences, Surgery and Neuroscience, Respiratory Disease and Lung Transplant Unit, Siena University, Siena, Italy
| | - Alfonso Carleo
- Department of Pulmonology, Hannover Medical School, Hannover, Germany
| | - Claudia Landi
- Department of Life Science, University of Siena, Siena, Italy
| | - Lucia Vietri
- Department of Medical Sciences, Surgery and Neuroscience, Respiratory Disease and Lung Transplant Unit, Siena University, Siena, Italy
| | - Nicola Lanzarone
- Department of Medical Sciences, Surgery and Neuroscience, Respiratory Disease and Lung Transplant Unit, Siena University, Siena, Italy
| | - Maria Pieroni
- Department of Medical Sciences, Surgery and Neuroscience, Respiratory Disease and Lung Transplant Unit, Siena University, Siena, Italy
| | - Piersante Sestini
- Department of Medical Sciences, Surgery and Neuroscience, Respiratory Disease and Lung Transplant Unit, Siena University, Siena, Italy
| | - Elena Bargagli
- Department of Medical Sciences, Surgery and Neuroscience, Respiratory Disease and Lung Transplant Unit, Siena University, Siena, Italy
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24
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Vietri L, Cameli P, Perruzza M, Cekorja B, Bergantini L, d'Alessandro M, Refini RM, Pieroni M, Fossi A, Bennett D, Spalletti M, Mazzei MA, Sestini P, Rottoli P, Bargagli E. Pirfenidone in idiopathic pulmonary fibrosis: real-life experience in the referral centre of Siena. Ther Adv Respir Dis 2021; 14:1753466620906326. [PMID: 32066332 PMCID: PMC7029533 DOI: 10.1177/1753466620906326] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background: Idiopathic pulmonary fibrosis (IPF) is the most common idiopathic interstitial pneumonia and has a median survival after diagnosis of 2–5 years. Pirfenidone is the first approved antifibrotic drug for the treatment of IPF. Here we report the functional progress, side effects and survival data of a population of patients with IPF, diagnosed at our centre and treated with pirfenidone. Methods: We enrolled 91 patients with IPF (71 males) treated with pirfenidone. Clinical, survival and functional details were collected retrospectively at start of therapy and after 12, 24, 36 and 48 months of treatment. Lung function tests at least 12 months before starting therapy were available for 40 patients and were entered in the database, as well as side effects. Results: During the observation period (922 ± 529 days), 27 patients died, 5 patients underwent lung transplant and 10 patients interrupted therapy due to adverse events or IPF progression. The median survival was 1606 days. There was a significant reduction in disease progression rate, as measured by trend of forced vital capacity, after 1 year of therapy with respect to before treatment (p = 0.0085). Forced vital capacity reduction rate was progressively higher in the subsequent years of treatment. Treatment-related side effects were reported in 25 patients and were predominantly mild. Overall, four patients discontinued therapy due to severe photosensitivity. Conclusions: Our findings confirm the efficacy of pirfenidone in reducing functional progression of IPF and its excellent safety profile in a real-life setting. This study, designed on a long-term follow up, contributes to the growing evidence on safety, tolerability and efficacy of pirfenidone in IPF. The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- Lucia Vietri
- Department of Medical and Surgical Sciences and Neurosciences, Respiratory Disease and Lung Transplant Unit, University of Siena, AOUS, Siena, Italy
| | - Paolo Cameli
- Department of Medical and Surgical Sciences and Neurosciences, Respiratory Disease and Lung Transplant Unit, University of Siena, Viale Bracci, Siena, 53100, Italy
| | - Marco Perruzza
- Department of Medical and Surgical Sciences and Neurosciences, Respiratory Disease and Lung Transplant Unit, University of Siena, AOUS, Siena, Italy
| | - Behar Cekorja
- Department of Medical and Surgical Sciences and Neurosciences, Respiratory Disease and Lung Transplant Unit, University of Siena, AOUS, Siena, Italy
| | - Laura Bergantini
- Department of Medical and Surgical Sciences and Neurosciences, Respiratory Disease and Lung Transplant Unit, University of Siena, AOUS, Siena, Italy
| | - Miriana d'Alessandro
- Department of Medical and Surgical Sciences and Neurosciences, Respiratory Disease and Lung Transplant Unit, University of Siena, AOUS, Siena, Italy
| | - Rosa Metella Refini
- Department of Medical and Surgical Sciences and Neurosciences, Respiratory Disease and Lung Transplant Unit, University of Siena, AOUS, Siena, Italy
| | - Maria Pieroni
- Department of Medical and Surgical Sciences and Neurosciences, Respiratory Disease and Lung Transplant Unit, University of Siena, AOUS, Siena, Italy
| | - Antonella Fossi
- Department of Medical and Surgical Sciences and Neurosciences, Respiratory Disease and Lung Transplant Unit, University of Siena, AOUS, Siena, Italy
| | - David Bennett
- Department of Medical and Surgical Sciences and Neurosciences, Respiratory Disease and Lung Transplant Unit, University of Siena, AOUS, Siena, Italy
| | - Marco Spalletti
- Department of Medical and Surgical Sciences and Neurosciences, Respiratory Disease and Lung Transplant Unit, University of Siena, AOUS, Siena, Italy
| | - Maria Antonietta Mazzei
- Department of Medical and Surgical Sciences and Neurosciences, Diagnostic Imaging Unit, University of Siena, AOUS, Siena, Italy
| | - Piersante Sestini
- Department of Medical and Surgical Sciences and Neurosciences, Respiratory Disease and Lung Transplant Unit, University of Siena, AOUS, Siena, Italy
| | - Paola Rottoli
- Department of Medical and Surgical Sciences and Neurosciences, Respiratory Disease and Lung Transplant Unit, University of Siena, AOUS, Siena, Italy
| | - Elena Bargagli
- Department of Medical and Surgical Sciences and Neurosciences, Respiratory Disease and Lung Transplant Unit, University of Siena, AOUS, Siena, Italy
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25
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Huang TH, Kuo CW, Chen CW, Tseng YL, Wu CL, Lin SH. Baseline plasma KL-6 level predicts adverse outcomes in patients with idiopathic pulmonary fibrosis receiving nintedanib: a retrospective real-world cohort study. BMC Pulm Med 2021; 21:165. [PMID: 33992083 PMCID: PMC8126113 DOI: 10.1186/s12890-021-01530-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/07/2021] [Indexed: 11/12/2022] Open
Abstract
Background Nintedanib is effective for treating idiopathic pulmonary fibrosis (IPF), but some patients may exhibit a suboptimal response and develop on-treatment acute exacerbation (AE-IPF), hepatic injury, or mortality. It remains unclear which patients are at risk for these adverse outcomes.
Methods We analysed the demographic and clinical data, baseline plasma levels of Krebs von den Lungen-6 (KL-6) and surfactant protein A (SPA), and longitudinal clinical courses of a real-world cohort of IPF patients who received nintedanib ≥ 14 days between March 2017 and December 2020. Cox proportional-hazards regression, subdistribution hazards regression, and sensitivity analyses were performed to investigate the association between baseline predictors and AE-IPF, mortality, and nintedanib-related hepatic injury. The relationship between baseline predictors and pulmonary function decline was determined. Results Fifty-seven patients were included, of whom 24 (42%) developed hepatic injury, 20 (35%) had AE-IPF, and 16 (28%) died on-treatment. A baseline plasma KL-6 level ≥ 2.5 ng/mL, and diffusion capacity for carbon monoxide (DLCO) < 55% predicted, were associated with increased risk of hepatic injury (adjusted hazard ratio [aHR] was 3.46; 95% CI 1.13–10.60; p = 0.029 for KL-6, and 6.05; 95% CI 1.89–19.32; p = 0.002 for DLCO). Both factors also predicted severe and recurrent hepatic injury. Patients with baseline KL-6 ≥ 2.5 ng/mL also had a higher risk of AE-IPF (aHR 4.52; 95% CI 1.63–12.55; p = 0.004). For on-treatment mortality, baseline KL-6 ≥ 3.5 ng/mL and SPA ≥ 600 pg/mL were significant predictors (aHR 5.39; 95% CI 1.16–24.97; p = 0.031 for KL-6, and aHR 12.28; 95% CI 2.06–73.05; p = 0.006 for SPA). Results from subdistribution hazard regression and sensitivity analyses supported these findings. Patients with elevated baseline plasma KL-6 levels also exhibited a trend towards faster pulmonary function decline. Conclusions For patients with IPF who are receiving nintedanib, we have identified baseline predictors, in particular plasma KL-6 levels, for the risk of adverse outcomes. Patients with these predictors may require close monitoring for unfavourable responses during treatment. Our findings also support the prognostic role of molecular markers like KL-6 and may contribute to future formulation of more individualized therapeutic strategies for IPF. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-021-01530-6.
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Affiliation(s)
- Tang-Hsiu Huang
- Division of Chest Medicine, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chin-Wei Kuo
- Division of Chest Medicine, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chian-Wei Chen
- Division of Chest Medicine, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yau-Lin Tseng
- Division of Thoracic Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chao-Liang Wu
- Department of Biochemistry and Molecular Biology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Sheng-Hsiang Lin
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan. .,Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan. .,Biostatistics Consulting Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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26
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Corrie L, Muzaffar-Ur-Rehman MD, Kukatil L, Manasa D, Shirisha A. Antifibrotic Drugs for COVID-19: From Orphan Drugs to Blockbusters? CURRENT RESPIRATORY MEDICINE REVIEWS 2021. [DOI: 10.2174/1573398x17666210304100043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
:
Antifibrotic agents are known to treat idiopathic pulmonary fibrosis. The two antifibrotic
agents approved and in usage are Pirfenidone and Nintedanib granted by the USFDA in 2014.
They are both known to decrease inflammation in the lungs. The fact that COVID-19 has shown to
cause inflammation and fibrosis in the lungs frames the theory of their usage in the treatment of the
disease by reducing lung scaring and allowing faster discharge of patients with post-COVID complications.
The need for them to change their status from orphans to blockbusters has not happened
yet due to fewer data and less research available on them as well as various other economic and patient-
related factors. Since COVID-19 is widespread and causes many complications of the lungs
that are similar to what these two drugs treat. We believe that the status of these drugs could be
changed due to an increase in demand for them.
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Affiliation(s)
- Leander Corrie
- School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, Punjab, 144411, India
| | - MD Muzaffar-Ur-Rehman
- Nalla Narasimha Reddy Educational Society, Chowdariguda, Narapally, Telangana State, 500088, India
| | - Latha Kukatil
- G. Pulla Reddy College of Pharmacy, Pillar No : 23 (PVNR elevated Expressway) Mehdipatnam, Hyderabad, Telangana State, 500028, India
| | - Devasari Manasa
- G. Pulla Reddy College of Pharmacy, Pillar No : 23 (PVNR elevated Expressway) Mehdipatnam, Hyderabad, Telangana State, 500028, India
| | - Adepu Shirisha
- G. Pulla Reddy College of Pharmacy, Pillar No : 23 (PVNR elevated Expressway) Mehdipatnam, Hyderabad, Telangana State, 500028, India
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27
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Yang S, Liu P, Jiang Y, Wang Z, Dai H, Wang C. Therapeutic Applications of Mesenchymal Stem Cells in Idiopathic Pulmonary Fibrosis. Front Cell Dev Biol 2021; 9:639657. [PMID: 33768094 PMCID: PMC7985078 DOI: 10.3389/fcell.2021.639657] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/15/2021] [Indexed: 12/17/2022] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) is an interstitial disease of unknown etiology characterized by progressive pulmonary fibrosis. Pirfenidone and nintedanib are the only drugs that can prolong the time to disease progression, slow down the decline in lung function, and prolong survival. However, they do not offer a cure and are associated with tolerability issues. The pluripotency of mesenchymal stem cells (MSCs) and their ability to regulate immunity, inhibit inflammation, and promote epithelial tissue repair highlight the promise of MSC therapy for treating interstitial lung disease. However, optimal protocols are lacking for multi-parameter selection in MSC therapy. This review summarizes preclinical studies on MSC transplantation for the treatment of interstitial lung disease and clinical studies with known results. An analysis of relevant factors for the optimization of treatment plans is presented, including MSCs with different sources, administration routes and timing, dosages, frequencies, and pretreatments with MSCs. This review proposes an optimized plan for guiding the design of future clinical research to identify therapeutic options for this complex disease.
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Affiliation(s)
- Shengnan Yang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,National Center for Respiratory Medicine, Beijing, China.,Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China.,National Clinical Research Center for Respiratory Diseases, Beijing, China.,WHO Collaborating Centre for Tobacco Cessation and Respiratory Diseases Prevention, Beijing, China.,Harbin Medical University, Harbin, China
| | - Peipei Liu
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yale Jiang
- School of Medicine, Tsinghua University, Beijing, China
| | - Zai Wang
- Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
| | - Huaping Dai
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,National Center for Respiratory Medicine, Beijing, China.,Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China.,National Clinical Research Center for Respiratory Diseases, Beijing, China.,WHO Collaborating Centre for Tobacco Cessation and Respiratory Diseases Prevention, Beijing, China
| | - Chen Wang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,National Center for Respiratory Medicine, Beijing, China.,Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China.,National Clinical Research Center for Respiratory Diseases, Beijing, China.,WHO Collaborating Centre for Tobacco Cessation and Respiratory Diseases Prevention, Beijing, China.,Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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28
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Ameri P, Tini G, Spallarossa P, Mercurio V, Tocchetti CG, Porto I. Cardiovascular safety of the tyrosine kinase inhibitor nintedanib. Br J Clin Pharmacol 2021; 87:3690-3698. [PMID: 33620103 DOI: 10.1111/bcp.14793] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 01/12/2021] [Accepted: 02/12/2021] [Indexed: 01/07/2023] Open
Abstract
The intracellular tyrosine kinase inhibitor nintedanib has shown great efficacy for the treatment of idiopathic pulmonary fibrosis (IPF) and other interstitial lung diseases. However, the incidence rate of myocardial infarction (MI) among participants in landmark IPF trials was remarkable, peaking at 3/100 patient-years. Although subjects with IPF often have a high cardiovascular (CV) risk profile, the occurrence of MI in nintedanib-treated patients may not be fully explained by clustering of CV risk factors. Nintedanib inhibits the vascular endothelial growth factor, platelet-derived growth factor and fibroblast growth factor pathways, which play important roles in the biology of the atherosclerotic plaque and in the response of the heart to ischaemia. Hence, unwanted CV effects may partly account for nintedanib-related MI. We review the evidence supporting this hypothesis and discuss possible actions for a safe implementation of nintedanib in clinical practice, building on the experience with tyrosine kinase inhibitors acquired in cardio-oncology.
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Affiliation(s)
- Pietro Ameri
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino - IRCCS Italian Cardiology Network, Genoa, Italy.,Department of Internal Medicine, University of Genova, Genoa, Italy
| | - Giacomo Tini
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino - IRCCS Italian Cardiology Network, Genoa, Italy.,Department of Internal Medicine, University of Genova, Genoa, Italy
| | - Paolo Spallarossa
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino - IRCCS Italian Cardiology Network, Genoa, Italy
| | - Valentina Mercurio
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences, Federico II University, Naples, Italy.,Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Federico II University, Naples, Italy
| | - Italo Porto
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino - IRCCS Italian Cardiology Network, Genoa, Italy.,Department of Internal Medicine, University of Genova, Genoa, Italy
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Common molecular pathways targeted by nintedanib in cancer and IPF: A bioinformatic study. Pulm Pharmacol Ther 2020; 64:101941. [DOI: 10.1016/j.pupt.2020.101941] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/29/2020] [Accepted: 08/25/2020] [Indexed: 02/06/2023]
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30
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Cameli P, Refini RM, Bergantini L, d'Alessandro M, Alonzi V, Magnoni C, Rottoli P, Sestini P, Bargagli E. Long-Term Follow-Up of Patients With Idiopathic Pulmonary Fibrosis Treated With Pirfenidone or Nintedanib: A Real-Life Comparison Study. Front Mol Biosci 2020; 7:581828. [PMID: 33102528 PMCID: PMC7498677 DOI: 10.3389/fmolb.2020.581828] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 08/13/2020] [Indexed: 12/14/2022] Open
Abstract
Background Pirfenidone and nintedanib are the sole pharmacological therapies currently approved for idiopathic pulmonary fibrosis (IPF). Limited comparison data is available in literature, despite they are both prescribed for mild-to-moderate disease. Here, we describe our almost 10 years real-life experience with antifibrotic treatment to investigate potential differences in terms of efficacy. Population and Methods We retrospectively recruited patients diagnosed with IPF and treated with pirfenidone or nintedanib at Siena Referral Center. Clinical, functional, safety and radiological data was collected at baseline and during the follow-up, according to our Center protocol. Results We retrospectively recruited 263 IPF patients (139 treated with pirfenidone and 124 with nintedanib) in the study. After 885.3 ± 559.5 days of observation, the median survival was 1224 days. No significant differences were found between pirfenidone and nintedanib in terms of survival and time to decline of forced vital capacity >10% (p = 0.8786 and p = 0.1677, respectively). A smaller lung diffusion for carbon monoxide (DLCO) decrease was found after 1 year of therapy with nintedanib in respect to pirfenidone (p = 0.0167). Overall, 21 patients permanently discontinued antifibrotic treatment due to side effects (14 with pirfenidone, 7 with nintedanib); no fatal adverse events were recorded. Discussion Our results showed a similar effectiveness between pirfenidone and nintedanib in terms of mortality and functional disease progression. Both drugs confirmed their good tolerability profile and no new safety alerts were observed. Nintedanib was associated with a smaller reduction of DLCO after 1 year of follow-up compared with pirfenidone, maybe due to its antiangiogenic properties.
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Affiliation(s)
- Paolo Cameli
- Respiratory Diseases Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Rosa Metella Refini
- Respiratory Diseases Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Laura Bergantini
- Respiratory Diseases Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Miriana d'Alessandro
- Respiratory Diseases Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Valerio Alonzi
- Respiratory Diseases Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Carlo Magnoni
- Respiratory Diseases Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Paola Rottoli
- Respiratory Diseases Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Piersante Sestini
- Respiratory Diseases Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Elena Bargagli
- Respiratory Diseases Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
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31
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Corral M, Chang E, Broder MS, Gokhale S, Reddy SR. Healthcare use and costs among Medicare enrollees on pirfenidone versus nintedanib for idiopathic pulmonary fibrosis. J Comp Eff Res 2020; 9:933-943. [PMID: 32851849 DOI: 10.2217/cer-2020-0084] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Aim: Compare healthcare utilization and costs between Medicare beneficiaries with idiopathic pulmonary fibrosis (IPF) receiving pirfenidone or nintedanib. Methods: Retrospective cohort study of Medicare beneficiaries (100% Research Identifiable Files) with IPF who initiated pirfenidone or nintedanib between 15 October 2014 and 31 December 2015. Inverse probability of treatment weighting using propensity scores adjusted for baseline covariates. Outcomes: hospitalization and monthly costs. Results: Hazard and incidence rate ratios (95% CI) for all-cause (0.79 [0.68-0.91]; 0.69 [0.59-0.82]) and respiratory-related (0.80 [0.65-0.97]; 0.71 [0.57-0.90]) hospitalizations favored pirfenidone versus nintedanib. Monthly inpatient costs were lower for pirfenidone versus nintedanib patients; outpatient and pharmacy costs were similar. Conclusion: In patients with IPF, pirfenidone compared with nintedanib has a moderate but significant protective effect on hospitalization, corresponding to lower inpatient costs.
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Affiliation(s)
- Mitra Corral
- US Medical Affairs, Genentech, Inc., CA 94080, USA
| | - Eunice Chang
- Health Services Research, Partnership for Health Analytic Research (PHAR), LLC, CA 90212, USA
| | - Michael S Broder
- Health Services Research, Partnership for Health Analytic Research (PHAR), LLC, CA 90212, USA
| | - Sohum Gokhale
- Health Services Research, Partnership for Health Analytic Research (PHAR), LLC, CA 90212, USA
| | - Sheila R Reddy
- Health Services Research, Partnership for Health Analytic Research (PHAR), LLC, CA 90212, USA
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Erasmus M, Samodien E, Lecour S, Cour M, Lorenzo O, Dludla P, Pheiffer C, Johnson R. Linking LOXL2 to Cardiac Interstitial Fibrosis. Int J Mol Sci 2020; 21:E5913. [PMID: 32824630 PMCID: PMC7460598 DOI: 10.3390/ijms21165913] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 07/23/2020] [Accepted: 07/29/2020] [Indexed: 12/12/2022] Open
Abstract
Cardiovascular diseases (CVDs) are the leading causes of death worldwide. CVD pathophysiology is often characterized by increased stiffening of the heart muscle due to fibrosis, thus resulting in diminished cardiac function. Fibrosis can be caused by increased oxidative stress and inflammation, which is strongly linked to lifestyle and environmental factors such as diet, smoking, hyperglycemia, and hypertension. These factors can affect gene expression through epigenetic modifications. Lysyl oxidase like 2 (LOXL2) is responsible for collagen and elastin cross-linking in the heart, and its dysregulation has been pathologically associated with increased fibrosis. Additionally, studies have shown that, LOXL2 expression can be regulated by DNA methylation and histone modification. However, there is a paucity of data on LOXL2 regulation and its role in CVD. As such, this review aims to gain insight into the mechanisms by which LOXL2 is regulated in physiological conditions, as well as determine the downstream effectors responsible for CVD development.
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Affiliation(s)
- Melisse Erasmus
- Biomedical Research and Innovation Platform, South African Medical Research Council, Cape Town 7501, South Africa; (M.E.); (E.S.); (P.D.); (C.P.)
- Department of Medical Physiology, Stellenbosch University, Cape Town 7505, South Africa
| | - Ebrahim Samodien
- Biomedical Research and Innovation Platform, South African Medical Research Council, Cape Town 7501, South Africa; (M.E.); (E.S.); (P.D.); (C.P.)
| | - Sandrine Lecour
- Hatter Institute for Cardiovascular Research in Africa (HICRA), University of Cape Town, Cape Town 7925, South Africa;
| | - Martin Cour
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Intensive-Réanimation, Place d’Arsonval, 69437 Lyon, France;
| | - Oscar Lorenzo
- Institute de Investigación Sanitaria-FJD, Faculty of Medicine, University Autónoma de Madrid, 28049 Madrid, Spain;
- Spanish Biomedical Research Centre in Diabetes and Associated Metabolic Disorders (CIBERDEM) Network, 28040 Madrid, Spain
| | - Phiwayinkosi Dludla
- Biomedical Research and Innovation Platform, South African Medical Research Council, Cape Town 7501, South Africa; (M.E.); (E.S.); (P.D.); (C.P.)
| | - Carmen Pheiffer
- Biomedical Research and Innovation Platform, South African Medical Research Council, Cape Town 7501, South Africa; (M.E.); (E.S.); (P.D.); (C.P.)
- Department of Medical Physiology, Stellenbosch University, Cape Town 7505, South Africa
| | - Rabia Johnson
- Biomedical Research and Innovation Platform, South African Medical Research Council, Cape Town 7501, South Africa; (M.E.); (E.S.); (P.D.); (C.P.)
- Department of Medical Physiology, Stellenbosch University, Cape Town 7505, South Africa
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Assayag D, Morisset J, Johannson KA, Wells AU, Walsh SLF. Patient gender bias on the diagnosis of idiopathic pulmonary fibrosis. Thorax 2020; 75:407-412. [DOI: 10.1136/thoraxjnl-2019-213968] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 01/15/2020] [Accepted: 01/16/2020] [Indexed: 01/20/2023]
Abstract
BackgroundPatient sex has clinical and prognostic implications in idiopathic pulmonary fibrosis (IPF). It is not known if sex-related and gender-related discrepancies exist when establishing a diagnosis of IPF. The aim was to determine how patient gender influences the diagnosis of IPF and the physician’s diagnostic confidence.MethodsThis study was performed using clinical cases compiled from a single centre, then scored by respiratory physicians for a prior study. Using clinical information, physicians were asked to provide up to five diagnoses, together with their diagnostic confidence. Logistic regression was used to assess the odds of receiving a diagnosis of IPF based on patient gender. Prognostic discrimination between IPF and non-IPF was used to assess diagnostic accuracy with Cox proportional hazards modelling.ResultsSixty cases were scored by 404 physicians. IPF was diagnosed more frequently in men compared with women (37.8% vs 10.6%; p<0.0001), and with greater mean diagnostic confidence (p<0.001). The odds of a male patient receiving an IPF diagnosis was greater than that of female patients, after adjusting for confounders (OR=3.05, 95% CI: 2.81 to 3.31), especially if the scan was not definite for the usual interstitial pneumonia pattern. Mortality was higher in women (HR=2.21, 95% CI: 2.02 to 2.41) than in men with an IPF diagnosis (HR=1.26, 95% CI: 1.20 to 1.33), suggesting that men were more often misclassified as having IPF.ConclusionPatient gender influences diagnosis of IPF: women may be underdiagnosed and men overdiagnosed with IPF.
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Holtze CH, Freiheit EA, Limb SL, Stauffer JL, Raimundo K, Pan WT, Flaherty KR, Kim HJ. Patient and site characteristics associated with pirfenidone and nintedanib use in the United States; an analysis of idiopathic pulmonary fibrosis patients enrolled in the Pulmonary Fibrosis Foundation Patient Registry. Respir Res 2020; 21:48. [PMID: 32041621 PMCID: PMC7011239 DOI: 10.1186/s12931-020-1315-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 02/04/2020] [Indexed: 01/25/2023] Open
Abstract
Background Pragmatic use of the anti-fibrotic medications pirfenidone and nintedanib for idiopathic pulmonary fibrosis (IPF) in the United States (US) has not been studied and may be different from international settings due to structural differences between health care systems. This study examined the relationship between patient- and site-level characteristics and anti-fibrotic (a) use and (b) selection. Methods Data from the Pulmonary Fibrosis Foundation Patient Registry was used to perform univariable and multivariable regressions with generalized linear mixed models. A random effects model examined registry site variation. Results 703 of 1218 (57.7%) patients were taking a single anti-fibrotic of which 312 (44.4%) were taking nintedanib and 391 (55.6%) were taking pirfenidone. Up to 25% of patients using an anti-fibrotic may have been excluded from clinical trial participation due to having too severe disease as measured by diffusion limitation for carbon monoxide. Age (OR = 0.974, p = 0.0086) and diffusion capacity of the lungs for carbon monoxide (per 10% increase in percent-predicted; OR = 0.896, p = 0.0007) was negatively associated with anti-fibrotic use while time (in log of days) since diagnosis (OR = 1.138, p < 0.0001), recent patient clinical trial participation (OR = 1.569, p = 0.0433) and oxygen use (OR = 1.604, p = 0.0027) was positively associated with anti-fibrotic use. Time (log of days) since diagnosis (OR = 1.075, p = 0.0477), history of coronary artery disease (OR = 1.796, p = 0.0030), presence of pulmonary hypertension (OR = 2.139, p = 0.0376), patient clinical trial participation in the prior 12 months (OR = 2.485, p = 0.0002), diffusion capacity of the lungs for carbon monoxide (per 10% increase in percent-predicted; OR = 1.138, p = 0.0184), anticoagulant use (OR = 2.507, p = 0.0028), and enrollment at a registry site in the Midwest region (OR = 1.600, p = 0.0446) were associated with pirfenidone use. Anti-fibrotic use varied by registry site. Rates of discontinuation were modest and nearly identical for the two medications with side effects being the most common reason given for discontinuation. Twenty-three percent (23%, 274) of persons with IPF were using or had recently used an immunomodulatory agent. Conclusions This analysis provides a detailed characterization of IPF treatment patterns in the US; many users of anti-fibrotic medications may not have qualified for inclusion in clinical trials. More research is needed to understand variations in medical decision-making for use and selection of anti-fibrotic medication.
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Affiliation(s)
- Colin H Holtze
- Department of Internal Medicine, Division of Pulmonary & Critical Care Medicine, University of Michigan, North Campus Research Center, 2800 Plymouth Rd, SPC 2800, Ann Arbor, MI, 48109, USA.
| | | | - Susan L Limb
- Genentech, Inc., US Medical Affairs, South San Francisco, CA, USA
| | - John L Stauffer
- Genentech, Inc., US Medical Affairs, South San Francisco, CA, USA
| | - Karina Raimundo
- Genentech, Inc., US Medical Affairs, South San Francisco, CA, USA
| | - Wayne T Pan
- Genentech, Inc., US Medical Affairs, South San Francisco, CA, USA.,BioMarin, San Rafael, CA, USA
| | - Kevin R Flaherty
- Department of Internal Medicine, Division of Pulmonary & Critical Care Medicine, University of Michigan, North Campus Research Center, 2800 Plymouth Rd, SPC 2800, Ann Arbor, MI, 48109, USA
| | - Hyun J Kim
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Minnesota, Minneapolis, MN, USA
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Antoniou K, Markopoulou K, Tzouvelekis A, Trachalaki A, Vasarmidi E, Organtzis J, Tzilas V, Bouros E, Kounti G, Rampiadou C, Kotoulas SC, Bardaka F, Bibaki E, Fouka E, Meletis G, Tryfon S, Daniil Z, Papakosta D, Bouros D. Efficacy and safety of nintedanib in a Greek multicentre idiopathic pulmonary fibrosis registry: a retrospective, observational, cohort study. ERJ Open Res 2020; 6:00172-2019. [PMID: 32010718 PMCID: PMC6983495 DOI: 10.1183/23120541.00172-2019] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 11/13/2019] [Indexed: 11/09/2022] Open
Abstract
Nintedanib is a tyrosine kinase inhibitor approved for the treatment of idiopathic pulmonary fibrosis (IPF). In a retrospective, real-world study across seven Greek hospitals, we evaluated the effectiveness and safety of nintedanib in routine clinical practice. Patients diagnosed with IPF, as per guideline criteria or multidisciplinary diagnosis, received nintedanib between January 2013 and January 2018. We evaluated 244 patients: mean±sd age 71.8±7.5 years, 79.1% male, 45.1% current smokers and 33.1% ex-smokers at treatment initiation. At baseline, predicted forced vital capacity (FVC) was 73.3±20.7% and predicted diffusing capacity of the lungs for carbon monoxide (DLCO) was 42.6±16.7%. On average, patients spent 23.6±15.0 months on nintedanib. At 3 years, 78 patients had died, equating to a 3-year survival rate of 59.4% (unaffected by treatment discontinuation or dose reduction). FVC% pred and DLCO% pred were largely stable at 3 years, with no significant difference from baseline (FVC 73.3±20.7% pred versus 78±20.1% pred, p=0.074; DLCO 42.6±16.7% pred versus 40.4±18.1% pred, p=0.334). Of the 244 patients, 55.7% reported an adverse event. Gastrointestinal events were the most common (173 (77.2%) out of 224 total events) and 45.0% of patients experienced diarrhoea. Only 32 (13.1%) patients had to permanently discontinue nintedanib due to an adverse event. This real-world study shows a 3-year survival rate of 59.4% and a low discontinuation rate due to adverse events. Our experience is consistent with previous findings in clinical trials of nintedanib in IPF. Findings from the largest registry of Greek patients with IPF receiving nintedanib in routine clinical practice show, over a 3-year period, a low discontinuation rate and efficacy data that support the results of the INPULSIS clinical trialshttp://bit.ly/35a2CS5
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Affiliation(s)
- Katerina Antoniou
- Dept of Thoracic Medicine, Faculty of Medicine, University of Crete, Heraklion, Greece.,These authors contributed equally
| | - Katerina Markopoulou
- Respiratory Medicine Dept, George Papanikolaou General Hospital, Thessaloniki, Greece.,These authors contributed equally
| | - Argyrios Tzouvelekis
- First Academic Dept of Pneumonology, Hospital for Diseases of the Chest, "Sotiria", Athens, Greece.,These authors contributed equally
| | - Athina Trachalaki
- Dept of Thoracic Medicine, Faculty of Medicine, University of Crete, Heraklion, Greece.,These authors contributed equally
| | - Eirini Vasarmidi
- Dept of Thoracic Medicine, Faculty of Medicine, University of Crete, Heraklion, Greece.,These authors contributed equally
| | - Jiannis Organtzis
- Respiratory Medicine Dept, Aristotle University of Thessaloniki, Papanikolaou General Hospital, Thessaloniki, Greece.,These authors contributed equally
| | - Vasilios Tzilas
- First Academic Dept of Pneumonology, Hospital for Diseases of the Chest, "Sotiria", Athens, Greece
| | - Evangelos Bouros
- First Academic Dept of Pneumonology, Hospital for Diseases of the Chest, "Sotiria", Athens, Greece
| | - Georgia Kounti
- Respiratory Medicine Dept, George Papanikolaou General Hospital, Thessaloniki, Greece
| | - Christina Rampiadou
- Respiratory Medicine Dept, George Papanikolaou General Hospital, Thessaloniki, Greece
| | | | - Fotini Bardaka
- Respiratory Medicine Dept, University General Hospital of Larissa, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Eleni Bibaki
- Respiratory Medicine Dept, Venizeleio Pananio General Hospital, Heraklion, Greece
| | - Evangelia Fouka
- Respiratory Medicine Dept, Aristotle University of Thessaloniki, Papanikolaou General Hospital, Thessaloniki, Greece
| | - Georgios Meletis
- Respiratory Medicine Dept, Venizeleio Pananio General Hospital, Heraklion, Greece
| | - Stavros Tryfon
- Respiratory Medicine Dept, George Papanikolaou General Hospital, Thessaloniki, Greece
| | - Zoe Daniil
- Respiratory Medicine Dept, University General Hospital of Larissa, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Despina Papakosta
- Respiratory Medicine Dept, Aristotle University of Thessaloniki, Papanikolaou General Hospital, Thessaloniki, Greece
| | - Demosthenes Bouros
- First Academic Dept of Pneumonology, Hospital for Diseases of the Chest, "Sotiria", Athens, Greece
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Valenzuela C, Torrisi SE, Kahn N, Quaresma M, Stowasser S, Kreuter M. Ongoing challenges in pulmonary fibrosis and insights from the nintedanib clinical programme. Respir Res 2020; 21:7. [PMID: 31906942 PMCID: PMC6945404 DOI: 10.1186/s12931-019-1269-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 12/23/2019] [Indexed: 01/06/2023] Open
Abstract
The approvals of nintedanib and pirfenidone changed the treatment paradigm in idiopathic pulmonary fibrosis (IPF), and increased our understanding of the underlying disease mechanisms. Nonetheless, many challenges and unmet needs remain in the management of patients with IPF and other progressive fibrosing interstitial lung diseases.This review describes how the nintedanib clinical programme has helped to address some of these challenges. Data from this programme have informed changes to the IPF diagnostic guidelines, the timing of treatment initiation, and the assessment of disease progression. The use of nintedanib to treat patients with advanced lung function impairment, concomitant emphysema, patients awaiting lung transplantation and patients with IPF and lung cancer is discussed. The long-term use of nintedanib and an up-to-date summary of nintedanib in clinical practice are discussed. Directions for future research, namely emerging therapeutic options, precision medicine and other progressive fibrosing interstitial lung diseases, are described.Further developments in these areas should continue to improve patient outcomes.
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Affiliation(s)
- Claudia Valenzuela
- Hospital Universitario de La Princesa, Instituto de Investigación Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - Sebastiano Emanuele Torrisi
- University Hospital Policlinico-Vittorio Emanuele, Catania, Italy
- Center for Interstitial and Rare Lung Diseases, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
| | - Nicolas Kahn
- Center for Interstitial and Rare Lung Diseases, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
- Translational Lung Research Center, Member of the German Center for Lung Research, Heidelberg, Germany
| | - Manuel Quaresma
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Susanne Stowasser
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Michael Kreuter
- Center for Interstitial and Rare Lung Diseases, Thoraxklinik, University of Heidelberg, Heidelberg, Germany.
- Translational Lung Research Center, Member of the German Center for Lung Research, Heidelberg, Germany.
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Morais A. Idiopathic pulmonary fibrosis: accurate diagnosis and early treatment. J Bras Pneumol 2019; 45:e20190353. [PMID: 31721894 PMCID: PMC7247766 DOI: 10.1590/1806-3713/e20190353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- António Morais
- . Grupo de Doenças Pulmonares Intersticiais, Centro Hospitalar de São João, Porto, Portugal.,. Faculdade de Medicina do Porto, Porto, Portugal
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Real-life comparison of pirfenidone and nintedanib in patients with idiopathic pulmonary fibrosis: A 24-month assessment. Respir Med 2019; 159:105803. [PMID: 31670147 DOI: 10.1016/j.rmed.2019.105803] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 09/28/2019] [Accepted: 10/17/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Real-life data on the use of pirfenidone and nintedanib to treat patients with idiopathic pulmonary fibrosis (IPF) are still scarce. METHODS We compared the efficacy of either pirfenidone (n = 78) or nintedanib (n = 28) delivered over a 24-month period in patients with IPF, followed at two regional clinic centers in Italy, with a group of patients who refused the treatment (n = 36), and who were considered to be controls. All patients completed regular visits at 1- to 3-month intervals, where primary [forced vital capacity (FVC) and diffusing capacity of the lungs for carbon monoxide (DLCO)] and secondary outcomes (side effects, treatment compliance, and mortality) were recorded. RESULTS Over time, the decline in FVC and DLCO was significantly higher (p = 0.0053 and p = 0.037, respectively) in controls when compared with the combined treated group, with no significant difference between the two treated groups. Compared to patients with less advanced disease (GAP (Gender, Age, Physiology) stage I), those in GAP stages II and III showed a significantly higher decline in both FVC and DLCO irrespective of the drug taken. Side effects were similarly reported in patients receiving pirfenidone and nintedanib (5% and 7%, respectively), whereas mortality did not differ among the three groups. CONCLUSION This real-life study demonstrated that both pirfenidone and nintedanib were equally effective in reducing the decline of FVC and DLCO versus non-treated patients after 24 months of treatment; however, patients with more advanced disease were likely to show a more rapid decline in respiratory function.
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Mari P, G. Jones M, Richeldi L. Contemporary Concise Review 2018: Interstitial lung disease. Respirology 2019; 24:809-816. [DOI: 10.1111/resp.13572] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 04/09/2019] [Indexed: 12/31/2022]
Affiliation(s)
- Pier‐Valerio Mari
- Fondazione Policlinico Universitario A. Gemelli IRCCSUniversitá Cattolica del Sacro Cuore Rome Italy
| | - Mark G. Jones
- NIHR Southampton Biomedical Research Centre and Clinical and Experimental Sciences University of Southampton UK
| | - Luca Richeldi
- Fondazione Policlinico Universitario A. Gemelli IRCCSUniversitá Cattolica del Sacro Cuore Rome Italy
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Armando RG, Mengual Gomez DL, Maggio J, Sanmartin MC, Gomez DE. Telomeropathies: Etiology, diagnosis, treatment and follow-up. Ethical and legal considerations. Clin Genet 2019; 96:3-16. [PMID: 30820928 DOI: 10.1111/cge.13526] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/12/2019] [Accepted: 02/26/2019] [Indexed: 12/13/2022]
Abstract
Telomeropathies involve a wide variety of infrequent genetic diseases caused by mutations in the telomerase maintenance mechanism or the DNA damage response (DDR) system. They are considered a family of rare diseases that often share causes, molecular mechanisms and symptoms. Generally, these diseases are not diagnosed until the symptoms are advanced, diminishing the survival time of patients. Although several related syndromes may still be unrecognized this work describes those that are known, highlighting that because they are rare diseases, physicians should be trained in their early diagnosis. The etiology and diagnosis are discussed for each telomeropathy and the treatments when available, along with a new classification of this group of diseases. Ethical and legal issues related to this group of diseases are also considered.
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Affiliation(s)
- Romina G Armando
- Laboratory of Molecular Oncology, Universidad Nacional de Quilmes, Buenos Aires, Argentina
| | - Diego L Mengual Gomez
- Laboratory of Molecular Oncology, Universidad Nacional de Quilmes, Buenos Aires, Argentina
| | - Julián Maggio
- Laboratory of Molecular Oncology, Universidad Nacional de Quilmes, Buenos Aires, Argentina
| | - María C Sanmartin
- Laboratory of Molecular Oncology, Universidad Nacional de Quilmes, Buenos Aires, Argentina
| | - Daniel E Gomez
- Laboratory of Molecular Oncology, Universidad Nacional de Quilmes, Buenos Aires, Argentina
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Pereira CADC, Baddini-Martinez JA, Baldi BG, Jezler SFDO, Rubin AS, Alves RLR, Zonzin GA, Quaresma M, Trampisch M, Rabahi MF. Segurança e tolerabilidade de Nintedanibe em pacientes com fibrose pulmonar idiopática no Brasil. J Bras Pneumol 2019; 45:e20180414. [PMID: 31531619 PMCID: PMC8653976 DOI: 10.1590/1806-3713/e20180414] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 04/12/2019] [Indexed: 11/21/2022] Open
Abstract
RESUMO Objetivo Ensaios clínicos mostraram que 150 mg de Nintedanibe duas vezes ao dia reduzem a progressão da doença em pacientes com Fibrose Pulmonar Idiopática (FPI), com um perfil de efeitos adversos que é controlável para a maioria dos pacientes. Antes da aprovação do Nintedanibe como tratamento para a FPI no Brasil, um Programa de Acesso Expandido (PEA) foi iniciado para fornecer acesso precoce ao tratamento e avaliar a segurança e a tolerância do Nintedanibe para este grupo de pacientes. Métodos Foram elegíveis para participar da PEA pacientes com diagnóstico de FPI nos últimos 5 anos, com capacidade vital forçada (CVF) ≥ 50% do previsto e capacidade de difusão dos pulmões para monóxido de carbono (DLco) 30%-79% do previsto. Os pacientes receberam Nintedanibe 150 mg, 2 vezes ao dia (bid). As avaliações de segurança incluíram eventos adversos que levaram à suspensão permanente do Nintedanibe e eventos adversos graves. Resultados O PEA envolveu 57 pacientes em 8 centros. A maioria dos pacientes era do sexo masculino (77,2%) e brancos (87,7%). No início do estudo, a média de idade foi de 70,7 (7,5) anos e a CVF foi de 70,7 (12,5%) do previsto. A média de exposição ao Nintedanibe foi de 14,4 (6,2) meses; a exposição máxima foi de 22,0 meses. Os eventos adversos frequentemente relatados pelo pesquisador como relacionados ao tratamento com Nintedanibe foram diarreia (45 pacientes, 78,9%) e náusea (25 pacientes, 43,9%). Os eventos adversos levaram à suspensão permanente do Nintedanibe em 16 pacientes (28,1%) que passaram por um evento adverso grave. Conclusões No PEA brasileiro, o Nintedanibe apresentou um perfil aceitável de segurança e tolerância em pacientes com FPI, condizendo com dados de ensaios clínicos.
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