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Interstitial pneumonia with autoimmune features: from research classification to diagnosis. Curr Opin Pulm Med 2021; 27:374-387. [PMID: 34183525 DOI: 10.1097/mcp.0000000000000802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The term interstitial pneumonia with autoimmune features (IPAF) was first proposed by an international task force in 2015 as a research classification to standardise nomenclature regarding patients with idiopathic interstitial pneumonia and features of connective tissue disease. However, how the use of this term and its proposed definition translates to clinical practice remains uncertain. This review will provide a comprehensive overview of studies of IPAF cohorts to date, discuss the consideration of IPAF as a distinct diagnostic entity and outline a suggested approach to patient management. RECENT FINDINGS Considerable heterogeneity exists between published IPAF cohorts, with some cohorts exhibiting similarities to those with connective tissue disease-associated interstitial lung disease (CTD-ILD), and others more similar to idiopathic interstitial pneumonias including idiopathic pulmonary fibrosis (IPF). Little data exist to inform the management of patients who fulfil the IPAF criteria. Preliminary data supports pragmatic management of these patients as having a working clinical diagnosis of either idiopathic interstitial pneumonia or CTD-ILD. Future research studies into this approach are required. SUMMARY The term IPAF, and its definition, have been of fundamental benefit to facilitating research in this diverse patient group. However, to date, there remain many unanswered questions regarding their natural histories and response to treatment.
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Interstitial Pneumonia with Autoimmune Features: Why Rheumatologist-Pulmonologist Collaboration Is Essential. Biomedicines 2020; 9:biomedicines9010017. [PMID: 33375368 PMCID: PMC7824155 DOI: 10.3390/biomedicines9010017] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/21/2020] [Accepted: 12/24/2020] [Indexed: 12/13/2022] Open
Abstract
In 2015 the European Respiratory Society (ERS) and the American Thoracic Society (ATS) “Task Force on Undifferentiated Forms of Connective Tissue Disease-associated Interstitial Lung Disease” proposed classification criteria for a new research category defined as “Interstitial Pneumonia with Autoimmune Features” (IPAF), to uniformly define patients with interstitial lung disease (ILD) and features of autoimmunity, without a definite connective tissue disease. These classification criteria were based on a variable combination of features obtained from three domains: a clinical domain consisting of extra-thoracic features, a serologic domain with specific autoantibodies, and a morphologic domain with imaging patterns, histopathological findings, or multicompartment involvement. Features suggesting a systemic vasculitis were excluded. Since publication of ERS/ATS IPAF research criteria, various retrospective studies have been published focusing on prevalence; clinical, morphological, and serological features; and prognosis of these patients showing a broad heterogeneity in the results. Recently, two prospective, cohort studies were performed, confirming the existence of some peculiarities for this clinical entity and the possible progression of IPAF to a defined connective tissue disease (CTD) in about 15% of cases. Moreover, a non-specific interstitial pneumonia pattern, an anti-nuclear antibody positivity, and a Raynaud phenomenon were the most common findings. In comparison with idiopathic pulmonary fibrosis (IPF), IPAF patients showed a better performance in pulmonary function tests and less necessity of oxygen delivery. However, at this stage of our knowledge, we believe that further prospective studies, possibly derived from multicenter cohorts and through randomized control trials, to further validate the proposed classification criteria are needed.
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Graham J, Bauer Ventura I, Newton CA, Lee C, Boctor N, Pugashetti JV, Cutting C, Joerns E, Sandhu H, Chung JH, Garcia CK, Kadoch M, Noth I, Adegunsoye A, Strek ME, Oldham JM. Myositis-specific Antibodies Identify A Distinct Interstitial Pneumonia with Autoimmune Features Phenotype. Eur Respir J 2020; 56:2001205. [PMID: 32675203 PMCID: PMC7943372 DOI: 10.1183/13993003.01205-2020] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/28/2020] [Indexed: 12/27/2022]
Abstract
Interstitial pneumonia with autoimmune features (IPAF) characterises individuals with interstitial lung disease (ILD) and features of connective tissue disease (CTD) who fail to satisfy CTD criteria. Inclusion of myositis-specific antibodies (MSAs) in the IPAF criteria has generated controversy, as these patients also meet proposed criteria for an anti-synthetase syndrome. Whether MSAs and myositis associated antibodies (MAA) identify phenotypically distinct IPAF subgroups remains unclear.A multi-center, retrospective investigation was conducted to assess clinical features and outcomes in patients meeting IPAF criteria stratified by the presence of MSAs and MAAs. IPAF subgroups were compared to cohorts of patients with idiopathic inflammatory myopathy-ILD (IIM-ILD), idiopathic pulmonary fibrosis (IPF) and non-IIM CTD-ILDs. The primary endpoint assessed was three-year transplant-free survival. Two hundred sixty-nine patients met IPAF criteria, including 35 (13%) with MSAs and 65 (24.2%) with MAAs. Survival was highest among patients with IPAF-MSA and closely approximated those with IIM-ILD. Survival did not differ between IPAF-MAA and IPAF without MSA/MAA cohorts. Usual interstitial pneumonia (UIP) morphology was associated with differential outcome risk, with IPAF patients with non-UIP morphology approximating survival observed in non-IIM CTD-ILDs. MSAs, but not MAAs identified a unique IPAF phenotype characterised by clinical features and outcomes similar to IIM-ILD. UIP morphology was a strong predictor of outcome in others meeting IPAF criteria. Because IPAF is a research classification without clear treatment approach, these findings suggest MSAs should be removed from the IPAF criteria and such patients should be managed as an IIM-ILD.
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Affiliation(s)
- Julia Graham
- Department of Internal Medicine, University of California at Davis
- These authors contributed equally
| | - Iazsmin Bauer Ventura
- Department of Medicine, Section of Rheumatology, University of Chicago
- These authors contributed equally
| | - Chad A Newton
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern
- These authors contributed equally
| | - Cathryn Lee
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago
| | - Noelle Boctor
- Department of Internal Medicine, University of California at Davis
| | - Janelle Vu Pugashetti
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California at Davis
| | - Claire Cutting
- Department of Internal Medicine, University of California at Davis
| | - Elena Joerns
- Department of Internal Medicine, Division of Rheumatology, University of Texas Southwestern
| | - Habrinder Sandhu
- Department of Internal Medicine, Division of Rheumatology, University of California at Davis
| | | | - Christine Kim Garcia
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University
| | - Michael Kadoch
- Department of Radiology, University of California at Davis
| | - Imre Noth
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Virginia
| | - Ayodeji Adegunsoye
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago
| | - Mary E Strek
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago
- These authors contributed equally
| | - Justin M Oldham
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California at Davis
- These authors contributed equally
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Abstract
Interstitial pneumonia with autoimmune features (IPAF) is a research classification proposed by the European Respiratory Society/American Thoracic Society Task Force on Undifferentiated Forms of Connective Tissue Disease-associated Interstitial Lung Disease as an initial step to uniformly define, identify, and study patients with interstitial lung disease (ILD) who have features of autoimmunity, yet fall short of a characterizable connective tissue disease. Since its publication in July 2015, there has been substantial interest in IPAF. Centers from around the world have published their findings of retrospectively identified cohorts of patients who fulfill IPAF criteria, suggestions for modification of the criteria have been offered, and patients who fulfill IPAF criteria are being included as a subset in the ongoing phase II multicenter unclassifiable ILD treatment trial with pirfenidone. The IPAF designation represents an important first step toward studying and furthering our understanding of the natural history of this cohort of patients with ILD using uniform nomenclature and a standardized set of criteria. Prospective evaluations and, ideally, interdisciplinary and multicenter collaborations will inform best practices for treatment and management and will guide future refinement to the IPAF criteria. This review focuses on the relevant background that led to the development of IPAF, summarizes the proposed criteria, discusses cohort studies of patients with IPAF published to date and what they have taught us about the IPAF phenotype, and offers insights into future directions in this arena. Clinical trial registered with www.clinicaltrials.gov (NCT03099187).
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Abstract
The European Respiratory Society/American Thoracic Society Task Force on Undifferentiated Forms of Connective Tissue Disease-associated Interstitial Lung Disease put forth the research classification interstitial pneumonia with autoimmune features as a step toward uniformly describing these patients. Diverse nomenclature and classification schemes had been proposed to characterize them. This classification has provided uniform nomenclature and criteria, fostering interdisciplinary engagement and research. Longitudinal surveillance is needed; some patients evolve to a defined connective tissue disease. This review discusses cohort studies of interstitial pneumonia with autoimmune features and what they have taught us about the phenotype, and offers insights into future directions.
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Affiliation(s)
- Aryeh Fischer
- Divisions of Rheumatology, Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, University of Colorado School of Medicine, 12631 East 17th Avenue, Academic Office Building One, Aurora, CO 80045, USA.
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Lee JS, Fischer A. POINT: Does Interstitial Pneumonia With Autoimmune Features Represent a Distinct Class of Patients With Idiopathic Interstitial Pneumonia? Yes. Chest 2019; 155:258-260. [PMID: 30732687 DOI: 10.1016/j.chest.2018.08.1074] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 08/24/2018] [Indexed: 11/28/2022] Open
Affiliation(s)
- Joyce S Lee
- Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO.
| | - Aryeh Fischer
- Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO
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Oldham JM, Danoff SK. COUNTERPOINT: Does Interstitial Pneumonia With Autoimmune Features Represent a Distinct Class of Patients With Idiopathic Interstitial Pneumonia? No. Chest 2019; 155:260-263. [PMID: 30732688 DOI: 10.1016/j.chest.2018.08.1073] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 08/24/2018] [Indexed: 11/27/2022] Open
Affiliation(s)
- Justin M Oldham
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of California at Davis, Sacramento, CA.
| | - Sonye K Danoff
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Mira-Avendano I, Abril A, Burger CD, Dellaripa PF, Fischer A, Gotway MB, Lee AS, Lee JS, Matteson EL, Yi ES, Ryu JH. Interstitial Lung Disease and Other Pulmonary Manifestations in Connective Tissue Diseases. Mayo Clin Proc 2019; 94:309-325. [PMID: 30558827 DOI: 10.1016/j.mayocp.2018.09.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/24/2018] [Accepted: 09/17/2018] [Indexed: 12/22/2022]
Abstract
Lung involvement in connective tissue diseases is associated with substantial morbidity and mortality, most commonly in the form of interstitial lung disease, and can occur in any of these disorders. Patterns of interstitial lung disease in patients with connective tissue disease are similar to those seen in idiopathic interstitial pneumonias, such as idiopathic pulmonary fibrosis. It may be difficult to distinguish between the 2 ailments, particularly when interstitial lung disease presents before extrapulmonary manifestations of the underlying connective tissue disease. There are important clinical implications in achieving this distinction. Given the complexities inherent in the management of these patients, a multidisciplinary evaluation is needed to optimize the diagnostic process and management strategies. The aim of this article was to summarize an approach to diagnosis and management based on the opinion of experts on this topic.
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Affiliation(s)
- Isabel Mira-Avendano
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, FL.
| | - Andy Abril
- Division of Rheumatology, Mayo Clinic, Jacksonville, FL
| | - Charles D Burger
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, FL
| | - Paul F Dellaripa
- Division of Rheumatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Aryeh Fischer
- Department of Medicine, University of Colorado, Denver, Aurora, CO
| | - Michael B Gotway
- Division of Cardiothoracic Radiology, Mayo Clinic, Scottsdale, AZ
| | - Augustine S Lee
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, FL
| | - Joyce S Lee
- Department of Medicine, University of Colorado, Denver, Aurora, CO
| | - Eric L Matteson
- Center for Clinical and Translational Science, Mayo Clinic, Rochester, MN
| | - Eunhee S Yi
- Division of Anatomic Pathology, Mayo Clinic, Rochester, MN
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
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Kolb M, Raghu G, Wells AU, Behr J, Richeldi L, Schinzel B, Quaresma M, Stowasser S, Martinez FJ. Nintedanib plus Sildenafil in Patients with Idiopathic Pulmonary Fibrosis. N Engl J Med 2018; 379:1722-1731. [PMID: 30220235 DOI: 10.1056/nejmoa1811737] [Citation(s) in RCA: 173] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Nintedanib is an approved treatment for idiopathic pulmonary fibrosis (IPF). A subgroup analysis of a previously published trial suggested that sildenafil may provide benefits regarding oxygenation, gas exchange as measured by the diffusion capacity of the lungs for carbon monoxide (DlCO), symptoms, and quality of life in patients with IPF and severely decreased DlCO. That idea was tested in this trial. METHODS We randomly assigned, in a 1:1 ratio, patients with IPF and a DlCO of 35% or less of the predicted value to receive nintedanib at a dose of 150 mg twice daily plus sildenafil at a dose of 20 mg three times daily (nintedanib-plus-sildenafil group) or nintedanib at a dose of 150 mg twice daily plus placebo three times daily (nintedanib group) for 24 weeks. The primary end point was the change from baseline in the total score on the St. George's Respiratory Questionnaire (SGRQ) at week 12 (the total score ranges from 0 to 100, with higher scores indicating worse health-related quality of life). Secondary end points included measures of dyspnea and safety. RESULTS A total of 274 patients underwent randomization. There was no significant difference in the adjusted mean change from baseline in the SGRQ total score at week 12 between the nintedanib-plus-sildenafil group and the nintedanib group (-1.28 points and -0.77 points, respectively; P=0.72). A benefit from sildenafil treatment was not observed with regard to dyspnea as measured with the use of the University of California, San Diego, Shortness of Breath Questionnaire. No new safety signals were observed, as compared with previous trials. CONCLUSIONS In patients with IPF and a DlCO of 35% or less of the predicted value, nintedanib plus sildenafil did not provide a significant benefit as compared with nintedanib alone. No new safety signals were identified with either treatment regimen in this population of patients. (Funded by Boehringer Ingelheim; INSTAGE ClinicalTrials.gov number, NCT02802345 .).
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Affiliation(s)
- Martin Kolb
- From McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); the University of Washington, Seattle (G.R.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, and the National Heart and Lung Institute, Imperial College, London (A.U.W.); Medizinische Klinik und Poliklinik V, University of Munich and Asklepios Klinik München-Gauting, German Center for Lung Research, Munich (J.B.), and Boehringer Ingelheim International, Ingelheim (B.S., M.Q., S.S.) - both in Germany; Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); and Weill Cornell Medicine, New York (F.J.M.)
| | - Ganesh Raghu
- From McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); the University of Washington, Seattle (G.R.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, and the National Heart and Lung Institute, Imperial College, London (A.U.W.); Medizinische Klinik und Poliklinik V, University of Munich and Asklepios Klinik München-Gauting, German Center for Lung Research, Munich (J.B.), and Boehringer Ingelheim International, Ingelheim (B.S., M.Q., S.S.) - both in Germany; Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); and Weill Cornell Medicine, New York (F.J.M.)
| | - Athol U Wells
- From McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); the University of Washington, Seattle (G.R.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, and the National Heart and Lung Institute, Imperial College, London (A.U.W.); Medizinische Klinik und Poliklinik V, University of Munich and Asklepios Klinik München-Gauting, German Center for Lung Research, Munich (J.B.), and Boehringer Ingelheim International, Ingelheim (B.S., M.Q., S.S.) - both in Germany; Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); and Weill Cornell Medicine, New York (F.J.M.)
| | - Jürgen Behr
- From McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); the University of Washington, Seattle (G.R.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, and the National Heart and Lung Institute, Imperial College, London (A.U.W.); Medizinische Klinik und Poliklinik V, University of Munich and Asklepios Klinik München-Gauting, German Center for Lung Research, Munich (J.B.), and Boehringer Ingelheim International, Ingelheim (B.S., M.Q., S.S.) - both in Germany; Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); and Weill Cornell Medicine, New York (F.J.M.)
| | - Luca Richeldi
- From McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); the University of Washington, Seattle (G.R.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, and the National Heart and Lung Institute, Imperial College, London (A.U.W.); Medizinische Klinik und Poliklinik V, University of Munich and Asklepios Klinik München-Gauting, German Center for Lung Research, Munich (J.B.), and Boehringer Ingelheim International, Ingelheim (B.S., M.Q., S.S.) - both in Germany; Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); and Weill Cornell Medicine, New York (F.J.M.)
| | - Birgit Schinzel
- From McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); the University of Washington, Seattle (G.R.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, and the National Heart and Lung Institute, Imperial College, London (A.U.W.); Medizinische Klinik und Poliklinik V, University of Munich and Asklepios Klinik München-Gauting, German Center for Lung Research, Munich (J.B.), and Boehringer Ingelheim International, Ingelheim (B.S., M.Q., S.S.) - both in Germany; Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); and Weill Cornell Medicine, New York (F.J.M.)
| | - Manuel Quaresma
- From McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); the University of Washington, Seattle (G.R.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, and the National Heart and Lung Institute, Imperial College, London (A.U.W.); Medizinische Klinik und Poliklinik V, University of Munich and Asklepios Klinik München-Gauting, German Center for Lung Research, Munich (J.B.), and Boehringer Ingelheim International, Ingelheim (B.S., M.Q., S.S.) - both in Germany; Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); and Weill Cornell Medicine, New York (F.J.M.)
| | - Susanne Stowasser
- From McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); the University of Washington, Seattle (G.R.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, and the National Heart and Lung Institute, Imperial College, London (A.U.W.); Medizinische Klinik und Poliklinik V, University of Munich and Asklepios Klinik München-Gauting, German Center for Lung Research, Munich (J.B.), and Boehringer Ingelheim International, Ingelheim (B.S., M.Q., S.S.) - both in Germany; Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); and Weill Cornell Medicine, New York (F.J.M.)
| | - Fernando J Martinez
- From McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); the University of Washington, Seattle (G.R.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, and the National Heart and Lung Institute, Imperial College, London (A.U.W.); Medizinische Klinik und Poliklinik V, University of Munich and Asklepios Klinik München-Gauting, German Center for Lung Research, Munich (J.B.), and Boehringer Ingelheim International, Ingelheim (B.S., M.Q., S.S.) - both in Germany; Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); and Weill Cornell Medicine, New York (F.J.M.)
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Cavagna L, Gonzalez Gay MA, Allanore Y, Matucci-Cerinic M. Interstitial pneumonia with autoimmune features: a new classification still on the move. Eur Respir Rev 2018; 27:27/148/180047. [PMID: 29950308 PMCID: PMC9488695 DOI: 10.1183/16000617.0047-2018] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 05/30/2018] [Indexed: 11/25/2022] Open
Abstract
In the past decade, the attention has been focused on the relationship between interstitial lung disease (ILD) and connective tissue diseases (CTDs). The clinical impact, as well as the therapeutic approach, classification and diagnosis have been addressed. These two latter items represent an area of great interest because the underlying conditions leading to ILD and the most appropriate treatment still needs to be defined. Recently, the European Respiratory Society/American Thoracic Society proposed the interstitial pneumonia with autoimmune features (IPAF) criteria which represents the effort of pulmonologists to classify patients that may remain clinically undefined [1]. The analysis of these criteria shows that IPAF, similarly to pulmonary arterial hypertension classification [2], may cluster conditions referring to a wide spectrum of rheumatic conditions such as systemic sclerosis, myositis, rheumatoid arthritis and overlap syndromes. These diseases are characterised by highly different characteristics, evolution and therapeutic approaches. Furthermore, IPAF criteria have an intrinsically changing structure, related to the regular update of existing CTD classification criteria and to the even more common identification of new biomarkers in CTDs. By far the most important effect of these criteria is the identification of a grey zone of not well-defined rheumatology conditions, e.g. anti-synthetase syndrome (ASSD) [3]. In this issue of the European Respiratory Review, Sambataroet al. [4] address the need to identify specific clinical characteristics and potential areas of improvement in IPAF patients. The starting point of the review is interesting because of the exclusion of papers that included patients diagnosed with ASSD, because no ASSD established classification criteria still exist. The authors' choice is related to the unique characteristics of ASSD, in which it is not unusual to observe the occurrence during follow-up of findings lacking at disease onset. [5]. However, as reported previously [6], in the case of anti-synthetase antibody positivity, the diagnostic scenario may vary with the same patient diagnosed with ASSD if referred to a rheumatologist, or IPAF if referred to a pulmonologist. In fact, a high prevalence of anti-synthetase antibody positivity is reported in the majority of papers evaluated by Sambataroet al. [4], thus confirming the fact that despite the presence of this antibody (identifying ASSD) patients may frequently end up being classified as having IPAF. However, some IPAF patients could not be tested for the entire spectrum of antibodies, probably due to the local unavailability of these tests, or because initial anti-Ro antibody positivity might have prompted the clinicians to evaluate further non-anti-Jo-1 myositis specific auto-antibodies. In fact, it is established that anti-Ro antibodies and anti-synthetase antibodies may co-occur in about 50% of cases, even when patients could be classified as IPAF [7]. Furthermore, we should also consider that if eight anti-synthetase antibodies have been identified to date, at least another 12 aminoacyl-tRNA synthetase enzymes exist, and that the entire spectrum of anti-synthetase antibodies is not covered by any of the existing commercially available tests. All these points clearly indicate the risk that anti-synthetase antibody positivity could be underestimated and that it could be clustered in IPAF. This evidence clearly suggests that well-established and clinically based ASSD classification criteria are needed to reduce the risk of stratifying patients across specialties, in areas that may contribute to real-time incorrectly diagnosed primary disease. Recently, the CLASS (classification criteria of anti-synthetase syndrome) project has been funded by the American College of Rheumatology and the European League against Rheumatism. The aim of the project is to define clinically based criteria of ASSD involving a large number of rheumatology, pulmonology, dermatology, immunology and internal medicine centres expert in the management of rheumatoid arthritis, systemic sclerosis, Sjogren's syndrome and other lung fibrosing conditions. From a scientific point of view, by putting together different specialists we hope to solve the daily discussions about “anti-synthetase antibody positive patient classification” that may delay the correct approach and treatment of affected patients. IPAF classification criteria include several autoimmune conditions with different evolution. The progression into established CTD is common and a continuous up-to-date process of classification criteria of both IPAF and CTD is mandatory.http://ow.ly/pXNW30knUzl
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Interstitial Pneumonia with Autoimmune Features: Overview of proposed criteria and recent cohort characterization. ACTA ACUST UNITED AC 2017; 24:191-196. [PMID: 29276366 DOI: 10.1097/cpm.0000000000000227] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The accurate diagnosis of interstitial lung disease (ILD) is essential for optimal prognostication and management. While connective tissue disease (CTD) is among the most common causes of ILD, some patients have features suggestive of autoimmunity without meeting criteria for a specific CTD. To help define and study this disease entity more uniformly, a 2015 research statement proposed consensus-based criteria and coined the term "interstitial pneumonia with autoimmune features" (IPAF). In this review, we summarize and compare previously proposed criteria to characterize these patients, provide an overview of the IPAF criteria and highlight recent investigations aimed at characterizing IPAF cohorts. We then call attention to questions that have arisen with the application of the IPAF criteria and discuss future areas of study.
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Chartrand S, Lee JS, Fischer A. Longitudinal assessment of interstitial pneumonia with autoimmune features is encouraged. Respir Med 2017; 132:267. [PMID: 28760577 DOI: 10.1016/j.rmed.2017.07.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 06/22/2017] [Accepted: 07/20/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Sandra Chartrand
- Department of Medicine, Hôpital Maisonneuve-Rosemont affiliated to Université de Montréal, Montréal, Québec, Canada
| | - Joyce S Lee
- University of Colorado School of Medicine, Department of Medicine, USA
| | - Aryeh Fischer
- University of Colorado School of Medicine, Department of Medicine, USA.
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