Real-world experience of nintedanib for progressive fibrosing interstitial lung disease in the UK

Background

Nintedanib slows progression of lung function decline in patients with progressive fibrosing (PF) interstitial lung disease (ILD) and was recommended for this indication within the United Kingdom (UK) National Health Service in Scotland in June 2021 and in England, Wales and Northern Ireland in November 2021. To date, there has been no national evaluation of the use of nintedanib for PF-ILD in a real-world setting.

Methods

26 UK centres were invited to take part in a national service evaluation between 17 November 2021 and 30 September 2022. Summary data regarding underlying diagnosis, pulmonary function tests, diagnostic criteria, radiological appearance, concurrent immunosuppressive therapy and drug tolerability were collected via electronic survey.

Results

24 UK prescribing centres responded to the service evaluation invitation. Between 17 November 2021 and 30 September 2022, 1120 patients received a multidisciplinary team recommendation to commence nintedanib for PF-ILD. The most common underlying diagnoses were hypersensitivity pneumonitis (298 out of 1120, 26.6%), connective tissue disease associated ILD (197 out of 1120, 17.6%), rheumatoid arthritis associated ILD (180 out of 1120, 16.0%), idiopathic nonspecific interstitial pneumonia (125 out of 1120, 11.1%) and unclassifiable ILD (100 out of 1120, 8.9%). Of these, 54.4% (609 out of 1120) were receiving concomitant corticosteroids, 355 (31.7%) out of 1120 were receiving concomitant mycophenolate mofetil and 340 (30.3%) out of 1120 were receiving another immunosuppressive/modulatory therapy. Radiological progression of ILD combined with worsening respiratory symptoms was the most common reason for the diagnosis of PF-ILD.

Conclusion

We have demonstrated the use of nintedanib for the treatment of PF-ILD across a broad range of underlying conditions. Nintedanib is frequently co-prescribed alongside immunosuppressive and immunomodulatory therapy. The use of nintedanib for the treatment of PF-ILD has demonstrated acceptable tolerability in a real-world setting.

Favourable outcome after a delayed complication secondary to COVID-19

A 41-year-old man was admitted to hospital with 7-day history of fever, cough and having had a positive SARS-CoV-2 PCR test. The chest radiograph (CXR) showed bilateral peripheral parenchymal infiltrates. He required 4 L/min oxygen via nasal cannula for 72 hours and was discharged after 7 days with appropriate advice. Four weeks from initial hospital admission, he presented with worsening cough, left chest pain and breathlessness. CXR showed left pneumothorax, and CT pulmonary angiogram (CTPA) scan confirmed left pneumothorax with mediastinal shift and a subpleural bulla. Intercostal chest drain was inserted with good resolution of symptoms and lung re-expansion. Follow-up CT scan 2 months later showed complete resolution of the parenchymal abnormalities. Our case demonstrates the development of pneumothorax as a delayed complication in a patient with COVID-19 who did not require ventilatory support. The case also illustrates a favourable outcome, that is, complete resolution of parenchymal destruction due to COVID-19.

How should complete lung collapse secondary to primary spontaneous pneumothorax be managed?

Management of primary spontaneous pneumothorax (PSP) depends on the symptoms and size of lung collapse. The British Thoracic Society recommends needle aspiration (NA) for all PSP requiring intervention, followed by intercostal drain (ICD) if NA fails. We compared the role of NA versus ICD as the first step in PSP with 'complete lung collapse'.This was a retrospective observational study of 877 consecutive pneumothorax episodes at University Hospitals of North Midlands, Stoke on Trent, UK. Chest X-ray (CXR) at presentation was reviewed to identify PSP with complete lung collapse. The primary outcome measure was successful lung re-inflation after initial intervention.Two-hundred and sixty-six PSP patients were identified; 69 had complete lung collapse on CXR of which 35 had NA and 34 had ICD. The ICD group had a significantly better immediate success compared with the NA group (62% versus 11%, odds ratio (OR) = 12.5, p<0.0001; after adjustment for potential confounders, OR increased to 26.4, p=0.0001) although long-term outcomes were comparable.There should be clear consensus on definition and management of complete lung collapse. PSP with complete lung collapse could be managed as a separate subgroup where ICD placement is considered to be the first intervention.