Acute exacerbations of interstitial lung disease: what is the best treatment?

Main Article Content

Keith C. Meyer

Keywords

chronic fibrosing interstitial lung diseases (CFILD), cute exacerbation (AE), acute exacerbations of Idiopathic pulmonary fibrosis (AE-IPF)

Abstract

There is an increasing recognition that patients with various forms of chronic fibrosing interstitial lung diseases (CFILD) are at risk for an acute exacerbation (AE) of their disease that can rapidly lead to death (1). While acute exacerbations of Idiopathic pulmonary fibrosis (AE-IPF) appear to be more common than acute exacerbations for other forms of CFILD and a considerable number of manuscripts have been published on risk factors, pathogenesis and treatments, no randomized and adequately powered clinical trials of therapies for AE-CFILD have been published to date. But because only a relatively small number of patients at any single center develop an AE over time, such a study would be very difficult to perform. Furthermore, funding entities with adequate resources to support a large clinical trial of licensed drugs are reluctant to support an evaluation drugs that are off patent. [...]

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References

1. Kolb M, Bondue B, Pesci A, Miyazaki Y, Song JW, Bhatt NY, et al. Acute exacerbations of progressive-fibrosing interstitial lung diseases. Eur Respir Rev. 2018 Dec 21;27(150):180071. doi: 10.1183/16000617.0071-2018. PMID: 30578331.
2. American Thoracic Society. Idiopathic pulmonary fibrosis: diagnosis and treatment. International consensus statement. American Thoracic Society (ATS), and the European Respiratory Society (ERS). Am J Respir Crit Care Med. 2000 Feb;161(2 Pt 1):646-64. doi: 10.1164/ajrccm.161.2.ats3-00. PMID: 10673212.
3. Idiopathic Pulmonary Fibrosis Clinical Research Network, Raghu G, Anstrom KJ, King TE Jr, Lasky JA, Martinez FJ. Prednisone, azathioprine, and N-acetylcysteine for pulmonary fibrosis. N Engl J Med. 2012 May 24;366(21):1968-77. doi: 10.1056/NEJMoa1113354. Epub 2012 May 20. PMID: 22607134; PMCID: PMC3422642.
4. Zisman DA, Lynch JP 3rd, Toews GB, Kazerooni EA, Flint A, Martinez FJ. Cyclophosphamide in the treatment of idiopathic pulmonary fibrosis: a prospective study in patients who failed to respond to corticosteroids. Chest. 2000 Jun;117(6):1619-26. doi: 10.1378/chest.117.6.1619. PMID: 10858393.
5. Raghu G, Rochwerg B, Zhang Y, Garcia CA, Azuma A, Behr J, et al. An Official ATS/ERS/JRS/ALAT Clinical Practice Guideline: Treatment of Idiopathic Pulmonary Fibrosis. An Update of the 2011 Clinical Practice Guideline. Am J Respir Crit Care Med. 2015 Jul 15;192(2):e3-19. doi: 10.1164/rccm.201506-1063ST. Erratum in: Am J Respir Crit Care Med. 2015 Sep 1;192(5):644. Dosage error in article text. PMID: 26177183.
6. Flaherty KR, Wells AU, Cottin V, Devaraj A, Walsh SLF, Inoue Y, et al. Nintedanib in Progressive Fibrosing Interstitial Lung Diseases. N Engl J Med. 2019 Oct 31;381(18):1718-1727. doi: 10.1056/NEJMoa1908681. Epub 2019 Sep 29. PMID: 31566307.
7. Wells AU, Flaherty KR, Brown KK, Inoue Y, Devaraj A, Richeldi L, et al. Nintedanib in patients with progressive fibrosing interstitial lung diseases-subgroup analyses by interstitial lung disease diagnosis in the INBUILD trial: a randomised, double-blind, placebo-controlled, parallel-group trial. Lancet Respir Med. 2020 May;8(5):453-460. doi: 10.1016/S2213-2600(20)30036-9. Epub 2020 Mar 5. PMID: 32145830.
8. Biondini D, Balestro E, Sverzellati N, Cocconcelli E, Bernardinello N, Ryerson CJ, et al. Acute exacerbations of idiopathic pulmonary fibrosis (AE-IPF): an overview of current and future therapeutic strategies. Expert Rev Respir Med. 2020 Apr;14(4):405-414. doi: 10.1080/17476348.2020.1724096. Epub 2020 Feb 3. PMID: 31994940.
9. Raghu G, Remy-Jardin M, Myers JL, Richeldi L, Ryerson CJ, Lederer DJ, et al. Diagnosis of Idiopathic Pulmonary Fibrosis. An Official ATS/ERS/JRS/ALAT Clinical Practice Guideline. Am J Respir Crit Care Med. 2018 Sep 1;198(5):e44-e68. doi: 10.1164/rccm.201807-1255ST. PMID: 30168753.
10. Innabi A, Gomez-Manjarres D, Alzghoul B, Chizinga M, Mehrad B, Patel D. Cyclophosphamide for the treatment of Acute Exacerbation of Interstitial Lung Disease: A Review of the Literature.
11. Collard HR, Ryerson CJ, Corte TJ, Jenkins G, Kondoh Y, Lederer DJ, et al. Acute Exacerbation of Idiopathic Pulmonary Fibrosis. An International Working Group Report. Am J Respir Crit Care Med. 2016 Aug 1;194(3):265-75. doi: 10.1164/rccm.201604-0801CI. PMID: 27299520.
12. Baughman RP, Meyer KC, Nathanson I, Angel L, Bhorade SM, Chan KM, et al. Monitoring of nonsteroidal immunosuppressive drugs in patients with lung disease and lung transplant recipients: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012 Nov;142(5):e1S-e111S. doi: 10.1378/chest.12-1044. PMID: 23131960; PMCID: PMC3610695.
13. Naccache JM, Montil M, Cadranel J, Cachanado M, Cottin V, Crestani B, et al. Study protocol: exploring the efficacy of cyclophosphamide added to corticosteroids for treating acute exacerbation of idiopathic pulmonary fibrosis; a randomized double-blind, placebo-controlled, multi-center phase III trial (EXAFIP). BMC Pulm Med. 2019 Apr 11;19(1):75. doi: 10.1186/s12890-019-0830-x. PMID: 30971235; PMCID: PMC6458697.
14. Donahoe M, Valentine VG, Chien N, Gibson KF, Raval JS, Saul M, et al. Autoantibody-Targeted Treatments for Acute Exacerbations of Idiopathic Pulmonary Fibrosis. PLoS One. 2015 Jun 17;10(6):e0127771. doi: 10.1371/journal.pone.0127771. Erratum in: PLoS One. 2015;10(7):e0133684. PMID: 26083430; PMCID: PMC4470587.