Burden of Disease In this module, we review the definition of idiopathic pulmonary fibrosis - PowerPoint Presentation

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Slide2

Burden of Disease

In this module, we review the definition of idiopathic pulmonary fibrosis (IPF). We discuss its prevalence and how it differentiates from other interstitial lung diseases (ILDs).

Slide3

Current Definition of IPF

IPF

Specific form of chronic, progressive, fibrosing interstitial pneumonia of unknown cause

Limited to the lungs

Occurs primarily in older adults

Raghu G, et al.

Am J

Respir

Crit Care Med. 2015;192:e3-e19. Nathan SD, et al. Chest. 2011;140:221-229.

Differentiation and activation of fibroblasts → declining lung function→ pulmonary failure→ death

ATS/ERS/JRS/ALAT 2011 guidelines [updated in 2015]:

“Patients with no identifiable alternative etiology for fibrotic ILD who had usual interstitial pneumonia (UIP) pattern on high-resolution computed tomography (HRCT)”

or

“Had specified combinations of HRCT pattern and surgical lung biopsy pattern were considered to have IPF”

Slide4

Increasing Prevalence of Idiopathic Pulmonary Fibrosis

Raghu G, et al. Lancet Respir Med. 2014;2:566-572.

Medicare Beneficiaries Age ≥65 y

Median survival = 3.8 y

Factors associated with lower survival: Age, index year, male gender

Slide5

Differentiating IPF From Other ILDs…

Category

Diseases

Subcategories/Examples

Idiopathic

Idiopathic Interstitial Pneumonias (IIPs)

Sarcoidosis

Amyloidosis

Lymphangiolyomyomatosis

PLCH, Eosinophilic pneumonia Neurofibromatosis, DAH

IPF

NSIP

Unclassifiable

COP

RB-ILD

DIP

AIP

LIP

PPFE

Immunologic

Connective Tissue Disorders

Inhalation

Inorganic

Asbestosis,

Silicosis

Organic:

Chronic hypersensitivity pneumonitis

Bird fancier’s disease, Farmer

’

s lung

Slide6

Differentiating IPF… continued

CategoryDiseasesSubcategories/ExamplesIatrogenicAntiarrhythmics, Antimicrobials, Chemotherapy agents, Biologics, Radiation InfectiousViralCMV, influenzaFungalPneumocystis cariniiNeoplasticLymphangitic carcinomatosisBronchoalveolar carcinomaChronic CHF

CHF,

congestive heart failure; CMV

, cytomegalovirus.

Slide7

Misdiagnosis and Its Consequences

IPF is often misdiagnosed or undiagnosed

Contributing factors

Low awareness

Differential diagnosis

Failure of stepped work-up

Potential impact

Inappropriate treatmentUnchecked disease progressionLower survival ratesImpaired quality of lifeDeath

Lee AS, et al.

Respir

Med.

2014;108:955-967.

Slide8

Diagnosing IPF

In this module, we discuss how to diagnose IPF, common symptoms, and the diagnostic tools and criteria used for an accurate diagnosis. In addition, we discuss what to look for in pulmonary function tests and how to measure disease severity.

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Improving Early Diagnosis

Awareness of diagnostic criteriaIncreased “comfort” with CT diagnosisDiagnosing IPF without surgical lung biopsy in select cases, when CT shows a probable UIP pattern Improving pathologic reviewExclusion of alternative diagnosis (eg, autoimmune conditions, chronic hypersensitivity pneumonitis)

Lynch DA, et al. Lancet Respir Med. 2018;6:138-153.

CT, computerized tomography.

Slide10

Common Symptoms of IPF

Chronic dry coughDyspneaFatigueExercise desaturationBibasilar inspiratory cracklesClubbing on fingers and/or toes (advanced disease)

NIH National Heart, Lung, and Blood Institute. Idiopathic Pulmonary Fibrosis. 2015

Sharif R

. Am J

Manag

Care

. 2017;23(11

Suppl

):S176-S182.

Slide11

Improving Diagnostic Tools: Pulmonary Function Tests

Spirometry may help differentiate between cardiac and pulmonary issuesForced Vital Capacity (FVC )Forced expired volume in 1 second (FEV1)Single-breath diffusing capacity for carbon monoxide (DLCO)Chest X-rayEchocardiogramRule out heart failure, pulmonary hypertension, valvular diseaseIf uninformative, pursue lung disease route

Cosgrove GP, et al. BMC Pulm Med. 2018;18:9.

CHD, coronary heart disease; CV, cardiovascular disease; DLCO, diffusing capacity of the lung for carbon monoxide.

Slide12

Pulmonary Function Testing

Most patients with IPF exhibit the following:Decreased FVC (FVC may be normal in early IPF)Normal-to-increased FEV1/FVC ratio Reduced DLCO Reduction in TLC Patients with concurrent emphysema may exhibit normal lung volumes and spirometry, but reduced DLCO Low baseline FVC, decline in FVC, low DLCO, and decline in 6MWT are associated with decreased survival

Oldham JM, et al. Respir Med. 2014;108:819-829.

FVC, forced vital capacity; FEV

1

, forced expiratory volume in one second ; DLCO, diffusing capacity of lungs for carbon monoxide; TLC, total lung capacity; 

6MWT, six-minute walking test.

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Measuring Disease Severity

FVCReductions, even as small as 5%‒10%, over 6 months can indicate an increased risk of mortalityHRCT  findings Most important for diagnosisMay correlate with progression and disease outcomes

Cosgrove GP, et al. BMC Pulm Med. 2018;18:9.

FVC, forced vital capacity.

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IPF

IPF

NSIP

COP

Slide15

Specialist Evaluation

Serology

HRCT imaging

Lung biopsy

(select cases)

King TE Jr, et al. N Engl J Med. 2014;370:2083-2092; Richeldi L, et al. N Engl J Med. 2014;370:2071-2082; Raghu G, et al. Am J Respir Crit Care Med. 2015;192:e3-19.

HRCT, high-resolution computed tomography.

Pulmonary rehabilitationOxygen therapyPalliative careTreat comorbiditiesEvaluate for clinical trials

PirfenidoneNintedanibLung transplant

Management

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HRCT Presentation

In this module, we discuss the significance of high-resolution computed tomography (HRCT), how IPF presents, and what IPF looks like on HRCT scans. We also discuss when to consider surgical biopsy and common pathological reviews. And last, we talk about the importance of multidisciplinary collaboration and review common comorbidities.

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Radiological Criteria: HRCT

HRCT required for all patients with IPF suspicionBoth inspiratory and expiratory imagesMay confirm diagnosis with distinct radiographic pattern in the right clinical context Enables greater detail (≤ 2.5 mm cuts) of lung parenchymaUsual interstitial pneumonia (UIP)Basilar predominant subpleural reticulation, honeycombing, +/-traction bronchiectasis, absence of inconsistent features

HRCT, high-resolution computed tomography.

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Interpreting HRCT Scans

Presence of Honeycombing Key characteristic of UIP patternDefined as clustered, thick-walled cystic spaces of similar diametersTypically located in dorsal, basal, and subpleural regionsSometimes seen only in upper lungsHoneycombing increases likelihood of UIP pattern

Lynch DA, et al. Lancet Respir Med. 2018;6:138-153.

HRCT, high-resolution computed tomography.

Slide19

Clinical Presentation

Honeycombing

Subpleural

reticulation

Slide20

What IPF Looks Like on an HRCT Scan

Lynch DA, et al. Lancet Respir Med. 2018;6:138-153.

HRCT, high-resolution computed tomography.

Reticular pattern

Network of fine lines irregularly spaced, with mix of thicker and thinner lines

Traction bronchiectasis

Irregular bronchial and bronchiolar dilatation caused by retractile fibrosis in the surrounding lung parenchyma

Distinguishing honeycombing from traction bronchiectasis can be challenging, but diagnostically important

Honeycombing and traction bronchiectasis often coexist

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CT Changes With IPF (images)

Honeycombing

Traction bronchiectasis

Traction

bronchiolectasis

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The Question of a Surgical Biopsy

Surgical lung biopsy should be considered in patientsWhen clinical or CT findings are indeterminate for IPFWhen CT pattern is inconsistent with UIPWhen clinical features suggest an alternative diagnosis Multidisciplinary approach is important when deciding to perform additional diagnostic assessmentsEvaluation, care coordination, treatment

Lynch DA, et al. Lancet Respir Med. 2018;6:138-153.

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Surgical Lung Biopsy

Biopsy samples should be taken from multiple lobesTarget areas of diseased but not end-stage lungBiopsy risk factors for mortality Increasing age (>65 years)ComorbiditiesOpen rather than thoracoscopic surgeryLung-diffusing capacity <50% predicted

Lynch DA, et al.

Lancet

Respir

Med

. 2018;6:138-153.

Slide24

Transbronchial Cryobiopsy

Alternative to lung biopsyCryoprobe cooled to -85° to -95°C is applied to desired tissueCryobiopsy samples much smaller than surgical lung biopsy samplesResults in ~80% correct diagnosisDiagnostic yield and complication rate are variable and depend on operator’s experience

Lynch DA, et al.

Lancet

Respir

Med

. 2018;6:138-153.

Slide25

Pathology: UIP Pattern

Slide26

Honeycombing: Pathological Review

Air-filled cystic spaces Lined by bronchiolar epitheliumClear, definable walls1- to 30-mm thick of dense fibrous tissue

Webb WR, Muller NL, Naidich DP. High-Resolution CT of the Lung. 5th ed. Philadelphia: Wolters Kluwer; 2014.

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Multidisciplinary Collaboration

Sharif R. Am J Manag Care. 2017;23(11 Suppl):S176-S182.Ryerson CJ, et al. Am J Respir Crit Care Med. 2017;196:1249-1254.

Pulmonologist

Thoracic Radiologist

Pathologist

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Impact of Multidisciplinary Team Discussion

UK study1 showed >50% with previous IPF diagnosis inaccurate after multidisciplinary discussionAustralian study2 (n=90) multidisciplinary discussion resulted in diagnosis change10 (37%) of 27 patients referred with a diagnosis of IPF changed tonon-IPF diagnosis7 patients had diagnosis changed to IPF because of discussion

Chaudhuri N, et al. J Clin Med. 2016; 5:66.Jo HE, et al. Respirology. 2016;21:1438-1444.

Referral diagnosis

of IPF (n=27)

No changes in

diagnosis of IPF (n=17)

MDM diagnosis

of IPF (n=25)

Slide29

Ryerson CJ, et al. Am J Respir Crit Care Med. 2017;196:1249-1254.

Patient presenting with fibrotic interstitial lung disease

Is there a leading diagnosis that

meets guidelines criteria

or has >90% confidence?

Is there a leading diagnosis that

has >50% confidence?

Confident diagnosis

High-confidence diagnosis(70%-89% confidence)

Low-confidence diagnosis(51%-69% confidence)

Unclassifiable ILD

Document differentialdiagnosis

Provisional diagnosis

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IPF Comorbidities

Sharif R. Am J Manag Care. 2017;23(11 Suppl):S176-S182.

Pulmonary

Extra-Pulmonary

Pulmonary hypertension

Infectious-aspergillomasObstructive sleep apnea

Gastroesophageal reflux disease

Coronary artery disease

Heart failure

Thromboembolic disease

Diabetes

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Therapeutic Strategies

In this module, we discuss current treatment options and therapeutic strategies for IPF, as well as dosing, monitoring, and common side effects from agents used to treat IPF. We also discuss the significance of and data from the Pulmonary Fibrosis Foundation patient registry. We talk about the latest data on emerging therapies and review key takeaways

from our presentation.

Slide32

Current Treatment Options

Medical therapyFDA-approved therapies only slow progressionSupportive care and nonpharmacologic measures for IPFTreatment of exacerbations (unproven)Lung transplant (only in select patients with advanced IPF)

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Supportive Care and Other Interventions

Supplemental oxygen therapy may improve QoLRecommended when patient’s desaturation is < 88% during 6MWTNocturnal oxygen with sleep apneaPulmonary rehabilitation impacts functional status and QoLAerobic conditioningStrength and flexibility trainingEducation about conditionNutritional counselingPsychosocial supportMechanical ventilation (only recommended if bridge to transplant) Palliative care services

Sharif R. Am J Manag Care. 2017;23(11 Suppl):S176-S182.

QoL, quality of life;

6MWT, 6-minute walk test.

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Drugs Not To Use for IPFPer ATS/ERS/JRS/ALAT 2011 Guidelines

Anticoagulants*Imatinib†—Studies show no benefitSelective endothelin receptor antagonist (ambrisentan)*Combination prednisolone/azathioprine/n-acetylcysteine* Trials show excess number of deaths

Raghu G, et al. N Engl J Med. 2012;366:1968-77. Raghu G, et al. Am J Respir Crit Care Med. 2015;192:e3-e19. Trawinska MA, et al. Ther Clin Risk Manag. 2016;12:563–574.

ATS, American Thoracic Society; ERS, European Respiratory Society; JRS, Japanese Respiratory Society; ALAT, Latin American Thoracic Association.

Raghu G, et al. 

N Engl J Med. 2012;366:1968-77.

*Low confidence in effect estimates.

†

Moderate confidence in effect estimates.

Raghu G, et al.

Am J

Respir

Crit

Care Med

. 2015;192:e3-19.

Slide35

Differentiating Between Disease-Modifying Agents

Determine therapy based on ContraindicationsPatient choice Review side-effect profiles with patients

Trawinska MA, et al. Ther Clin Risk Manag. 2016;12:563–574.

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Current Therapeutic Strategies for IPF

Nintedanib: Tyrosine kinase inhibitor Reduces fibrogenesis Prolonged time to acute exacerbationReduced rates of FVC declinePirfenidone: Distinct antifibrotic propertiesReduced disease progressionReduced rates of FVC declineImproved progression-free survivalCheck liver function before initiating therapy, also during treatment

Varone F, et al. Expert Opin Pharmacother. 2018:1-9.

FVC, forced vital capacity. 

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Nintedanib Reduces Loss of FVC

Richeldi L, et al. N Engl J Med. 2014;370:2071-82.

FVC, forced vital capacity.

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Nintedanib

150 mg bid (n=638)Placebo (n=423)Patients with ≥1 acute exacerbation, n (%)31 (4.9)32 (7.6)

HR 0.64 (95% CI; 0.39, 1.05)P=.0823

Time to First Acute Exacerbation (Investigator-reported): INPULSIS Pooled

Adapted from Richeldi L, et al. N Engl J Med. 2014;370:2071-2082.

Placebo

Nintedanib

150 mg bid

Slide39

King TE Jr, et al. N Engl J Med. 2014;370:2083-92.

Results from phase 3 ASCEND trial of

pirfenidone

in patients with IPF

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Pirfenidone and Mortality

Pooled AnalysisP valueMeta-analysisP valueACMPirfenidone (n=623)Placebo(n=624)Pirfenidone(n=806)Placebo(n=769)Week 5222 (3.5%)42 (6.7%)0.01025 (3.1%)50 (6.5%)0.004Week 7232 (5.1%)50 (8.0%)0.04035 (4.3%)58 (7.5%)0.016End of Study38 (6.1%)54 (8.7%)0.07841 (5.1%)62 (8.1%)0.034TE ACMWeek 5214 (2.2%)32 (5.1%)0.009Week 7220 (3.2%)39 (6.3%)0.015End of study26 (4.2%)43 (6.9%)0.042IPF-related ACMWeek 5210 (1.6%)28 (4.5%)0.002Week 7217 (2.7%)35 (5.6%)0.010End of study22 (3.5%)39 (6.3%)0.023

Nathan SD, et al.

Lancet Respir Med.

2017;5(1):33-41.

Slide41

Dosing

NintedanibOne capsule (150 mg) twice a day with food Pirfenidone Titrated to 3 capsules, 3 times a day with food Days 1–7 267 mg (1 capsule) every 8 hrs with food; days 8–14 534 mg (2 capsules) every 8 hrs with food; Day >15 801 mg (3 capsules) every 8 hrs with foodAdjust dosing to manage side effectsContinue to review latest data

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Disease Monitoring and Management

Continue pulmonary function tests (PFT)6MWT used for prognosticationAssess treatment response

6MWT, six-minute walk test.

Slide43

King TE Jr., et al. N Engl J Med. 2014;370:2083-2092. Richeldi L, et al; INPULSIS Trial Investigators. N Engl J Med. 2014;370(22):2071-82.

Pirfenidone

NintedanibGastrointestinalAnorexia (8%), nausea (20%), dyspepsia (12%), vomiting (7%), diarrhea (6%), weight loss (5%)Diarrhea (44%), nausea (17%), vomiting (9%), GI perforation (0.3%)DermatologicRash (20%)Photosensitivity (8%)CardiovascularMyocardial infarction (1.1%)HematologicBleeding events (3%)HepaticTransaminitis (2.5%)TransaminitisEmbryofetal toxicityYes

Common Side Effects

Slide44

Pulmonary Fibrosis Foundation Patient Registry

Goal: Create cohort of well-characterized patients for participation in retrospective and prospective research.Registry enrollment began in March 2016As of March 31, 2017 (n=767)Targeting 60% IPF patients of 2,000 goal of ILD participants across 40 clinical sitesThe PFF Patient Registry is actively enrolling participants.

Flaherty KR, et al. Pulmonary Fibrosis Foundation Patient Registry. Pulmonary Fibrosis Foundation. 2017.

ILD, interstitial lung diseases.

Slide45

PFF Data Results

Adapted from Flaherty KR, et al. Pulmonary Fibrosis Foundation Patient Registry. Pulmonary Fibrosis Foundation. 2017.

PFF, Pulmonary Fibrosis Foundation; FEV1, forced expiratory volume in one second; FVC, forced vital capacity; DLCO, diffusing capacity of lungs for carbon monoxide.

VariableIPFn=448non-IPFn=319p-valueComorbidityGERD64%55%0.02Sleep Apnea29%27%0.45Depression17%16%0.60Anxiety10%16%0.03Coronary Artery Disease24%17%0.02Medical TherapyImmunosuppression, any4%59%<0.0001Antifibrotic65%5%<0.0001N-acetylcysteine3%1%0.14

Variable

IPF

n=448

non-IPF

n=319

p-value

Consented Biorepository

93%

89%

0.11

Age, years

70 (8)

64 (12)

<0.01

Male

74%

45%

<0.01

Former Smoker

66%

50%

<0.01

Pulmonary Function

FEV

1

, %

pred

71 (17)

70 (20)

0.39

FVC, %

pred

67 (17)

68 (19)

0.81

DLCO, % pred

41 (18)

45 (18)

<0.01

Home oxygen use

45%

43%

0.64

Slide46

PFF Patient Registry Conclusions

A large number of patients with IPF and non-IPF are enrolling in the Registry and Biorepository.The diagnostic process for IPF and non-IPF is similar.Use of immunosuppression vs anti-fibrotic therapy differs dramatically between IPF and non-IPF.

Flaherty KR, et al. Pulmonary Fibrosis Foundation Patient Registry. Pulmonary Fibrosis Foundation. 2017.

PFF, Pulmonary Fibrosis Foundation; ILD, interstitial lung diseases.

Slide47

Latest Research on Emerging Therapies

CompoundCompanyStructure/Route of AdministrationStage of DevelopmentMechanism of ActionBackground TherapyClinicalTrials.gov Identifier: PRM-151Promedior/BMSmAb/IVPhase 2Rh-pentraxin-2 proteinpirfenidone or nintedanib allowedNCT02550873 SAR-156597SanofimAb/SCPhase 2Anti IL-4/IL-13pirfenidone or nintedanib allowedNCT02345070 FG-3019FibrogenmAb/IVPhase 2Anti-CTGFpirfenidone or nintedanib allowed only in the sub studyNCT01890265 STX-100/BG00011BiogennAb/SCPhase 2Anti-integrin avB6pirfenidone allowedNCT01371305 PBI-4050PrometricSm/oralPhase 2CTGF expression inhibitorpirfenidone or nintedanib allowedNCT02538536 TD139Galecto/BMSSm/InhalationPhase 2Galectin-3 inhibitorNot allowedNCT02257177

ClinicalTrials.gov

Sm, small molecule;

mAb

, monoclonal antibody; IV, intravenous; SC, subcutaneous; IL, interleukin; CTGF, connective tissue growth factor; BMS, Bristol-Meyers Squibb.

Slide48

Latest Research on Emerging Therapies (cont)

CompoundCompanyStructure/Route of AdministrationStage of DevelopmentMechanism of ActionBackground TherapyClinicalTrials.gov Identifier: MN-001 (tipelukast)MediciNovaSm/oralPhase 2Leukotriene receptor antagonistnintedanib allowedNCT02503657 KD025KadmonSm/oralPhase 2ROCK2 inhibitorNot allowedNCT02688647 CC-90001CalgeneSm/oralPhase 2JNK1 inhibitorNANCT03142191 GLPG-1690GalapagosSm/oralPhase 2Autotaxin inhibitorNANCT02738801 OmipalisibGSKSm/oralPhase 2P13K/mTORNANCT10725139GBT440Global Blood TherapeuticsSm/oralPhase 2Hb O2 release stimulantNANCT02846324

ClinicalTrials.gov

Sm, small molecule;

mAb

, monoclonal antibody; IV, intravenous; ROCK2, Rho-associated protein kinases; JNK, Jun N-terminal kinases; P13K, Phosphoinositide 3-kinases; mTOR, mammalian target of rapamycin; GSK, GlaxoSmithKline.

Slide49

Emerging Treatments (cont)

CompoundCompanyStructure/Route of AdministrationStage of DevelopmentMechanism of ActionBackground TherapyClinicalTrials.gov Identifier:Inhaled TreprostinilUnited TherapeuticsSm/inhalationPhase 3ProstacyclinNANCT00705133 Mesenchymal stem cellsCells/IVPhase 3Regeneration of alveolar epitheliumNANCT02013700 Cotrimoxazole/DoxycyclineSm/oralPhase 3AntimicrobialNANCT02759120 SildenafilSm/oralPhase 3PDE5 inhibitorNANCT00517933 LosartanSm/oralPhase 3ARBNANCT00879879

ClinicalTrials.gov

Sm, small molecule; PDE5, phosphodiesterase type-5 inhibitor; ARB, Angiotensin II receptor blockers.

Slide50

Key Takeaways

Prognosis

for IPF is unpredictable.

An early diagnosis and appropriate management are vital to maintain quality of life and slow disease progression.

Disease management is crucial for patients with IPF, and includes the following:

Antifibrotic

therapy

Pulmonary rehabilitation

Managing comorbidities

Supplemental oxygen (if and when needed)

Social/psychological support

Lung transplant for select patients (early referral encouraged)

Clinical trial enrollment.