interstitial lung diseases
TRANSCRIPT
By
Dr. Riham Hazem RaafatLecturer of Chest Diseases
Ainshams University
Lung
Interstitial PulmonaryInterstitial Pulmonary Fibrosis (IPF):Fibrosis (IPF):
• 1ry (Idiopathic)
• Occupational
• Collagenic
• Granulomatous
• Irradiation
• Resection
• Drug induced(Bleomycin, Methotrexate, Cyclophosphamide)
Pleura
• Pleural effusion
• Pneumothorax
• Pleural fibrosis
• Pleural tumours
• Pleural thickeningChest Wall
• Trauma
• Kyphoscoliosis
• Ankylosing Spondylitis
• Neuromuscular Disease (Myasthenia/Guillain Barre)
• Morbid obesity
• Scleroderma
Abdomen
Severe Distension
Restrictive Lung DiseasesRestrictive Lung DiseasesExtra-ParenchymalParenchymal
Parenchymal RLD Extraparenchymal RLD
FVC Decreased Decreased
MVV Normal Decreased
DLCO Decreased Normal
FVC: Forced Vital Capacity
MVV: Maximum Voluntary Ventilation
DLCO: Carbon Monoxide Diffusion
Adapted from: ATS/ERS Guidelines for IIP. AJRCCM. 2002;165:277-304.
Diffuse Parenchymal Lung Disease (DPLD)
DPLD of known cause, eg, drugs or association, eg, collagen vascular disease
Idiopathic interstitial
pneumonias
Granulomatous DPLD, eg,
sarcoidosis
Other forms of DPLD, eg, LAM,
HX, etc
Idiopathic pulmonary
fibrosis
IIP other than idiopathic
pulmonary fibrosis
Desquamative interstitial pneumonia
Acute interstitial pneumonia
Nonspecific interstitial pneumonia (provisional)
Respiratory bronchiolitis interstitial lung disease
Cryptogenic organizing pneumonia
Lymphocytic interstitial pneumonia
Pleuroparenchymal fibroelastosis
Travis WD, et al; ATS/ERS Committee on Idiopathic Interstitial Pneumonias. Am J Respir Crit Care Med. 2013;188(6):733-748.
Major Idiopathic Interstitial Pneumonias
Category
Clinical-Radiologic-Pathologic Diagnosis
Associated Radiographic and/or Pathologic pattern
Chronic fibrosing
IPF UIP
Idiopathic nonspecific interstitial Pneumonia (iNSIP) NSIP
Smoking-related
Respiratory bronchiolitis-ILD (RB-ILD) Respiratory bronchiolitis
Desquamative interstitial pneumonia (DIP) Desquamative interstitial pneumonia
Acute/ subacute
Cryptogenic organizing pneumonia (COP) Organizing pneumonia
Acute interstitial pneumonia (AIP) Diffuse alveolar damage
Travis et al. Am J Respir Crit Care Med. 2013;188:733-748.
Other Idiopathic Interstitial Pneumonias
Category Clinical-Radiologic-Pathologic Diagnosis
Associated Radiographic and/or Pathologic pattern
Rare
Idiopathic lymphoid interstitial pneumonia (iLIP)
Lymphoid interstitial pneumonia
Idiopathic pleuroparenchymal fibroelastosis (IPPFE)
Pleuroparenchymal fibroelastosis
Unclassifiable Unclassifiable IIP Many
Travis et al. Am J Respir Crit Care Med. 2013;188:733-748.
*Causes of unclassifiable IIP: (1) Inadequate clinical, radiologic, or pathologic data (2) Major discordance between clinical, radiologic, and
pathologic findings that may occur in the following situations:
(a) Previous therapy resulting in substantial alteration of radiologic or histologic findings (e.g., biopsy of DIP after steroid therapy, which shows only residual NSIP)
(b) New entity, or unusual variant of recognized entity, not adequately characterized by the current ATS/ERS classification (e.g., variant of organizing pneumonia with supervening fibrosis); and
(c) Multiple HRCT and/or pathologic patterns that may be encountered in patients with IIP.
Clinical-Radiologic-Pathologic Approach to ILD
When Should I Suspect ILD?One from Column A and one from Column B
“ACES”
ILD FeaturesSimilarities Differences
• Dyspnea– Progressive– Exertional
• Cough– Non-productive
• Bibasilar crackles• Restrictive ventilatory
defect• Exertional desaturation• ILD on HRCT
• Prior/current exposures• Extrapulmonary findings
– Sarcoidosis– Connective tissue disease– Joint involvement
• Serologies• HRCT
– Honeycombing– Ground glass – Distribution of abnormalities
• Histopathology
Known Causes of ILD: History & Physical Exam
• Drugs– eg, Amiodarone, bleomycin,
nitrofurantoin
• Radiation‒ External beam radiation therapy to
thorax
• Connective Tissue Diseases– Rheumatoid arthritis– Systemic sclerosis (scleroderma)– Idiopathic inflammatory
myopathies– Vasculitis
• Occupational/Environmental– Inorganic antigens
(Pneumoconioses)• Asbestosis• Coal worker’s
pneumoconiosis• Silicosis
– Organic antigens (Hypersensitivity Pneumonitis)
• Birds• Mold
Serological Evaluation
• Minimum: ANA, RF, CCP (ATS/ERS guidelines)• Based on history & physical exam, consider:
– Extractable nuclear antigen (ENA) autoantibody panel– Anti-centromere antibody– ESR & CRP– MPO/PR3 (ANCA) antibodies– Anti-cardiolipin antibodies, lupus anticoagulant– Creatine kinase, aldolase– Hypersensitivity pneumonitis panel
• Should be performed before a biopsy
Pleuroparenchymal Fibroelastosis
•Pleural thickening•Traction bronchiectasis &
Fibrotic changes
Elastotic tissue intra-alveolar
Idiopathic Pulmonary Fibrosis• Peripheral lobular fibrosis of unknown cause• Clinical impact
– Exertional dyspnea– Cough– Functional and exercise limitation– Impaired quality-of-life– Risk for acute respiratory failure and death
• Median survival time of 3-5 years• Two new drugs approved by the FDA in October 2014
‒ Nintedanib (Ofev)‒ Pirfenidone (Esbriet, Pirfenex)
IPF is defined as a specific form of chronic,
fibrosing interstitial pneumonia of unknown
cause, typically affecting adults over 50 years,
limited to the lungs, and associated with the
histopathologic and/or radiologic pattern of usual
interstitial pneumonia (UIP)
Risk Factors for IPFRisk Factors for IPF
Hereditary Acquired
* Gene Mutations • Smoking (> 20 packs.year).
• Pneumoconiosis.
• GERD: microaspiration.
• Viral infections (HCV, Herpes)
• Autoimmunity.
Clinical-Radiologic-Pathologic Approach to ILD
Major CriteriaA.Exclusion of known causes.B.Abnormal pulmonary function tests with evidence of restriction and impaired gas exchange.C.Bibasilar reticular abnormalities with minimal or no ground glass opacities on HRCT scans.D.Transbronchial biopsy or bronchoalveolar lavage showing no features to support an alternative diagnosis.
Minor CriteriaA. Age older than 50 yearsB. Insidious onset of otherwise unexplained dyspnea on exertionC. Duration of illness more than 3 monthsD. Bibasilar inspiratory crackles on chest auscultation
The presence of all of the major diagnostic criteria, as well as at least three of the four minor criteria, increases the likelihood of a correct clinical diagnosis.
Diagnostic Algorithm for IPF
Raghu G, et al. Am J Respir Crit Care Med. 2011;183:788-824.
Suspected IPF
Identifiable causes for ILD?
HRCT
Surgical Lung Biopsy
MDD
IPF/Not IPFIPF Not IPF
No
Possible UIPInconsistent w/ UIP
UIPProbable UIPNon-classifiable fibrosis
Raghu G, et al. Am J Respir Crit Care Med. 2011;183:788-824.
2011 ATS/ERS Diagnostic Criteria for IPF
*also known as diffuse parenchymal lung disease, DPLD
Exclusion of known causes of ILD*
UIP pattern on HRCT without surgical biopsy
ORDefinite/possible UIP pattern on HRCT with a surgical lung
biopsy showing definite/probable UIP
AND
HRCT Criteria for UIP
UIP Pattern
Possible UIP
PatternSubpleural, basal predominance + +Reticular abnormality + +Honeycombing (+/- traction bronchiectasis) + -Absence of “inconsistent” features + +
Raghu G, et al. Am J Respir Crit Care Med. 2011;183:788-824.
Idiopathic Pulmonary Fibrosis
Normal Lungs Usual Interstitial Pneumonia
UIP Pattern
Possible UIP Pattern
traction bronchiectasis
HRCT features inconsistent with IPFInconsistent Features
Upper lobe predominant
Peribronchovascular predominance
Ground-glass > extent of reticular abnormality
Profuse micronodules
Discrete cysts
Diffuse mosaic attenuation/gas-trapping
Consolidation
Inconsistent With UIP
distinctlobular pattern
Before You Biopsy…
• Can you confirm the diagnosis without a biopsy?• Is it safe?
– Extensive honeycombing– Pulmonary hypertension– High oxygen requirements– Progressive disease
• Avoid a “diagnostic trial” of steroids if possible
Diagnosis of IPF by Lung Biopsy
Raghu G, et al. Am J Respir Crit Care Med. 2011;183:788-824.
UIP Probable UIP
Possible UIP Not UIP Not
performed
UIP IPF IPF IPF Not IPF IPF
Possible UIP IPF IPF +/- IPF Not IPF Not IPF
Inconsistent with UIP +/- IPF Not IPF Not IPF Not IPF Not IPF
Histopathologic Pattern
Radi
olog
ic P
atter
n
Idiopathic Pulmonary Fibrosis
Normal Lung Usual Interstitial Pneumonia
Idiopathic Pulmonary Fibrosis
Normal Lung Fibroblastic focus inUsual Interstitial Pneumonia
Management
2011 Guidelines on Management of IPF
Treatment Strong For
WeakFor
Weak Against
Strong Against
Corticosteroid X
Colchicine X
Cyclosporine A X
Interferon γ 1b X
Bosentan X
Etanercept X
NAC/Azathioprine/Prednisone X
NAC X
Anticoagulation X
Pirfenidone X
Mechanical ventilation X
Pulmonary rehab X
Long-term oxygen X
Lung transplantation X
Three Recent IPF Clinical Trials American Thoracic Society 2014
• PANTHER N-acetylcysteine (NAC)• ASCEND pirfenidone• INPULSIS nintedanib (BIBF1120)
PANTHERN-acetylcysteine (NAC)
Possible NAC Mechanisms of Action
• Increase glutathione antioxidation • Downregulate lysyl oxidase (LOX) activity,
(essential for collagen deposition)
PANTHER 2012 Adverse Events
• Triple therapy has higher incidence of adverse events than placebo
P-value for each comparison < 0.05
IPFNet writing committee. N Engl J Med 2012;366;1968-77.
P-values < 0.05
Raghu G, et al. N Engl J Med. 2012;366:1968-1977.
Perc
enta
ge
ATS 2011
2011-2013 2014Pre-2011
PANTHER Adverse Effects 2014:NAC Does Not Reduce FVC Decline
Martinez FJ, et al. N Engl J Med. 2014;370(22):2093-2101.
Conclusion: NAC offered no significant benefit with respect to the preservation of FVC in patients with IPF with mild-to-moderate impairment in lung function
ASCENDPirfenidone
Possible Mechanisms of Pirfenidone Action
TNF-αIL-6
Pirfenidone
TGF-βIL-6
MMPsCollagenases
ROIs
Collagen
• Antifibrotic• Molecular target
unclear• Active in several
animal models of fibrosis (lung,
liver, kidney)
CAPACITY 2011
CAPACITY-2 CAPACITY-1
• One pirfenidone trial was positive, one was negative• CAPACITY-1 placebo group FVC declined more slowly than expected
ATS 2011
2011-2013 2014Pre-2011
CAPACITY Endpoints
Endpoint CAPACITY-2 CAPACITY-1FVC XX
Overall survival XX XX
Progression-free survival XX
Six-minute walk distance XX DLCO XX XX
Dyspnea XX XX
Exertional desaturation XX XX
ASCEND 2014ATS
20112011-2013Pre-2011 2014
Endpoints
10: Δ FVC or death
20: 6-MWDPFSDyspneaDeath
ASCEND Study Design
King TE, et al. N Engl J Med. 2014;370(22):2083-2092.
Oral Pirfenidone 2403 mg Daily
Placebo
52 Weeks
PFS - Progression-free survival
Inclusion Criteria
•Age 40-80•Confirmed IPF•50 - 90% FVC pred •30 - 90% DLCO pred •FEV1/FVC ≥ 0.80 •6-MWD ≥ 150 m
555 Patients
ASCEND Summary
• Treatment with pirfenidone for 52 weeks significantly reduced disease progression, as measured by – Changes in % predicted FVC (P < 0.001) – Changes in 6-minute walk distance (P = 0.04)– Progression-free survival (P < 0.001)
• Treatment with pirfenidone reduced all-cause mortality and treatment emergent IPF-related mortality in pooled analyses at week 52
• Pirfenidone was generally safe and well tolerated
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• Pirfenidone, as compared with placebo, reduced disease progression in patients with IPF
• Treatment was generally safe, had an acceptable side effect profile, and was associated with fewer deaths
ASCEND Conclusions
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• Approved October 15, 2014• Indicated for the treatment of IPF• Dosage and administration
– 801 mg (three 267 mg capsules) three times daily with food – Doses should be taken at the same time each day– Initiate with titration
• Days 1 through 7: 1 capsule 3x per day• Days 8 through 14: 2 capsules 3x per day• Days 15 onward: 3 capsules 3x per day
– Consider temporary dosage reduction, treatment interruption, or discontinuation for management of adverse reactions.
• Prior to treatment, conduct liver function tests.
*Pirfenex is the indian form (200mg, 30 cap, 195 L.E)
FDA Approval of Pirfenidone (Esbriet)
Pirfenidone Warnings and PrecautionsTemporary dosage reductions or discontinuations may be required
• Elevated liver enzymes: ALT, AST, and bilirubin elevations have occurred with pirfenidone. Monitor ALT, AST, and bilirubin before and during treatment.
• Photosensitivity and rash: Photosensitivity and rash have been noted with pirfenidone. Avoid exposure to sunlight and sunlamps. Wear sunscreen and protective clothing daily.
• Gastrointestinal disorders: Nausea, vomiting, diarrhea, dyspepsia, gastro-esophageal reflux disease, and abdominal pain have occurred with pirfenidone.
Adverse Effects, CautionsAdverse Effects, Cautions
Adverse EffectAdverse Effect CautionCaution
GI Upset (N, V, dyspepsia) Taken after food to these upsets (though food significantly its absorption)
Photosensitivity Avoid exposure to sunlight, use sunscreen.
Transaminases Check at baseline, monthly for 6 M, then every 3 M
Dizziness Avoid before driving vehicles
Weight Loss Monitor weight, caloric intake if needed.
Pirfenidone: Other Considerations• Post-marketing experience (reactions of unknown frequency)
– Agranulocytosis – Angioedema – Bilirubin increased in combination with increases of ALT and
AST• Drug interactions
– Metabolized primarily via CYP1A2– Activators and inhibitors of CYP1A2 should be used with
caution with pirfenidone• Use with caution with mild/moderate hepatic impairment, not
recommended for patients with severe impairment• Use with caution with mild/moderate/severe renal impairment,
not recommended for patients with ESRD requiring dialysis• Smoking causes decreased exposure to pirfenidone. Instruct
patients to stop smoking prior to treatment with pirfenidone and to avoid smoking when using pirfenidone.
INPULSISNintedanib
Possible Mechanisms of Nintedanib Action
• Triple kinase inhibitor• Phosphatase activator• Antiangiogenic,
antitumor activity VEGF
Nintedanib
PDGF FGF SHP-1
Pleiotropic Effects
Richeldi L, et al. N Engl J Med.2011:365;1079-1089.
Nintedanib Showed Promise for FVC Endpoint
ATS 2011
2011-2013 2014Pre-2011
INPULSIS 2014ATS
20112011-2013Pre-2011 2014
Richeldi L, et al. N Engl J Med. 2014;370(22):2071-2082.
INPULSIS-1 and INPULSIS-2 Study Design
Endpoints
10: ΔFVC
20: Time to first AE Δ SGRQ
Inclusion Criteria
•Age > 40•IPF ≤ 5y•≥ 50% FVC pred •30 - 79% DLCO pred •HRCT within 1y
Nintedanib 300 mg Daily
Placebo
52 Weeks
3
2
1066 Patients
AE – Acute ExacerbationSGRQ – St. George’s Respiratory Questionnaire
INPULSIS Summary
• Nintedanib had significant benefit in adjusted annual rate of change in FVC • INPULSIS-1 Δ = 125.3 ml P < 0.001• INPULSIS-2 Δ = 93.7 ml P < 0.001
• Nintedanib had significant benefit in time to the first acute exacerbation in INPULSIS-2• INPULSIS-1 HR = 1.15 P = 0.67• INPULSIS-2 HR = 0.38 P = 0.005
• Significant difference in favor of nintedanib for the change from baseline in the total SGRQ score in INPULSIS-2 but not INPULSIS-1
INPULSIS Conclusions
• Nintedanib reduced the decline in FVC, which is consistent with a slowing of disease progression
• Nintedanib was frequently associated with diarrhea, which led to discontinuation of the study medication in less than 5% of patients
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• Approved October 15, 2014• Indicated for the treatment of IPF• Dosage and administration
– 150 mg twice daily approximately 12 hours apart taken with food– Consider temporary dose reduction to 100 mg, temporary
interruption, or discontinuation for management of adverse reactions.
– Prior to treatment, conduct liver function tests.
FDA Approval of Nintedanib (Ofev)
Richeldi L, et al. N Engl J Med. 2014;370(22):2071-2082.
Common Nintedanib Adverse Events
Event INPULSIS-1 INPULSIS-2
Nintedanib (n = 309)
Placebo (n = 204)
Nintedanib (n = 329)
Placebo (n = 219)
Any (%) 96 89 94 90Diarrhea (%) 62 19 63 18
Nausea(%) 23 6 26 7
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• Elevated liver enzymes: ALT, AST, and bilirubin elevations have occurred with nintedanib. Monitor ALT, AST, and bilirubin before and during treatment. Temporary dosage reductions or discontinuations may be required.
• GI disorders: Diarrhea, nausea, and vomiting have occurred with nintedanib. Treat patients at first signs with adequate hydration and antidiarrheal medicine (e.g., loperamide) or anti-emetics. Discontinue nintedanib if severe diarrhea, nausea, or vomiting persists despite symptomatic treatment.
• Embryofetal toxicity: Women of childbearing potential should be advised of the potential hazard to the fetus and to avoid becoming pregnant.
• Arterial thromboembolic events have been reported. Use caution when treating patients at higher cardiovascular risk including known CAD.
• Bleeding events have been reported. Use nintedanib in patients with known bleeding risk only if anticipated benefit outweighs the potential risk.
• GI perforation has been reported. Use nintedanib with caution when treating patients with recent abdominal surgery. Discontinue nintedanib in patients who develop GI perforation. Only use nintedanib in patients with known risk of GI perforation if the anticipated benefit outweighs the potential risk.
Nintedanib Warnings and Precautions
http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?fuseaction=Search.DrugDetails/. Accessed October 2014.
Nintedanib: Other Considerations• Drug interactions
– Nintedanib is a substrate of P-glycoprotein (P-gp) and CYP3A4– Concomitant use of P-gp and CYP3A4 inducers with nintedanib should
be avoided– Patients treated with P-gp and CYP3A4 inhibitors and nintedanib
should be monitored closely for adverse reactions • Nintedanib is a VEGFR inhibitor, and may increase the risk of
bleeding. Monitor patients on full anticoagulation therapy closely for bleeding and adjust anticoagulation treatment as necessary.
• Nintedanib not recommended for patients with moderate or severe hepatic impairment
• < 1% excreted via the kidney; no data on patients with severe renal impairment and ESRD
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Current Phase 2 Trials for IPFNext Generation Therapy?
Trial Target N Primary Endpoint
Co-trimoxazole (Ph 3) Pneumocystis jiroveci 56 Change in FVC or respir. Hospital’n
FG-3019 Anti-CTGF 90 Change in FVC from baseline
Rituximab CD-20 58 Titers of anti-HEp-2 autoantibodies
Simtuzumab Anti-LOXL2 500 PFS
GC-1008 TGF- 25 Safety, tolerability, PK
QAX576 Anti-IL-13 40 Safety, tolerability, FVC
Tralokinumab Anti-IL-13 302 Change in FVC from baseline
STX-100 αvβ6 32 Adverse events
BMS-986020 LPA Receptor 300 Rate of change in FVC
Clinical Trial Conclusions • 2014 is a watershed year in IPF
– NAC did not show efficacy (PANTHER)– Pirfenidone (ASCEND) and nintedanib (INPULSIS) showed
efficacy in mild/moderate IPF– Pirfenidone and nintedanib approved 10/15/14 for the
treatment of IPF– Still need data on advanced disease, combination therapy,
long-term safety, adherence• Implications of having approved drug(s)
– Need early and accurate diagnosis– Role of IPF and ILD Centers of Excellence is evolving
Oxygen Therapy
Pulmonary Rehabilitation
Risk Factor Reduction
Lung Transplantation for IPF:2014 Referral Guidelines
• Histopathologic or radiographic evidence of usual interstitial pneumonitis (UIP)
• Abnormal lung function: FVC < 80% predicted or DLCO < 40% predicted
• Any dyspnea or functional limitation attributable to lung disease
• Any oxygen requirement, even if only during exertion
Weill D, et al. J Heart Lung Transplant.2014 Jun 26. [Epub ahead of print].
Other Therapies
• Stem Cell Therapy• Proteolytic Enzymes ??
Acute Exacerbation of IPFAcute Exacerbation of IPF
Diagnostic CriteriaPrevious or concurrent diagnosis of idiopathic pulmonary fibrosis.
• Unexplained worsening or development of dyspnea within 30 days.
• HRCT with new bilateral ground-glass abnormality and/or consolidation superimposed on background reticular or honeycomb pattern consistent with UIP.
• Exclusion of alternative causes: Infection Left heart failure Pulmonary embolism
It’s an acute, clinically significant deterioration of unidentifiable cause and proposed four diagnostic criteria
Baseline IPF Exacerbation
Reducing the risk of exacerbations
*Steroids up to pulse dose +/- Immunosuppresives +/- PMX Bimobilized
Fiber Column Hemoperfusion & Tacrolimus showed response acc. to HRCT pattern*Sildenafil, Imatinib, Bosentan & Triple therapy were tried with no reported improvement. *Pirfenidone has shown inconsistent effects on AEx-IPF.
*Nintedanib reported a lower incidence of AEx-IPF in patients treated with nintedanib 300 mg/day than placebo(It is interesting that nintedanib may have an effect on AEx-IPF whereas the tyrosine kinase inhibitor imatinib, which inhibits the platelet-derived growth factor receptor (PDGFR), did not . Nintedanib is an inhibitor of PDGFR, vascular endothelial growth factor receptor (VEGFR), and fibroblast growth factor receptor (FGFR) and this specificity of inhibition may be key to its effects on AEx-IPF)
*Antacid might decrease frequency
Diagnosis of IPF
IF increased risk of mortality
Evaluate and list for lung transplantation at time of diagnosis