Overview of Idiopathic Pulmonary Fibrosis: Diagnosis and Therapy

Transcription

1 Overview of Idiopathic Pulmonary Fibrosis: Diagnosis and Therapy Jeff Swigris, DO, MS Director, ILD Program National Jewish Health

2 Disclosures Speaker - Boehringer Ingelheim and Genentech

3 Objectives Describe how to diagnose IPF Develop strategy to distinguish IPF from other ILDs Comprehensive therapeutic approach to IPF Patient education and taking aim at improving QOL

4 ILD Inflammation and/or scar In the INTERSTITIUM

5 To an ILD doc, the interstitium is located Along BV bundles In interlobular septae In the subpleural region Within alveolar walls (largest area)

6 Secondary Pulmonary Lobule ~1.5cm

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9 Etiology-based classification scheme Exposure-related mold, bacteria, birds medications XRT dusts cigarette smoke ILD Genetic FPF Autoimmune-related RA Systemic sclerosis PM/DM Sjögren s syndrome MCTD SLE IBD Idiopathic Sarcoidosis LAM IIP

10 Idiopathic interstitial pneumonias (IIP) Major IIP Idiopathic pulmonary fibrosis (IPF) Idiopathic nonspecific interstitial pneumonia (NSIP) Respiratory bronchiolitis-ild (RB-ILD) Desquamative interstitial pneumonia (DIP) Cryptogenic organizing pneumonia (COP) Acute interstitial pneumonia (AIP)

11 ILD IIP IPF IPF: specific type of ILD within the IIP IPF: specific type of pulmonary fibrosis UIP-pattern IPF: Diagnosis of exclusion Rule out Exposure (environment, Rx, occupational) Connective tissue disease

12 Histology-based classification scheme FLAMMAT I ON S C AR UIP pattern lives here

13 Etiology-based classification scheme Exposure-related mold, bacteria, birds medications XRT dusts cigarette smoke INFLAMMAT I S C AR O N ILD Genetic FPF S C AR INFLAMMAT I N Autoimmune-related RA Systemic sclerosis PM/DM Sjögren s syndrome MCTD INFLAMMAT I S C AR O N O Idiopathic Sarcoidosis LAM IIP INFLAMMAT I S C AR O N

14 Pr N op ot e fo rty rr o f ep Pr ro es du en ct te io r n

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17 Pr N op ot e fo rty rr o f ep Pr ro es du en ct te io r n

18 Idiopathic disease + UIP-pattern IPF

19 What to do when you have a patient in front of you and you are considering the possibility of IPF as the clinical summary diagnosis

20 Making the diagnosis of IPF You have to be a detective History Exam Pulmonary physiology Radiography +/- surgical lung biopsy

21 History

22 History Typically IPF presents with: Dyspnea subacute, insidious onset I thought it was just that I was a year older, 5# heavier, and out of shape +/- dry cough Fatigue/low stamina Not pain, swollen joints, rash

23 Identify symptoms of rheumatologic illness Eyes/skin/joints/muscles Family history Pulmonary fibrosis Rheumatologic illness Exposures History Smoking, dusts, M/M/B/B

24 Physical Exam

25 Physical examination Hands Chest Crackles Joints Skin ANY VELCRO CRACKLE IS ABNORMAL MAKE SURE YOU LISTEN AT THE BASES

26 Laboratory

27 Laboratory assessment Serologies ANA RF/anti-CCP Scl-70 SSA/SSB Myositis panel What to do with positive????

28 Pulmonary Physiology and Gas Exchange

29 Pulmonary physiology Pulmonary function testing Measures of resting and exercise-related gas exchange

30 Radiology ILD protocol HRCT No IV contrast Supine and prone Inspiratory and expiratory images High-resolution reconstruction algorithm 1-1.5mm thick slices

31 Lung Biopsy

32 Lung biopsy Transbronchial biopsy Sarcoidosis Lymphangitic carcinomatosis Subacute HP Surgical Thorascopic, multiple lobes When classic HRCT pattern absent

33 History Exam Labs Putting it all Together ANA, RF, anti-ccp Physiology Full PFTs Gas exchange 6MWT Radiology HRCT Pathology Integrate to get summary diagnosis

34 Making the diagnosis of IPF UIP-pattern IPF Suspected IPF Identifiable causes for ILD? No HRCT Possible UIP Indeterminate UIP Consider VATSx Lung Biopsy Clin/Rad/Path IPF or not IPF UIP Probable/Possible UIP Non-classifiable fibrosis Yes Other Dx Not UIP Not IPF

35 IPF CTD Park et al. AJRCCM 2007

36 Ann Intern Med. 2012;156(10):

37 Pr N op ot e fo rty rr o f ep Pr ro es du en ct te io r n IPF: Cause of Death Olson et al. Am J Respir Crit Care Med 2007

38 What s not IPF? 48 yo F with achey joints, cracked hands, Raynauds and anti-pl-7 antibodies

39 What s the Diagnosis? 69 yo M with anti-ccp positive RA, now with cough and exertional dyspnea

40 What s not IPF? 69 yo M with parrot, exertional dyspnea and cough, VATSx bx = UIP-pattern with poorly-formed granulomas

41 What s not IPF? 73 yo F never-smoker, retired teacher, with chronic UTI on nitrofurantoin for > 4 years

42 What s not IPF? 53 yo F, executive secretary, uses her indoor hot tub daily, now with 4 months increasing dyspnea

43 What s the Diagnosis? 62 yo M former smoker, retired Air Force fighter pilot, no CTD symptoms, no exposures, VATSx bx with UIP-pattern histology

44 Therapeutic Maneuvers O2 keep SpO2 > 89% regardless of activity level Improves fatigue, functioning, dyspnea Pulmonary rehabilitation Improves fatigue, functioning, QOL Vaccinations

45 Therapeutic Maneuvers Probably look for and treat GERD, OSA, PH Education knowledge is power

46 Therapeutic Maneuvers Anti-fibrotics

47 Pathogenesis of IPF

48 Anti-fibrotics work here

49 Nintedanib or Pirfenidone Placebo Placebo P o Placebo

50 Pirfenidone: adverse events Adverse Event Pirfenidone (%) Placebo (%) (%) (N = 278) (N = 277) Nausea Rash Dyspepsia Anorexia GERD Weight Loss Insomnia Dizziness Vomiting King TE, et al. N Engl J Med. 2014

51 Nintedanib: Adverse Events Event INPULSIS-1 Nintedanib (n = 309) Placebo (n = 204) INPULSIS-2 Nintedanib (n = 329) Placebo (n = 219) Any (%) Diarrhea (%) Nausea (%) Richeldi L, et al. N Engl J Med. 2014;370(22):

52 Summary Main Points IPF = idiopathic + UIP Thorough history, exam and HRCT Therapeutic approach: anti-fibrotics Simple things most important: Disease education O2 Pulmonary rehab