Overview of Idiopathic Pulmonary Fibrosis: Diagnosis and Therapy Jeff Swigris, DO, MS Director, ILD Program National Jewish Health
Disclosures Speaker - Boehringer Ingelheim and Genentech
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
ILD Inflammation and/or scar In the INTERSTITIUM
To an ILD doc, the interstitium is located Along BV bundles In interlobular septae In the subpleural region Within alveolar walls (largest area)
Secondary Pulmonary Lobule ~1.5cm
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
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)
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
Histology-based classification scheme FLAMMAT I ON S C AR UIP pattern lives here
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
Pr N op ot e fo rty rr o f ep Pr ro es du en ct te io r n
Pr N op ot e fo rty rr o f ep Pr ro es du en ct te io r n
Idiopathic disease + UIP-pattern IPF
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
Making the diagnosis of IPF You have to be a detective History Exam Pulmonary physiology Radiography +/- surgical lung biopsy
History
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
Identify symptoms of rheumatologic illness Eyes/skin/joints/muscles Family history Pulmonary fibrosis Rheumatologic illness Exposures History Smoking, dusts, M/M/B/B
Physical Exam
Physical examination Hands Chest Crackles Joints Skin ANY VELCRO CRACKLE IS ABNORMAL MAKE SURE YOU LISTEN AT THE BASES
Laboratory
Laboratory assessment Serologies ANA RF/anti-CCP Scl-70 SSA/SSB Myositis panel What to do with positive????
Pulmonary Physiology and Gas Exchange
Pulmonary physiology Pulmonary function testing Measures of resting and exercise-related gas exchange
Radiology ILD protocol HRCT No IV contrast Supine and prone Inspiratory and expiratory images High-resolution reconstruction algorithm 1-1.5mm thick slices
Lung Biopsy
Lung biopsy Transbronchial biopsy Sarcoidosis Lymphangitic carcinomatosis Subacute HP Surgical Thorascopic, multiple lobes When classic HRCT pattern absent
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
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
IPF CTD Park et al. AJRCCM 2007
Ann Intern Med. 2012;156(10):684-691
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
What s not IPF? 48 yo F with achey joints, cracked hands, Raynauds and anti-pl-7 antibodies
What s the Diagnosis? 69 yo M with anti-ccp positive RA, now with cough and exertional dyspnea
What s not IPF? 69 yo M with parrot, exertional dyspnea and cough, VATSx bx = UIP-pattern with poorly-formed granulomas
What s not IPF? 73 yo F never-smoker, retired teacher, with chronic UTI on nitrofurantoin for > 4 years
What s not IPF? 53 yo F, executive secretary, uses her indoor hot tub daily, now with 4 months increasing dyspnea
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
Therapeutic Maneuvers O2 keep SpO2 > 89% regardless of activity level Improves fatigue, functioning, dyspnea Pulmonary rehabilitation Improves fatigue, functioning, QOL Vaccinations
Therapeutic Maneuvers Probably look for and treat GERD, OSA, PH Education knowledge is power
Therapeutic Maneuvers Anti-fibrotics
Pathogenesis of IPF
Anti-fibrotics work here
Nintedanib or Pirfenidone Placebo Placebo P o 0 100 200 Placebo
Pirfenidone: adverse events Adverse Event Pirfenidone (%) Placebo (%) (%) (N = 278) (N = 277) Nausea 36 13.4 22.6 Rash 28.1 8.7 19.4 Dyspepsia 17.6 6.1 11.5 Anorexia 15.8 6.5 9.3 GERD 11.9 6.5 5.4 Weight Loss 12.6 7.9 4.7 Insomnia 11.2 6.5 4.7 Dizziness 17.6 13 4.6 Vomiting 12.9 8.7 4.2 King TE, et al. N Engl J Med. 2014
Nintedanib: Adverse Events Event INPULSIS-1 Nintedanib (n = 309) Placebo (n = 204) INPULSIS-2 Nintedanib (n = 329) Placebo (n = 219) Any (%) 96 89 94 90 Diarrhea (%) 62 19 63 18 Nausea (%) 23 6 26 7 Richeldi L, et al. N Engl J Med. 2014;370(22):2071 2082.
Summary Main Points IPF = idiopathic + UIP Thorough history, exam and HRCT Therapeutic approach: anti-fibrotics Simple things most important: Disease education O2 Pulmonary rehab