a new era in ipf: trials and treatments craig thurm, md director, pulmonary medicine director,...
TRANSCRIPT
A NEW ERA in IPF:Trials and Treatments
Craig Thurm, MDDirector, Pulmonary Medicine
Director, Pulmonary FellowshipMedical Director, Respiratory CareJamaica Hospital Medical Center
Disclosure of Relevant Financial RelationshipsIt is the policy of The France Foundation to ensure balance, independence, objectivity, and scientific rigor in all its sponsored educational activities. All faculty, activity planners, content reviewers, and staff participating in this activity will disclose to the participants any significant financial interest or other relationship with manufacturer(s) of any commercial product(s)/device(s) and/or provider(s) of commercial services included in this educational activity. The intent of this disclosure is not to prevent a person with a relevant financial or other relationship from participating in the activity, but rather to provide participants with information on which they can base their own judgments. The France Foundation has identified and resolved any and all conflicts of interest prior to the release of this activity.
Faculty DisclosuresCraig Thurm, MD has received research and grant support from Boehringer Ingelheim, Bristol-Myers Squibb, Cubist, and Forest Pharmaceuticals. He has served as a consultant for Meda Pharmaceuticals and Sunovion Pharmaceuticals, and is a shareholder with Teva Pharmaceuticals. He has received honoraria from Boehringer Ingelheim, CSL Behring, Forest Pharmaceuticals, GlaxoSmithKlein, InterMune, Janssen Pharmaceuticals, and Merck.
Activity Staff DisclosuresThe planners, reviewers, editors, staff, or other members at The France Foundation who control content have no relevant financial relationships to disclose.
Educational SupportSupported by educational grants from Boehringer Ingelheim and InterMune.
Accreditation / Designation Statements
The France Foundation is accredited with commendation by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The France Foundation designates this activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
How to Receive CME Credit
• Complete the pretest (page one of your handout) and give this page to the coordinator when you leave
• Keep page two of your handout and follow the instructions to go online to claim CME credit
• Your CME certificate will be available to download
Educational Activity Learning Objective
Upon completion of this course, the participants should be able to:• Explain the considerations associated with clinical evaluation,
imaging, and surgical biopsy in differentially diagnosing IPF• Identify opportunities for interdisciplinary collaboration and
consultation and key aspects of guideline recommendations that can facilitate early and accurate IPF diagnosis
• Summarize the current understanding of the IPF disease process and strategies that can help measure disease progression and treatment response
• Evaluate clinical trial data on available and emerging treatments for IPF
• Identify opportunities for referral as part of multidisciplinary IPF management plan
Outline
• Diagnosis• Pathophysiology model• IPF drug trials
–PANTHER (NAC)–ASCEND (pirfenidone)– INPULSIS (nintedanib)
• Recent drug approvals!• Referral of patients with IPF
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)
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
ATS/ERS Consensus Statement. Am J Respir Crit Care Med. 2002;165:277-304.
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.
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
Idiopathic Pulmonary Fibrosis
Normal Lungs Usual Interstitial Pneumonia
Idiopathic Pulmonary Fibrosis
Normal Lung Usual Interstitial Pneumonia
Idiopathic Pulmonary Fibrosis
Normal Lung Fibroblastic Focus inUsual Interstitial Pneumonia
Clinical-Radiologic-Pathologic Approach to ILD
Specific diagnosis
Clinical picture
Radiologic pattern (HRCT)Pathologic pattern
(lung biopsy)
DrugsInfections-viruses
RadiationOther diseases
Steele MP, Schwartz DA. Annu Rev Med. 2013;64:265-276.
Exogenous and Endogenous stimuli
Microscopic lung injury:Separated spatially and temporally
Lung homeostasis Interstitial lung disease
Dust Fumes
Cigarette smokeAutoimmune conditions
Genetic predisposition
Wound healingIntact Aberrant
ILD Disease Progression
Eras of Care for IPF
ATS Statement2011
Pre-ATS Statement 2011 2011-2013 2014
Trial N Primary Endpoint ResultInterferon-beta (1999) 167 Progression-free survival time Negative
Interferon-gamma (GIPF-001) 330 Progression-free survival Negative
Interferon-gamma (Inspire) 826 Survival time Negative
Pirfenidone (CAPACITY 1) 344 Change in FVC Negative
Pirfenidone (CAPACITY 2) 435 Change in FVC Positive
Pirfenidone (Ogura) 275 Change in FVC Positive
Etanercept 100 Change in DLco, FVC Negative
Imatinib Mesylate 120 Progression-free survival Negative
Bosentan (BUILD 1 and 2) 132 Change in 6MW Negative
Bosentan (BUILD 3) 390 Progression-free survival time Negative
Anticoagulation 56 Survival Positive
N-acetylcysteine (NAC) (IFIGENIA) 184 Change in FVC, DLco Positive
Sildenafil (STEP) 29 Change in 6MWD, Borg dyspnea index Negative
Completed Trials for IPF: Prior to 2011 Consensus Statement
Noth I, et al. Am J Respir Crit Care Med. 2012 Jul 1;186(1):88-95.\
Subsequent trials showed that warfarin and NAC/azathioprine/prednisone
should not be used for IPF
2011 Guidelines on Management of IPFTreatment Strong
ForWeak
ForWeak
AgainstStrong Against
Corticosteroid XColchicine XCyclosporine A XInterferon γ 1b XBosentan XEtanercept XNAC/Azathioprine/Prednisone XNAC XAnticoagulation XPirfenidone XMechanical ventilation XPulmonary rehab XLong-term oxygen XLung transplantation X
Three Recent IPF Clinical Trials American Thoracic Society 2014
• PANTHER N-acetylcysteine (NAC)• ASCEND pirfenidone• INPULSIS nintedanib (BIBF1120)
PANTHERN-acetylcysteine (NAC)
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
Hilberg O, et al. Clin Respir J. 2012;6:131-143.
TNF-αIL-6
Pirfenidone
TGF-βIL-6
MMPsCollagenases
ROIs
Collagen
• Antifibrotic• Molecular target
unclear• Active in several
animal models of fibrosis (lung, liver, kidney)
Noble P, et al. Lancet. 2011;377:1760-1769.
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 X
Overall survival X X
Progression-free survival X
Six-minute walk distance X DLCO X X
Dyspnea X X
Exertional desaturation X X
Noble P, et al. Lancet. 2011;377:1760-1769.
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
Primary ASCEND Endpoint Achieved
King TE, et al. N Engl J Med. 2014;370(22):2083-2092.
Patie
nts
with
≥ 1
0% F
VC
Dec
line
or D
eath
(%)
Week
Primary Endpoint
48% RelativeReduction
Pirfenidone Increased Progression-Free Survival*
King TE, et al. N Engl J Med. 2014;370(22):2083-2092.
*Progression is first occurrence of death, 10% ↓ FVC, or 50 m ↓ 6MWD
Pirfenidone Reduces Loss of FVC
<0.000001King TE, et al. N Engl J Med. 2014;370(22):2083-2092.
235 ml
428 ml
Rank ANCOVA P-value < 0.00001 at each indicated time point
Mea
n Ch
ange
(ml)
Week
More Pirfenidone Patients Maintain Walk Distance or Survive
King TE, et al. N Engl J Med. 2014;370(22):2083-2092.
Prop
ortio
n of
Pati
ents
with
≥5
0 m
Dec
line
or D
eath
(%)
Week
King TE, et al. N Engl J Med. 2014;370(22):2083-2092.
ASCEND Adverse Events Adverse Event Pirfenidone (%)
(N = 278)Placebo (%)
(N = 277)Δ (%)
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
… … … …
Dyspnea 14.7 17.7 -3 Cough 25.2 29.6 -4.4 IPF 9.4 18.1 -8.7
King TE, et al. N Engl J Med. 2014;370(22):2083-2092.
Pirfenidone Associated with Less MortalityASCEND and CAPACITY data
From randomization to 28 days after last doseCox proportional hazard modelLog-rank test
King TE, et al. N Engl J Med. 2014;370(22):2083-2092.
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
37
• 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
38
• 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.
FDA Approval of Pirfenidone (Esbriet)
http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?fuseaction=Search.DrugDetails/. Accessed October 2014.
http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?fuseaction=Search.DrugDetails/. Accessed October 2014.
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.
http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?fuseaction=Search.DrugDetails/. Accessed October 2014.
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
Hilberg F, et al. Cancer Res. 2008;68(12):4774-4782.Tai WT, et al. J Hepatol. 2014;61(1):89-97.
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
Richeldi L, et al. N Engl J Med. 2014;370(22):2071-2082.
Primary INPULSIS Endpoint AchievedAnnual Rate of Change of FVC
INPULSIS-1 INPULSIS-2
45% RelativeReduction
52% RelativeReduction
Nintedanib Placebo
Nintedanib Reduces Loss of FVC
INPULSIS-1
INPULSIS-2
Mea
n O
bser
ved
Chan
ge fr
om B
asel
ine
in F
VC (m
L)
Richeldi L, et al. N Engl J Med. 2014;370(22):2071-2082. Week
Mixed Findings for Time to First Acute Exacerbation
Cum
ulati
ve In
cide
nce
of F
irst A
cute
Exa
cerb
ation
(%)
INPULSIS-1
INPULSIS-2
Richeldi L, et al. N Engl J Med. 2014;370(22):2071-2082. Days
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
Richeldi L, et al. N Engl J Med. 2014;370(22):2071-2082.
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
Richeldi L, et al. N Engl J Med. 2014;370(22):2071-2082.
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
52
• 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)
http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?fuseaction=Search.DrugDetails/. Accessed October 2014.
53
• 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.
54
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
http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?fuseaction=Search.DrugDetails/. Accessed October 2014.
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
EARLY REFERRAL for SPECIALTY CARE
Why refer early to an ILD Center?
• Diagnostic expertise–Standardized assessment–Confirmation of diagnosis
• Management expertise–Choice of an appropriate therapy–Oxygen prescription–Pulmonary rehabilitation–Attention to obesity and sarcopenia/frailty–Potential enrollment in a clinical trial –Transplant evaluation Flaherty et al. Am J Respir Crit Care Med 2004;170:904-10.
Flaherty et al. Am J Respir Crit Care Med 2007;175:1054-60.Lamas et al. Am J Respir Crit Care Med 2011;184:842-7.
ILD Checklist
• Therapeutic options x• Supplemental oxygen• Age-appropriate vaccinations • Risk factor reduction x• Pulmonary rehabilitation x• Clinical trials x• Lung transplant evaluation x• Patient education • Advocacy group involvement
x• Mental health needs x
ReferralOpportunity?
Delayed Care Associated with Higher Mortality
Lamas et al. Am J Respir Crit Care Med. 2011;184:842-847.
P for trend = 0.04
Lung Transplantation is Increasing
http://www.ishlt.org/registries/slides.asp?slides=heartLungRegistry. Accessed August 2014.
19901991
19921993
19941995
19961997
19981999
20002001
20022003
20042005
20062007
20082009
20102011
0
500
1,000
1,500
2,000
2,500
3,000CF IPF COPD Alpha-1 IPAH Re-Tx
Num
ber o
f Tra
nspl
ants
IPF
CF
COPD
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].
Conclusions
• Pirfenidone and nintedanib are FDA approved for treatment of IPF
• Diagnosis of IPF requires a patient history, physical exam, lab tests, HRCT, and sometimes a biopsy
• Patients should be referred early –Pulmonary rehabilitation– ILD center– Lung transplantation evaluation
To Receive Credit for this Activity:Please Complete the Evaluation and Posttest
at www.pilotforipf.org/credit/##
Supplemental Slides
Possible NAC Mechanisms of Action
• Increase glutathione antioxidation • Downregulate lysyl oxidase (LOX) activity,
(essential for collagen deposition)
Li S, et al. Respiration. 2012;84(6):509-517.Rushworth GF, et al. Pharmacol Ther. 2014;141(2):150-159.
Demedts M, et al. New Engl J Med. 2005;353:2229-2242.
+ azathioprine + steroids
+ azathioprine + steroids
Early Evidence for a NAC Cocktail
Acetylcysteine + azathioprine + steroids
Placebo + azathioprine + steroids
ATS 2011
2011-2013 2014Pre-2011
PANTHER 2012
Raghu G, et al. N Engl J Med. 2012;366:1968-1977.
ATS 2011
2011-2013 2014Pre-2011
PANTHER 2012 Interim Results
• Triple therapy has no benefit for FVC
• Increased risk of death
Primary Triple Therapy Placebo P-value
FVC (liters) -0.24 -0.23 0.85
Raghu G, et al. N Engl J Med. 2012;366:1968-1977.
Prob
abili
ty
Time to DeathKaplan–Meier Analysis
Weeks Since Randomization
HR 9.26 (95% CI 1.16-74.1)
P = 0.01
ATS 2011
2011-2013 2014Pre-2011
PANTHER 2012 Adverse Events
Death
Respira
tory Dea
th
Hospita
lization
Acute
Exac
erbati
on
Serio
us Adve
rse Ev
ent
05
101520253035
Placebo Pred/Aza/NAC
• 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 2012 Conclusions
• Compelling evidence against the use of the triple combination for patients with mild-to-moderate IPF
• Next steps–Combination arm terminated–Two arms of study continued (NAC vs placebo)
Raghu G, et al. N Engl J Med. 2012;366:1968-1977.
Martinez FJ, et al. N Engl J Med. 2014;370(22):2093-2101.
PANTHER 2014ATS
20112011-2013Pre-2011 2014
• Subjects: 264 patients with IPF (2 arm continuation of PANTHER-IPF)
• Treatment: acetylcysteine (600 mg) or placebo 3 times daily
• Duration: 60 weeks• Primary end point: change in FVC • Secondary end points
– Time to the first acute exacerbation – Change from baseline in the total score on the St.
George’s Respiratory Questionnaire
PANTHER Study Design
Martinez FJ, et al. N Engl J Med. 2014;370(22):2093-2101.
To Receive Credit for this Activity, Please Complete the Evaluation and Posttest:
PILOTforIPF.org/credit/13