Exploring Prescribing Patterns of Antifibrotic Agents for Idiopathic Pulmonary Fibrosis

^{By Yvette Terrie, RPh}

Idiopathic pulmonary fibrosis (IPF) is a progressive disease characterized by scarring of the lungs. Unfortunately, IPF is often associated with a poor long-term prognosis and has a negative effect on patient quality of life and productivity.¹ Research indicates that the pathogenesis of IPF is thought to be exposure to an inciting agent (e.g., smoke, environmental pollutants, environmental dust, viral infections, gastroesophageal reflux disease and chronic aspiration) in a susceptible host which may lead to the initial alveolar epithelial damage.² Genetics also play a role in its pathogenesis.² Approximately 50,000 new cases of IPF are diagnosed each year.³ Most IPF patients first start noticing symptoms between the ages of 50 and 70 years.  It is more common in men, but the number of cases of IPF in women is esclating.³  In October 2014, the FDA approved Esbriet (pirfenidone) and  Ofev (nintedanib) as the first FDA approved disease specific therapies for IPF in the US.⁴ Clinical studies have demonstrated that the usage of these agents slow the progression of IPF and may diminish the risk of acute respiratory depression.⁵ 

Recently, a group of researchers examined the use of these antifibrotics since there is little information about the prescribing patterns for these agents in a real-world United States setting.⁵ A team led by researchers at the University of Michigan and Genentech conducted a detailed analysis of how the two FDA treatments are prescribed. They collected records from 1,999 cases registered in the Pulmonary Fibrosis Foundation Patient Registry. A total of 1,218 cases of individuals diagnosed with IPF for whom prescription information was available were included in the analysis.⁵  Key findings from the study included the following:^5,6

• In the study, 740 patients (60.7%) were taking at least one anti-fibrotic medication, and that only 37 individuals used both medications in the prior year.
• A large number of patients — 703 of the total, or 57.7% — were taking a single anti-fibrotic medication at the time of the study.
• Among these, 312 (44.4%) were taking Ofev, while 391 (55.6%) were on Esbriet.
• Rates of discontinuation were modest and nearly identical for the two medications with ADRs being the most common reason given for discontinuation.^5,6 

In spite of the availability of these novel therapies, the study revealed that an estimated 40% of patients with IPF are not prescribed either antifibrotic agents.^5,6  Researchers noted that, “It is possible that provider unfamiliarity with these newer medications, concerns about side effects, or concerns about financial cost may be reasons for deferral of medication initiation.” ⁵ The authors concluded that more research is warranted to gain a better understanding of the variations in medical decision-making for use and selection of anti-fibrotic medication. 

As experts in pharmacotherapy, pharmacists can provide pertinent clinical information to other health care professionals and patients suffering with IPF about the most recent clinical data regarding the safety and efficacy of approved and emerging agents. Specifically, pharmacists may contribute to the care of patients with IPF via:

• assisting to ensure the safe and efficacious use of medicines,
• counseling patients about treatment expectations,
• offering pertinent drug information to patients and other health care professionals,
• encouraging medication adherence,
• emphasizing the need for routine patient care.

Prior to initiating treatment with agents such as pirfenidone and nintedanib, an in-depth conversation with the patient and family members should take place to ensure that patients understand the proper administration of the selected agent.⁶ Patients should also be counseled on the benefits, risks, and limitations of therapy.⁶ It is vital that pharmacists counsel patients on the dosing, administration and review the most common and serious adverse drug reactions. Research demonstrates that early identification of IPF and encouraging patients to participate in educational programs can help to augment patient knowledge of IPF which in turn enables patients and family members to have a better comprehension of the consequences of this persistently progressive and often fatal disease.7 This knowledge also allows patients and their family members to make informed choices about their health and the management options. A collaborative effort between pharmacists, pulmonary professionals and patients/caregivers, coupled with patient education and emphasizing the critical nature of patient adherence is fundamental for efficaciously managing IPF and possibly delaying the progression of this detrimental and often fatal pulmonary disease.

Yvette C. Terrie, RPh, Consultant Pharmacist and Medical Writer in Northern Virginia and creator of A Pharmacist’s Perspective (https://apharmacistsperspective.blogspot.com/  )