Recent 2015 IPF Guidelines Update Adds New Agents.

By Dr Deepu

I have written this post giving an overview of  the latest IPF guidlines.The update to the 2011 guidelines appeared in the July 15 issue of the American Journal of Respiratory and Critical Care Medicine. At the end I have provided download links for the article and supplements.

  Pirfenidone  and Nintedanib were recommended for use in idiopathic pulmonary fibrosis (IPF) with a moderate level of confidence, in a guideline update from ATS/ERS/JRS/ALAT
      It also mentions that the methods used by guideline panels to appraise the evidence are different than those used by regulatory agencies like FDA when they review applications seeking market approval for the use of pharmacologic agents for treatment of IPF.

Image Shows Comparison of 2015 and 2011 guidelines. Image published in AJRCCM

 
  The guidline doesnot provide recommendations for one treatment regimen over another.  The guideline does not provide suggestions for or against combination regimens or sequential therapies.
     
The updated guidline has given strong recommendation against using prednisone with azathioprine and N-acetylcysteine,The update also included strong recommendations against use of warfarin or other anticoagulants due to signals for harm in randomized trials in both cases. Both previously had been suggested as not appropriate for most patients but perhaps reasonable for some.
   
 Imatinib and ambrisentan, not previously addressed in the guidelines, got strong recommendations against use in IPF patients. Sildenafil is included in the guidelines, and got a conditional recommendation against use.

     The guidelines also updates on the dual endothelin receptor antagonists macitentan and bosentan , it has changed from a strong to a conditional recommendation against use.

   The Lung transplantation which was not addressed in 2011 was also included but formulation of recommendation for single vs bilateral lung transplantation was deffered.

   There is no change in the recommendation for anatacid therapy and N acetyl cysteine monotherapy which remains as conditional recommendation for use and conditional recommendation against use respectively.

     Adverse effects were common with nintedanib therapy, particularly diarrhea, although serious adverse events were not increased and relatively few patients discontinued the drug due to adverse effects. 
      Pooled results from the pirfenidone trials showed more risk of photosensitivity, fatigue, stomach discomfort, and anorexia with the drug.
 I have Provide the links to Download article from ATS.. Happy reading :)

1.http://www.atsjournals.org/doi/suppl/10.1164/rccm.201506-1063ST/suppl_file/executive_summary.pdf
2.http://www.atsjournals.org/doi/suppl/10.1164/rccm.201506-1063ST/suppl_file/raghu_data_supplement.pdf
3.http://www.atsjournals.org/doi/suppl/10.1164/rccm.201506-1063ST/suppl_file/raghu_data_supplement+2.pdf

Two Medications May Be Effective Against XDR-TB, New Research Reveals

By Dr Deepu

MedPage Today (7/16, Smith) reports that researchers found that “a drug being studied as a treatment for extensively drug-resistant tuberculosis (XDR-TB) had durable efficacy in a small trial.” One “year after the end of treatment with linezolid (Zyvox), combined with a background regimen, 27 of 38 patients had negative results on sputum culture, according to Clifton Barry III, PhD, of the National Institute of Allergy and Infectious Disease in Bethesda, Md., and colleagues.” Meanwhile, “in another brief report, investigators said post-hoc analysis of three trials of the investigational drug delamanid – a mycobacterial cell wall synthesis inhibitor – suggests it, too, is effective against XDR-TB.” The findings were published in the New England Journal of Medicine.

Here are the link to the published article.

1.http://www.nejm.org/doi/full/10.1056/NEJMc1415332

2.http://www.nejm.org/doi/full/10.1056/NEJMc1500286

MELTING ICE(CUBE) SIGN

By Dr Deepu

 The melting ice(cube) sign describes the resolution of. pulmonary haemorrhage following pulmonary embolism. 
When there is pulmonary haemorrhage without infarction following PE, the typical wedge-shaped, pleural-based opacification (Hamptons Hump) resolves within a week while preserving its typical shape. It is named due to its resemblance with a melting ice cube.

1. Webb WR, Higgins CB. Thoracic Imaging: Pulmonary and Cardiovascular Radiology, North American Edition. Lippincott Williams & Wilkins. (2010) ISBN:1605479764. 


Suggested Reading
1. Chest X Ray Part 1- Normal Anatomy And ItsVariants

2. BASICS OF CHEST X RAY- PART 2 , EASY WAY TO INTERPRET CXR.

3.Basics of Chest X Ray Part 3- systematic approach, silhouette sign and Hidden areas in chest Xray

4. BASICS OF CHEST X RAY-PART 4, THE HEART AND PERICARDIUM
5.  BASICS OF CHEST X RAY-PART 5, THE HILUM AND MEDIASTINUM

FDA Issues New Warning About Risk Of Heart Attack, Stroke With NSAID Use

By Dr Deepu

The CBS Evening News (7/10, story 6, 1:35, Pelley) reported in continuing coverage on the FDA’s new “warning about common pain relievers.” According to the broadcast, “the FDA says everyone may be at risk, but the biggest concerns are for people with an underlying heart condition.”

        The Washington Post (7/11, Cha) reported that the warning updates will apply to “nonsteroidal anti-inflammatory drugs (NSAIDs), a group of medications used for temporary relief of pain and inflammation,” and that include ibuprofen and naproxen. The article added that “consumers should be careful not to take more than one product that contains an NSAID at a time” and to watch for symptoms such as “chest pain, breathing trouble, sudden weakness in one part or side of the body or slurred speech.”

        HealthDay (7/10, Thompson)and The Hill(7/10, Wheeler) also covered the story.

FDA approves new drug STIOLTO for airway diseases.

By Dr Deepu

Patients with COPD and asthma have yet another medicinal option as Stiolto was approved in May  2015 by the U.S. Food and Drug Administration (US FDA). The medicine should now be available in pharmacies around the U.S. and few other countries.

The medicine is in the list of ever growing combination medicines approved for asthma and COPD. 

Stiolto contains:

• Tiotropium bromide (Spiriva), a long acting anticholinergic (LAAC)
• Olodaterol (Striverdi), a long acting beta adrenergic (LABA)

Studies showed Spiriva by itself improved lung function. another study has showed that Spiriva used in combination with Symbicort, a medicine that contains both a LABA and an inhaled corticosteroid, improves lung function by as much as 62 percent.

Before concluding I want to emphasise the fact that, approved medicine might benefit in people who are not relieved with other medicines. They are class of ultra long acting drugs so the dosage frequency is decreased which on a long run may decrease the treatment cost and also need for rescue medicines.

Time has to tell whether this medicine combination with satisfy the end user I.e the patient himself has to decide whether it works or not.

Further reading:

1. www.stiolto.com
2. RT Magazine: COPD Treatment Stiolto Respimat Available in U.S
3. Study: Spiriva improves lung function