Antifibrotic choice in idiopathic pulmonary fibrosis

Introduction: Pirfenidone and nintedanib are therapeutic options in IPF. Treatment choice is based on physician-patient discussion regarding suitability and side effect profile. Aims: To establish the proportion of patients in whom antifibrotic choice is physician or patient-led and reasons for choice. Methods: Patients with an MDT diagnosis of IPF initiated on antifibrotic therapy between Oct 17-Jan 18 were included. Demographic data, treatment choice and reason for choice was collected. Results: 51 patients (mean age 72, 80.4% male) started on antifibrotic therapy; 27 (52.9%) nintedanib and 24 (47.1%) pirfenidone. In 22 (43.1%) patients the choice of antifibrotic was physician-led; pirfenidone in 13 (59.1%) and nintedanib in 9 (40.9%). Reasons for physician choice of pirfenidone included concomitant anticoagulation (69.2%), active angina (7.7%), liver cirrhosis (7.7%) and physician preference (15.4%). Reasons for physician choice of nintedanib included history of skin cancer (44.5%), concomitant UV light treatment (11.1%), CKD (11.1%), weight loss (22.2%) and constipation (11.1%). In 29 (56.9%) cases the choice was patient-led. Patients chose nintedanib in 18 (62.1%) cases and pirfenidone in 11 (37.9%). Patients choosing pirfenidone over nintedanib wanted to avoid the side effect of diarrhoea. Reasons for choosing nintedanib included reluctance to apply sunscreen (44.5%), pill burden (27.8%), constipation (16.7%), photosensitivity (5.5%), and indigestion (5.5%). Conclusions: In over half of cases, antifibrotic choice was patient-led. Avoiding the need to wear sunscreen (nintedanib) and diarrhoea (pirfenidone) were the common reasons stated for choice. Physician-led choice was predominantly due to relative contraindications.