Editorials: Point and Counterpoint |

Rebuttal From Drs King and Nathan FREE TO VIEW

Christopher S. King, MD, FCCP; Steven D. Nathan, MD, FCCP
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following: S. D. N. is on speaker’s bureaus and advisory boards and has received financial support for research from Roche and Boerhinger Ingelheim. None declared (C. S. K.).

Advanced Lung Disease and Transplant Clinic, Inova Fairfax Hospital, Falls Church, VA

CORRESPONDENCE TO: Christopher S. King, MD, FCCP, Inova Fairfax Hospital, Advanced Lung Disease and Transplantation Clinic, 3300 Gallows Rd, Falls Church, VA 22042

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(2):278. doi:10.1016/j.chest.2016.04.035
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We agree with Dr Brown’s philosophical approach, exemplified by his concluding comment that there should be “thoughtful and reasoned discussion between a patient and the physician about hopes and expectations for the future, the goals of treatment, and the risks and benefits of any chosen course.” However, the devil lies in the details of this discussion and how the choice is portrayed to the patient, since the consulting physician’s bias will inevitably influence the patient’s decision. As an example, on one end of the spectrum, the patient can be guided to a “no treatment” choice by the following “we have two new medications; both appear to slow the disease progression in some patients. However, it is uncertain how this might translate to other more meaningful benefits. Both drugs have significant side effects and are very expensive. You would not have been eligible for any of the trials that demonstrated that these drugs worked, so I cannot be sure that either will help you. Do you want to give either of these a try?” Any reasoned patient would likely respond, “heck no” to this preamble. A more favorably predisposed clinician might have a slightly different conversation with the same patient, “You have a disease with an average survival of only 2½ to 4 years. Unfortunately, we are unable to predict the course in individual patients, and even those with well-maintained lung function may have unpredictable precipitous declines. We have two drugs that slow the rate of loss of lung function. We know that patients who lose lung function over time have worse outcomes. Both drugs have some side effects, but not everyone experiences them and they are usually quite manageable. Although your profile does not fit exactly with those patients enrolled in the clinical trials, it is not unreasonable to assume that if they work in selected patients with idiopathic pulmonary fibrosis (IPF), they are likely to work in others as well. Do you want to try one of these?” A possible response to this might be “seems like a no-brainer.”

Dr Brown highlights that the criteria for enrollment in the Assessment of Pirfenidone to Confirm Efficacy and Safety in IPF (ASCEND) trial were modified from those of the Clinical Studies Assessing Pirfenidone in IPF: Research of Efficacy and Safety Outcomes (CAPACITY) study. Changes were enacted to enrich the patient population for those whose condition was more likely to decline over the course of the 52-week study. There is nothing wrong with that, just smart planning. Dumb luck would be to enroll patients who were predestined to be stable over the course of the study, since even if the experimental agent halted IPF in its tracks, the study would fail to show a difference.

It is interesting that in the midst of this political season, folks will conjure up ways to disagree even when there is much common ground between them. Dr Brown’s “con” argument is not too far from our “pro” argument. We agree that the option of therapy is a discussion to be brought to the table with all patients who have IPF. However, as with a fine gourmet meal, it is all in the presentation.


Brown K.K. . Counterpoint: Should all patients with idiopathic pulmonary fibrosis, even those with more than moderate impairment, be treated with nintedanib or pirfenidone? No. Chest. 2016;150:276-278 [PubMed]journal




Brown K.K. . Counterpoint: Should all patients with idiopathic pulmonary fibrosis, even those with more than moderate impairment, be treated with nintedanib or pirfenidone? No. Chest. 2016;150:276-278 [PubMed]journal
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