Should All Patients with IPF Be Treated with Antiacid Medications?

Background

In 2011, the American Thoracic Society, the European Respiratory Society, the Japanese Respiratory Society, and the Latin American Thoracic Association published evidence-based clinical practice guidelines for the diagnosis and treatment of IPF.1 Recently, these guidelines were updated based on new evidence reported since publication of the prior guidelines, and treatment recommendations were updated accordingly.2 Addressed specifically was the question, "Should patients with IPF be treated with antiacid medications?"

Gastroesophageal reflux (GER) is very common among patients with IPF, occurring in over 90% of patients, even in the absence of classical reflux symptoms.3 GER is a risk factor for aspiration and microaspiration, which could lead to pneumonitis.2 It is postulated that this could cause or worsen IPF. Accordingly, the risk for microaspiration-associated lung injury or damage may be decreased with the use of antiacid treatments, such as proton pump inhibitors (PPIs) or histamine-2 blocker receptor antagonists (H2RAs).

What They Did

Pertinent literature was obtained through a search strategy using medical subject heading keywords and text words.2 The Ovid platform was used to search MEDLINE, EMBASE, Cochrane Registry of Controlled Trials, Health Technology Assessment, and the Database of Abstracts of Reviews of Affects for May 2010 through May 2014. Two reviewers screened titles and abstracts to identify articles for full review and evaluated the full text of articles deemed potentially relevant by either reviewer. Results from identified studies with the same treatment agent were pooled, and meta-analyses were reviewed.

What They Found

A survival benefit for patients receiving antiacid medication (hazard ratio [HR], 0.47; 95% CI, 0.24-0.93; adjusted analysis) was suggested by 1 retrospective analysis of longitudinal cohorts.4 A separate aggregate analysis of 3 randomized, controlled trials of different pharmacologic therapies in patients with IPF examined all the patients who were randomized to the placebo groups. Researchers compared 124 patients receiving a PPI or H2RA at baseline (91% PPI, 9% H2RA) to 118 patients not receiving antiacid treatment and not receiving other study medications. For those receiving antiacid treatment at baseline, a significantly smaller decrease in forced vital capacity during the study period was found (mean difference, 0.07 L; 95% CI, 0-0.14; P=.05).5 Of note, in patients who received antiacid treatment, there were no episodes of adjudicated acute exacerbations compared with placebo. However, there were no differences in all-cause mortality or all-cause hospitalization.

What It Means

Based on these data, the guidelines suggest that "clinicians use regular antiacid treatment for patients with IPF (conditional recommendation, very low confidence in estimates of effect)."2 In making this recommendation, the guidelines committee placed a higher value on possible improved lung function and survival and the low cost of therapy, and a lower value on the potential increased risk for pneumonia with antiacid therapy.

Link to abstract: http://www.ncbi.nlm.nih.gov/pubmed/26177183



References

  1. Raghu G, Collard HR, Egan JJ, et al. An official ATS/ERS/JRS/ALAT statement: idiopathic pulmonary fibrosis: evidence-based guidelines for diagnosis and management. Am J Respir Crit Care Med. 2011;183:788-824.
  2. Raghu G, Rochwerg B, Zhang Y, et al. An Official ATS/ERS/JRS/ALAT clinical practice guideline: treatment of idiopathic pulmonary fibrosis. An update of the 2011 clinical practice guideline. Am J Respir Crit Care Med. 2015;192:e3-e19.
  3. Tobin RW, Pope CE, Pellegrini CA, et al. Increased prevalence of gastroesophageal reflux in patients with idiopathic pulmonary fibrosis. Am J Respir Crit Care Med. 1998;158:1804-1808.
  4. Lee JS, Ryu JH, Elicker BM, et al. Gastroesophageal reflux therapy is associated with longer survival in patients with idiopathic pulmonary fibrosis. Am J Respir Crit Care Med. 2011;184:1390-1394.
  5. Lee JS, Collard HR, Anstrom KJ, et al. Anti-acid treatment and disease progression in idiopathic pulmonary fibrosis: an analysis of data from three randomised controlled trials. Lancet Respir Med. 2013;1:369-376.