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Comorbidity management

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Managing patients with IPF: Comorbidity management

Patients with IPF often have 1 or more comorbidities

  • Pulmonary hypertension
  • Emphysema
  • Lung cancer
  • GERD
  • CAD
  • Sleep apnea
CAD, coronary artery disease; GERD, gastroesophageal reflux disease.

1. Collard HR et al. J Med Econ. 2012;15(5);829-835.
2. Le Jeune I et al. Respir Med. 2007;101(12):2534-2540.

Pulmonary hypertension

1. Collard HR et al. J Med Econ. 2012;15(5);829-835.
2. Le Jeune I et al. Respir Med. 2007;101(12):2534-2540.

Patients with IPF have a significantly increased risk for pulmonary hypertension

Patients with IPF and PH have an increased risk of death3

HR = 1.96 (P=0.002)
 
Patients with IPF and PH have an increased 1-year mortality rate compared with patients without PH4

IPF+PH: 29%, IPF only: 6% (P=0.002)

aCompared to age- and gender-matched controls
PH, pulmonary hypertension.

1. Collard HR et al. J Med Econ. 2012;15(5);829-835.
3. King TE Jr et al. Am J Respir Crit Care Med2001; 164(7):1171-1181.
4. Lettieri CJ et al. Chest. 2006;129(3):746-752.

Pulmonary hypertension reduces health status for patients with IPF

Combined IPF and PH is associated with3,4:
  • Low DLCO
  • Shorter walk distances
  • Desaturation during exercise
  • An increased risk of death
Symptoms of PH in patients with IPF may be nonspecific5

DLCO, diffusing capacity for carbon monoxide.

3. King TE Jr et al. Am J Respir Crit Care Med2001; 164(7):1171-1181.
4. Lettieri CJ et al. Chest. 2006;129(3):746-752.
5. Patel NM et al. Chest. 2007;132(3):998-1006.

Presence and severity of PH affects survival time of patients with IPF

Adapted from Nadrous HF et al. Chest. 2005;128(4):2393-2399.

6. Nadrous HF et al. Chest. 2005;128(4):2393-2399.

Treating comorbidities in IPF may or may not influence clinical outcomes

There is no recommendation for or against treating PH in patients with IPF at this time7
 
7. Raghu G et al. Am J Respir Crit Care Med. 2015;192(2):e3-e19.

Emphysema

1. Collard HR et al. J Med Econ. 2012;15(5);829-835.
2. Le Jeune I et al. Respir Med. 2007;101(12):2534-2540.

Patients with IPF have a significant risk of having concomitant emphysema

Patients with CPFE have more severe outcomes than patients with IPF alone8,9
 
Risk factors include male gender and smoking8

In small studies, the reported prevalence of CPFE is ~28%-43%8,9

CPFE, combined IPF and emphysema.

8. Mejía M et al. Chest. 2009;136(1):10-15.
9. Sugino K et al. Respirology. 2014;19(2):239-245.

Patients with CPFE have more severe outcomes than patients with IPF alone

A single-institution cohort of patients with IPF diagnosed between 1996 and 2006 found that emphysema produced an HR of 1.99 (P=0.02) for mortality8

Reproduced with permission from the American College of Chest Physicians. Mejía M et al. Chest. 2009;136(1):10-15.

HR, hazard ratio.

8. Mejía M et al. Chest. 2009;136(1):10-15.
 

The presence of PH corresponds with higher mortality in patients with CPFE

Severe PH associated with emphysema may contribute to the higher mortality rate in patients with CPFE in this subgroup of patients9

Reproduced from Sugino K et al. Respirology. 2014;19(2):239-245. 
aNo PH; mean pulmonary artery pressure <25 mm Hg.
bPH; mean pulmonary artery pressure ≥25 mm Hg

9. Sugino K et al. Respirology. 2014;19(2):239-245.

CPFE: Example

Conserved spirometry and lung volumes with diminished diffusing capacity may suggest the presence of CPFE10-12
 
PFT, pulmonary function test.

10. Jankowich MD et al. Chest. 2012;141(1):222-231.
11. Wiggins J et al. Respir Med. 1990;84(5):365-369.
12. Doherty MJ et al. Thorax. 1997;52( 11 ):998-1002.

CPFE has a different PFT profile than IPF alone

10. Jankowich MD et al. Chest. 2012;141(1):222-231.

Treating CPFE

There are currently no evidence-based recommendations for treating emphysema in patients with IPF13
 
13. Raghu G et al. Am J Respir Crit Care Med. 2011; 183(6):788-824.

Lung cancer

Relative risk (RR) of having various comorbidities in patients with IPF1,2

1. Collard HR et al. J Med Econ. 2012;15(5);829-835.
2. Le Jeune I et al. Respir Med. 2007;101(12):2534-2540.

Lung cancer is found at higher rates in patients with IPF than in controls

  • Several studies have shown a higher incidence of lung cancer in patients with IPF1,2,14,15
  • Incidence of lung cancer is even higher in patients with CPFE than those with IPF alone16

1. Collard HR et al. J Med Econ. 2012;15(5):829-835.
2. Le Jeune I et al. Respir Med. 2007;101(12):2534-2540.
14. Ozawa Y et al. Respirology. 2009;14(5):723-728.
15. HubbardR et al. Am J Respir Crit Care Med. 2000;161(1):5-8.
16. Tomassetti S et al. Chest. 2015;147(1):157-164.

The cumulative incidence of lung cancer in patients with IPF increases over time

Out of 103 patients with IPF at a single center, 15% developed lung cancer by 5 years postdiagnosis14
 
14. Ozawa Y et al. Respirology. 2009;14(5):723-728.

Patients with IPF and lung cancer have lower survival rates than those with only IPF

 LC, lung cancer.
 
16. Tomassetti S et al. Chest. 2015;147(1):157-164.

Treating lung cancer

The USPSTF recommends annual lung cancer screening for people ages 55-80 with a 30-pack-year history and currently smoke or have quit in the past 15 years17

There is no recommendation for routine lung cancer screening specifically for patients with IPF13

USPTF, US Preventative Services Task Force.

13. Raghu G et al. Am J Respir Crit Care Med. 2011;183(6):788-824.
17. USPSTF. Ann Intern Med 2014; 160(5):330-338.

Gastroesophageal reflux disease

Relative risk (RR) of having various comorbidities in patients with IPF1,2

1. Collard HR et al. J Med Econ. 2012;15(5);829-835.
2. Le Jeune I et al. Respir Med. 2007;101(12):2534-2540.

GERD is a common comorbidity in patients with IPF

GERD is considered a risk factor for IPF13, although the role of chronic microaspiration in IPF pathogenesis or disease progression is poorly understood19,20

As many as 94% of patients with IPF may have GERD18,21
 
13. Raghu G et al. Am J Respir Crit Care Med. 2011;183(6):788-824.
18. Raghu G et al. Eur Respir J 2015;46(4):1113-1130.
19. Raghu G et al. Eur Respir J. 2006;27(1):136-142.
20. Lee JS et al. Am J Respir Crit Care Med. 2011;184(12):1390-1394.
21. Tobin RW et al. Am J Respir Crit Care Med. 1998;158:1804-1808.

Several studies have shown an increased prevalence of GERD in patients with IPF

Approximately 50% of all cases of GERD in IPF are asymptomatic, making it difficult to diagnose GERD by symptoms alone19, 21, 22

Esophageal monitoring may offer a more accurate diagnosis of GERD23,24
 
18. Raghu G et al. Am J Respir Crit Care Med. 2011;183(6):788-824.
19. Raghu G et al. Eur Respir J 2015;46(4):1113-1130.
21. Tobin RW et al. Am J Respir Crit Care Med. 1998;158:1804-1808.
22. Sweet MP et al. J Thorac Cardiovasc Surg. 2007;133:1078-1084.
23. Lee JS et al. Am J Med 2010;123(4):304-311.
24. Emerenziani S, Sifrim D. Curr Opin Gastroenterol. 2005;21:450-453.

Treating GERD

The ATS/ERS/JRS/ALAT guidelines provide a conditional recommendation for the use of anti-acids for treating GERD7

The need for GERD treatment should be evaluated on a case-by-case basis

7. Raghu G et al. Am J Respir Crit Care Med. 2015; 192(2):e3-e19.
20. Lee JS et al. Am J Respir Crit Care Med. 2011;184(12):1390-1394.

Coronary artery disease

1. Collard HR et al. J Med Econ. 2012;15(5);829-835.
2. Le Jeune I et al. Respir Med. 2007;101(12):2534-2540.

Up to 25% of patients with IPF may have underlying coronary artery disease

In a study of 18,572 patients with IPF and their age- and gender-matched controls, CAD was significantly more common in patients with IPF1
 
1. Collard HR et al. J Med Econ. 2012;15(5):829-835.

HRCT can be used to screen for CAD in patients with IPF

A single-institution study found that HRCT could predict underlying moderate to severe CAD in 57 patients with IPF who received LHC during evaluation for lung transplant25

LHC, left heart catheterization.

25. Nathan SD et al. Respirology. 2011;16(3):481-486.

Presence of significant CAD reduces overall survival in patients with IPF

In a single-institution study, significant CAD was correlated with mortality (HR=4.5) in a group of patients with IPF (n=73) or COPD (n=56)26

26. Nathan SD et al. Respir Med. 2010;104(7):1035-1041.

Obstructive sleep apnea

1. Collard HR et al. J Med Econ. 2012;15(5);829-835.
2. Le Jeune I et al. Respir Med. 2007;101(12):2534-2540.

IPF often disrupts patients’ sleep

  • Sleep disturbance may result from coughing and nocturnal hypoxia27
  • Sleep disturbance from coughing contributes to increased daytime sleepiness in patients with IPF27
OSA, obstructive sleep apnea.

27. Rasche K et al. J Physiol Pharmacol. 2009;60(Suppl 5):13-14.

Obstructive sleep apnea is common in patients with chronic lung diseases

In a single-center study, 50 patients with IPF underwent NPSG to evaluate the prevalence of OSA in IPF28

No OSA (AHI 0-5 events/h).
Mild OSA (5.1-15 events/h).
Moderate-to-severe OSA (AHI >15 events/h).
Adapted from Lancaster LH et al. Chest. 2009;136(3):772-778.
AHI, apnea-hypopnea index; NPSG, nocturnal polysomnography; OSA, obstructive sleep apnea.

13. Raghu G et al. Am J Respir Crit Care Med. 2011;183(6):788-824.
28. Lancaster LH et al. Chest. 2009;136(3):772-778.

Treating OSA

There are currently no evidence-based recommendations for treatment of sleep-related breathing disorders in patients with IPF13
 
13. Raghu G et al. Am J Respir Crit Care Med. 2011;183(6):788-824.

Summary

  • Patients with IPF often have one or more comorbidities1
  • Common comorbidities in patients with IPF include pulmonary hypertension, emphysema, and lung cancer1
  • It is not clear whether treating comorbidities influences outcomes for patients with IPF13
  • However, many health care providers may manage these comorbidities in addition to treating IPF and its symptoms29
1. Collard HR et al. J Med Econ. 2012;15(5);829-835.
13. Raghu G et al. Am J Respir Crit Care Med. 2011;183(6):788-824.
29. Lee JS et al. Curr Opin Pulm Med2011;17(5):348-354.

References

  1. Collard HR et al. J Med Econ. 2012;15(5);829-835.
  2. Le Jeune I et al. Respir Med. 2007;101(12):2534-2540.
  3. King TE Jr et al. Am J Respir Crit Care Med2001; 164(7):1171-1181.
  4. Lettieri CJ et al. Chest. 2006;129(3):746-752.
  5. Patel NM et al. Chest. 2007;132(3):998-1006.
  6. Nadrous HF et al. Chest. 2005;128(4):2393-2399.
  7. Raghu G et al. Am J Respir Crit Care Med2015;192(2):e3-e19.
  8. Mejía M et al. Chest. 2009;136(1):10-15.
  9. Sugino K et al. Respirology. 2014;19(2):239-245.
  10. Jankowich MD et al. Chest. 2012;141(1):222-231.
  11. Wiggins J et al. Respir Med. 1990;84(5):365-369.
  12. Doherty MJ et al. Thorax. 1997;52( 11 ):998-1002.
  13. Raghu G et al. Am J Respir Crit Care Med. 2011;183(6):788-824.
  14. Ozawa Y et al. Respirology. 2009;14(5):723-728.
  15. HubbardR et al. Am J Respir Crit Care Med. 2000;161(1):5-8.
  16. Tomassetti S et al. Chest. 2015;147(1):157-164.
  17. USPSTF. Ann Intern Med 2014; 160(5):330-338.
  18. Raghu G et al. Eur Respir J 2015;46(4):1113-1130.
  19. Raghu G et al. Eur Respir J. 2006;27(1):136-142.
  20. Lee JS et al. Am J Respir Crit Care Med. 2011;184(12):1390-1394.
  21. Tobin RW et al. Am J Respir Crit Care Med. 1998;158:1804-1808.
  22. Sweet MP et al. J Thorac Cardiovasc Surg. 2007;133:1078-1084.
  23. Lee JS et al. Am J Med 2010;123(4):304-311.
  24. Emerenziani S, Sifrim D. Curr Opin Gastroenterol. 2005;21:450-453.
  25. Nathan SD et al. Respirology. 2011;16(3):481-486.
  26. Nathan SD et al. Respir Med. 2010;104(7):1035-1041.
  27. Rasche K et al. J Physiol Pharmacol. 2009;60(Suppl 5):13-14.
  28. Lancaster LH et al. Chest. 2009;136(3):772-778.
  29. Lee JS et al. Curr Opin Pulm Med2011;17(5):348-354.