Key Clinical Summary: Integrating Emerging Evidence intro Practice

This is a micro-learning module summary of Prof. Corey Kershaw’s session which you can find here. Before participating, please read our CME and disclosure information which can be found here.

Acknowledgment: This activity is supported by an educational grant from This program is supported by an independent educational grant from Bristol Myers Squibb (BMS). This online education program has been designed solely for healthcare professionals in the USA. The content is not available for healthcare professionals in any other country.

Introduction

Integrating antifibrotic therapy into practice starts with preparing patients for the realities of treatment. Antifibrotics slow lung-function decline, but they do not reliably improve symptoms, and each medication carries its own tolerability challenges. Meaningful care depends on clear expectation-setting, proactive management of adverse events, and attention to comorbidities that often drive cough, fatigue, and dyspnoea more than the fibrosis itself. By addressing these factors openly and consistently, clinicians can support persistence, improve quality of life, and help patients navigate the day-to-day realities of living with pulmonary fibrosis.

Brief Patient Recap

After receiving a diagnosis of idiopathic pulmonary fibrosis (IPF) and learning about approved antifibrotic treatments, Mr. Rice feels encouraged, but also hopeful that therapy will improve his symptoms. His central question captures a common patient expectation: “These medications are going to make me feel better, right?” Addressing this expectation is essential to delivering honest, effective, patient-centred care.

Understanding What Antifibrotic Therapy Can and Cannot Do

A critical part of counselling patients with IPF is clarifying that antifibrotic therapies slow disease progression, they do not reliably improve symptoms such as cough or dyspnoea. While these medications preserve lung function over time, most clinical trials show minimal change in patient-reported symptoms.

Honest expectation setting is therefore central to therapy success and long-term persistence.

Managing Side Effects of FDA-Approved Antifibrotics

Pirfenidone: Key Considerations

Common adverse effects include:

• Nausea
• Dyspepsia and acid reflux
• Sun-sensitive rash: The photosensitivity risk requires proactive counselling. Patients should cover all of their skin before going outside including using sunscreen, protective clothing, and avoiding excessive sunlight.
• Anorexia and weight loss: Weight loss can be distressing; clinicians should monitor nutrition and intervene early.

Pill burden is another challenge: the target dose is 801 mg three times daily (originally three 267 mg tablets). A single 801 mg tablet can simplify dosing, though still three times per day.

These factors may influence adherence and should be addressed upfront.

Nintedanib: Key Considerations

Common adverse effects include:

• Diarrhoea (very common)
• Nausea
• Anorexia and weight loss
• Epistaxis (bleeding), typically mild, such as nosebleeds. Bleeding risk warrants caution in patients with coagulopathies or those on anticoagulants, though not an absolute contraindication.

Diarrhoea management requires a structured approach:

• Take each dose with a full meal that must include protein
• Consider dietary counselling
• Use loperamide as needed
• Implement brief medication "holidays" in persistent cases

Nerandomilast: Key Considerations

Nerandomilast generally appears to be well tolerated. Diarrhoea remains the most common side effect but is substantially lower in patients not taking background antifibrotic therapy.

Advantages include:

• No need for lab monitoring
• No food requirements for dosing

This may make nerandomilast a favourable option for treatment-naïve patients or those unable to tolerate other antifibrotics.

Symptom-Centred Care: Beyond Antifibrotic Therapy

Because antifibrotics do not reliably improve cough or dyspnoea, addressing comorbidities and symptom contributors is essential.

Comorbidities such as pulmonary hypertension, reflux, and sleep apnea can significantly worsen cough and breathlessness. These conditions often influence one another, improving sleep apnea may help cough, and treating reflux may reduce discomfort or dyspnoea. Addressing these issues is essential, as they frequently affect quality of life as much as, or even more than, the fibrosis itself.

Common Comorbidities That Worsen IPF Symptoms

• Pulmonary hypertension → consider inhaled treprostinil
• GERD → treat aggressively to minimise microaspiration
• Obstructive sleep apnoea → sleep study (PSG) and CPAP
• Cough from other causes → suppressants, neuromodulators, speech-language pathology referrals
• Dyspnoea → pulmonary rehabilitation, palliative care support
• Anxiety/depression → psychiatry, psychology, support groups

Managing these comorbidities may meaningfully improve quality of life, even when antifibrotics do not improve direct respiratory symptoms.

Conclusion

Integrating emerging evidence into practice requires balancing optimism with realism. Antifibrotics preserve lung function and slow decline, but true quality-of-life improvement comes from comprehensive care: managing comorbidities, supporting tolerability, addressing emotional burden, and personalising therapy. Through this holistic approach, clinicians can help patients with IPF navigate both the science and the lived experience of their disease.

Content is accurate as of the date of release on 6 January 2026.