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Letter to the Editor
Triple Therapy in Idiopathic Pulmonary Fibrosis
Triple terapia en fibrosis pulmonar idiopática
Diego Castillo Villegasa,b,
Corresponding author
d.castillo@rbht.nhs.uk

Corresponding author.
, Silvia Barril Farréb
a Royal Brompton Hospital, Londres, United Kingdom
b Servicio de Neumología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We have read with particular interest the new &#8220;Guidelines for the diagnosis and treatment of idiopathic pulmonary fibrosis &#40;IPF&#41;&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It is clear that&#44; as in the previous guidelines published in 2003 &#40;one of the most widely read articles of this journal&#41;&#44; Xaubet et al&#46; have made a brilliant summary of the most important aspects of this disease&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">One of the main novelties compared to the previous guidelines is regarding treatment&#46; In the past 10 years there has been a shift in the treatment of the IPF patient from immunomodulators to the new antifibrotic drugs&#44; and this is clearly reflected in the document&#46; However&#44; there is one clinical situation that has not been clarified&#58; how should patients already diagnosed with IPF that are stable on triple therapy &#40;N-acetylcysteine&#44; low-dose prednisone and azathioprine&#41; be managed&#63; Certainly&#44; many other clinicians like ourselves will have asked the same question when reading the guidelines&#46; This is a problem that we would like to examine further&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Although the provisional results of the PANTHER study were widely received with alarm&#44; as Wells et al&#46; recently pointed out&#44; this does not mean a permanent farewell to immunomodulators in IPF&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> It should be remembered that the IFIGENIA study data showed a reduction in disease progression in patients receiving triple therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Moreover&#44; the adverse effects reported in the PANTHER study were associated with the use of high-dose steroids&#46; For this reason&#44; many experts believe that it is reasonable to maintain triple therapy with low-dose steroids in patients who have remained stable on this regimen&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Accordingly&#44; each case can be evaluated by following three simple steps&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0025" class="elsevierStylePara elsevierViewall">IPF diagnosis&#58; this is another great step forward reflected in the guidelines&#46; Diagnostic criteria are becoming ever more specific&#46; And we know that patients with an incorrect diagnosis of IPF tend to respond better to immunosuppressive treatment&#44; particularly those with non-specific interstitial pneumonia&#46; Thus&#44; the first step consists of reviewing the clinical records to confirm that the patient meets the diagnostic criteria specified in the new guidelines&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Clinical stability&#58; patients often continue to receive a certain treatment indefinitely&#44; despite complete lack of response&#46; For this reason&#44; the next step would be to review clinical&#44; radiological and functional parameters to ensure that the patient does not present significant deterioration&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Tolerance and complications from immunosuppressive treatment&#58; the final step would consist of determining the symptoms caused by the treatment&#44; the extent of the side effects&#44; and particularly the effect of the immunosuppressive treatment on the patient &#40;repeated or severe infections&#44; leukopenia&#44; cancer&#44; etc&#46;&#41;&#46;</p></li></ul></p><p id="par0040" class="elsevierStylePara elsevierViewall">These three simple steps could be useful for correctly weighing up the situation of the patient and the effectiveness of the treatment&#46; Nevertheless&#44; the most important factor is indubitably missing from this equation&#58; the opinion of the patient&#46; Another essential step is to discuss the new therapeutic options&#44; and the risks and benefits compared to the previous ones&#44; since&#44; as in life&#44; two heads are generally better than one in coming to the right decision&#46;</p></span>"
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ISSN: 15792129
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