Letter to the Director
Recommendations for perioperative management of new pharmacological antifibrotic therapy in idiopathic pulmonary fibrosis
Recomendaciones perioperatorias para los nuevos fármacos antifibróticos en la fibrosis pulmonar idiopática
O. González Larrocha
, P. Romero Rojano, U. Ortega Mera, A. Arízaga Maguregui
Corresponding author
Servicio Anestesiología y Reanimación, Hospital de Galdakao-Usánsolo, Galdakao, Vizcaya, Spain
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"apellidos" => "Guadalupe Fernández" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935617302001" "doi" => "10.1016/j.redar.2017.07.010" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935617302001?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192918300143?idApp=UINPBA00004N" "url" => "/23411929/0000006500000003/v3_201803240409/S2341192918300143/v3_201803240409/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Director</span>" "titulo" => "Recommendations for perioperative management of new pharmacological antifibrotic therapy in idiopathic pulmonary fibrosis" "tieneTextoCompleto" => true "saludo" => "To the Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "178" "paginaFinal" => "179" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "O. González Larrocha, P. Romero Rojano, U. Ortega Mera, A. Arízaga Maguregui" "autores" => array:4 [ 0 => array:4 [ "nombre" => "O." "apellidos" => "González Larrocha" "email" => array:1 [ 0 => "oscar.gonzalezlarrocha@osakidetza.net" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Romero Rojano" ] 2 => array:2 [ "nombre" => "U." "apellidos" => "Ortega Mera" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Arízaga Maguregui" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio Anestesiología y Reanimación, Hospital de Galdakao-Usánsolo, Galdakao, Vizcaya, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Recomendaciones perioperatorias para los nuevos fármacos antifibróticos en la fibrosis pulmonar idiopática" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Two active substances have so far been authorised for the treatment of idiopathic pulmonary fibrosis (IPF): pirfenidone (Esbriet<span class="elsevierStyleSup">®</span>), approved in November 2011, and nintedanib (Ofev<span class="elsevierStyleSup">®</span>), approved in March 2015. Studies into new antifibrotic drugs are underway in the hope of reducing the progression of this disease.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Both these drugs are indicated in mild or moderate IPF with a collagen volume fraction (CVF) between 50% and 80% of predicted, in the absence of underlying liver disease. They cannot as yet be recommended in patients with severe disease, due to the absence of data.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The ASCEND and CAPACITY studies performed with pirfenidone, and the TOMORROW and INPULSIS 1 and 2 studies in nintedanib, showed that these drugs slow the decline of forced vital capacity in these patients. There are not enough data to show the superiority of either product, and the choice is made based on their efficacy and the patient's ability to tolerate adverse effects.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Pirfenidone attenuates fibroblast proliferation, production of fibrosis-associated proteins and cytokines, and the increased biosynthesis and accumulation of extracellular matrix in response to cytokine growth factors such as, transforming growth factor-beta (TGF-β) and platelet-derived growth factor (PDGF).</p><p id="par0025" class="elsevierStylePara elsevierViewall">Its adverse effects include gastrointestinal, skin (photosensitivity), immunological (angioedema) or hepatic (elevated transaminase) reactions, and liver function tests should be performed before and during treatment.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Patients with IPF have higher surgery-related mortality. This is generally secondary to the development of acute exacerbation of the disease, which appears in 5–15% of cases after thoracic surgery, with a short-term mortality of approximately 50%. Two recent studies have supported the safety of pirfenidone and confirm its potential efficacy in reducing acute exacerbations of IPF at 30 days after thoracic surgery.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3</span></a> Few studies have investigated pirfenidone in non-lung surgery patients.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Nintedanib, meanwhile, blocks the action of tyrosine kinase vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF) and fibroblast growth factor (FGF) receptors.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Due to their mechanism of action, these drugs could cause multiple cardiovascular adverse effects, such as increased blood pressure, myocardial infarction or haemostasis disorders with increased risk of bleeding, although these effects have not been confirmed in pivotal clinical trials. They are also thought to increase the risk of gastrointestinal perforation or wound healing complications, and the summary of product characteristics advises against initiating treatment less than 4 weeks prior to abdominal surgery, and in the case of perioperative interruption only resuming treatment based on clinical judgement of adequate wound healing.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">While awaiting the publication of specific recommendations for the perioperative management of these drugs, and given the considerable differences between them in terms of their potential for adverse effects and their possible influence on the postoperative evolution of baseline respiratory disease, we would recommend considering the following:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0050" class="elsevierStylePara elsevierViewall">Maintain pirfenidone throughout the perioperative period.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0055" class="elsevierStylePara elsevierViewall">Suspend nintedanib 4 weeks before the procedure and restart it after complete healing (around 4 weeks after surgery).</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">Given the protective effect of pirfenidone in the postoperative evolution of IPF, it may be beneficial to replace nintedanib with pirfenidone 4 weeks before surgery, if agreed by the prescribing physician, and re-evaluate resumption of nintedanib 4 weeks after surgery.</p></li></ul></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: González Larrocha O, Romero Rojano P, Ortega Mera U, Arízaga Maguregui A. Recomendaciones perioperatorias para los nuevos fármacos antifibróticos en la fibrosis pulmonar idiopática. Rev Esp Anestesiol Reanim. 2018;65:178–179.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Ficha técnica autorizada Esbriet<span class="elsevierStyleSup">®</span> (pirfenidone). 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Available from: <a id="intr0015" class="elsevierStyleInterRef" href="http://www.aemps.gob.es/medicamentosUsoHumano/informesPublicos/docs/IPT-nintedanib.pdf">http://www.aemps.gob.es/medicamentosUsoHumano/informesPublicos/docs/IPT-nintedanib.pdf</a> [Published 18.12.15; corrected 21.11.16]." ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23411929/0000006500000003/v3_201803240409/S2341192918300076/v3_201803240409/en/main.assets" "Apartado" => null "PDF" => "https://static.elsevier.es/multimedia/23411929/0000006500000003/v3_201803240409/S2341192918300076/v3_201803240409/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192918300076?idApp=UINPBA00004N" ]
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