Immunosuppression in fibrotic ILD: no survival benefit in a trial emulation, and possible harm in two subtypes

The edition in brief

A multicentre emulation of a randomised trial in 2,270 patients with non-IPF fibrotic ILD found starting mycophenolate or azathioprine was not associated with better three-year transplant-free survival or lung function in any subtype, and was associated with worse survival in non-IPF idiopathic interstitial pneumonia (HR 1.38) and fibrotic hypersensitivity pneumonitis (HR 1.62). It is observational, and guidelines have not changed. An international working group extended the definition of acute exacerbation from IPF to all fibrotic ILDs, anchored on diffuse alveolar damage, and introduced 'acute respiratory worsening' for deteriorations from other causes. In the European SHARP registry, 3,876 adults with severe asthma improved similarly on biologics whether never, former or current smokers, though smokers were less often prescribed them. AMAZE-lung, a single-arm phase 2 trial, found amivantamab, lazertinib and bevacizumab gave a 33% 12-week response rate after progression on a third-generation EGFR inhibitor, with frequent infusion reactions and rash.