Do you generally recommend starting nintedanib prior to immunosuppressive therapy in a patient with CTD-ILD?

Patients with autoimmune disease-associated ILDs such as those with rheumatoid arthritis-related ILD, Sjogren and inflammatory myositis-related ILD are usually on background DMARD/immunosuppressive therapy already at the time the ILD is detected. These therapies are also important in helping to reduce the burden of the ILD, and are used in combination. So, in general, the antifibrotic is being added to the background immunosuppressive therapy. In scleroderma, there are still unanswered questions about the role of immunosuppression for management of the ILD, but the SENCIS trial of systemic sclerosis-associated interstitial lung disease treated with nintedanib +/-mycophenolate did suggest additional benefit from combination of the antifibrot...

The CTD-ILD patients who were part of the INBUILD study were not on any DMARDs during the trial. There was no sub-group analysis but in the overall population, the adjusted rate of decline in the FVC over the 52-week period was more favorable in the nintedanib group regardless of underlying diagnosis. However, I personally favor starting and optimizing immunosuppression in patients with CTD-ILD prior to starting nintedanib.

Nintedanib disrupts the ongoing fibrotic process by preventing the proliferation of fibroblasts thereby delaying progression, however, there is no reasonable expectation for improvement. It will only delay what is inevitable. Patients with CTD-ILD have ongoing inflammation underlying the progression of their lung disease...

Not typically, for a few reasons. We all have patients where their joints are totally fine and their lungs are leading the way, but the average CTD-ILD patient's ILD is synchronous with their extra-pulmonary disease. As a result, we see more overall benefits in treating these patients with immune suppression upfront. Most data for inflammatory ILDs indicate stabilization with immune suppression (as defined by PFTs, typically FVC and DLCO), whereas antifibrotics just slow things down.

Generally not as in CTD-ILD, it is the underlying CTD that is driving ILD and this must be controlled. Furthermore, patients with CTD often have extrapulmonary manifestations of their disease that need to be addressed in order to decrease morbidity and mortality. However, I am quick to prescribe nintedanib if I see a UIP pattern on HRCT (particularly in RA).