How do you plan to integrate nerandomilast into the treatment algorithm for patients with ILD?

That’s a great question and one we’re all still actively defining in real time as this new agent enters practice.

First, I always start with the basics—diagnosis and disease behavior. Before starting any antifibrotic, I make sure the ILD diagnosis is solid through multidisciplinary review and that the patient truly meets progressive fibrotic criteria.

Now, when it comes to idiopathic pulmonary fibrosis (IPF), nerandomilast will definitely enter my first-line conversation. However, while it clearly...

Dr. @Dr. First Last has eloquently discussed the expected use of nerandomilast above.

The decision that I foresee myself struggling with is whether to use nerandomilast as an add-on agent or a replacement for those patients already on anti-fibrotic therapy but continues to decline. While it showed efficacy in mono-therapy and combination therapy groups, the side effects were significantly higher in the latter. So perhaps, if the patient is tolerating existing therapy without any adverse effect, ...

Given that its efficacy is similar to what we already have, it's probably the drug I would start someone on as a new start, just given the side effect profile and lack of drug monitoring. If patients are tolerating esb or ofev at the max dose, I wouldn't see any reason to change them over to nerandomilast unless I have clear documentation that they are not responding.