What is your approach to using nintedanib in patients on baseline immunosuppression?

Typically I start antifibrotic therapy in a few situations:

1. The most common reason is ILD progression despite adequate immune suppression, defined as no extra-pulmonary disease activity (usually joint disease, but can tailor according to the patient's disease/situation, such as by presence of rash, ...

Generally, I like to prescribe nintedanib after someone has been stabilized on their immunosuppressive therapy in order to help mitigate potential adverse events that could be wrongly assigned to nintedanib. This is the strategy that was taken in the pivotal trials.

Remembering that mycophenolate is also an anti-fibrotic, meaning that it interferes with the fibrotic pathway and the evolution of fibrosis. If we look at the SLS trials which demonstrated significant improvement with CYC and MMF each in pulmonary function, HRQoL and symptoms scales, skin score (wit...

My approach is to add the nintedanib to the baseline immunosuppression, and not to stop immunosuppression.

If you look at Figure 4B in this Delphi consensus paper on treating patients with SSc-ILD, the consensus of expert pulmonologists/rheumatologists is to "add on" additional therapies to MMF if there is lack of response, unable to tolerate MMF, etc. Rahaghi et al., PMID 36624431.