Would you consider the use of dual antifibrotic therapy (nintedanib and pirfenidone together) for progressive fibrosing ILD?

Pirfenidone and Nintedanib have different antifibrotic mechanisms of action, and emerging data suggests that these complex molecules may possess previously unknown pleiotropic properties. It is unclear whether a synergistic effect might be realized from combination therapy with these agents, and indeed other disease states (e.g. COPD, asthma, heart failure, diabetes) have benefited from a multi-pronged approach utilizing multiple drugs with diverse targets. Currently, data supporting the use of ...

I don't think we are at a place where this should be routine practice. There are case reports of patient stabilization when a second antifibrotic is added, but I agree the best data we have are from INJOURNEY. There's also this from Flaherty et al., PMID 29946005 which is a bit longer but comes to similar conclusions.

It doesn't seem you get a ton of bang for your buck with the addition of a second agent (or if you do the studies to date have not gone on long enough to tell). Combine that with in...

One of the difficulties of having to rely on surrogate endpoints for antifibrotic RCTs is that these important sequencing and combination questions are incredibly difficult to answer.

Clearly, in meta-analytic analyses, there is a mortality benefit from antifibrotic therapy but the n required to find that signal was greater than 1000 patients i.e., the NNT for mortality benefit is remarkably high. Importantly there is no QOL improvement in these trials either for patients on meds compared to pla...

Never.

1. Costly therapies requiring separate approvals, and resource utilization limits make it impossible in real-world scenarios.
2. Each drug has SIGNIFICANT ramp-up side effects. If patients are unable to tolerate due to side effects, will be a situation difficult to separate the trigger agent from the other (tolerated) therapy.
3. Not possible to attribute "benefit" to one therapy at follow-up.