Would you initiate antifibrotic therapy in a patient with CTD-ILD experiencing worsening symptoms and declining lung function, despite no clear evidence of fibrosis on CT scans?  

If the predominant findings on CT were ground glass opacities and/or nodules without any evidence of fibrosis on CT, I would not start with an antifibrotic and, instead, would start with immunosuppression as a first-line agent. Based on the American College of Rheumatology (ACR) and American Thoraci...

In the INBUILD study apart from having 10% fibrosis on CT, they also needed to have at least one of the following criteria for the progression of ILD within the 24 months before screening:  1. Despite standard treatment with an agent other than nintedanib or pirfenidone: a relative decline in ...

Evidence of pulmonary fibrosis was required in the clinical trials of pulmonary antifibrotics. An RTC exploring the effects of an antifibrotic on individuals who have CTD-ILD without fibrosis and with worsening lung function would need to be done to give an informed answer to this question.

There are many other factors you need to consider, including the subtype of autoimmune disease and the current imaging pattern. Patients with rheumatoid arthritis and scleroderma are more likely to have a progressive fibrobiotic phenotype than patients with myositis/synthetase. So it really depends ...