Frail patients with interstitial lung disease are less likely to be prescribed and tolerate antifibrotics, according to new study

A new study, led by St. Paul’s Hospital respirologist Dr. Alyson Wong and funded by the  Carraresi Foundation Early Career Clinician Investigator Award, has found that frailty impacts how antifibrotic medications are prescribed for and tolerated in patients with idiopathic pulmonary fibrosis (IPF), a form of interstitial lung disease (ILD). However, these impacts were not seen with immunosuppressive medications, which are used to treat other types of ILD. This study, which was recently published in the European Respiratory Journal, could help to guide future prescribing practices. 

Dr. Wong was one of the 2023 recipients of the Carraresi Foundation Early Career Clinician Investigator Award, which provides funding for early career researchers to explore research projects. Her funded project aimed to fill a gap in data around how frailty impacts medication tolerability for patients with ILD, and the need for them to discontinue treatment. It additionally looked at whether prescribing practices for ILD treatments differ based on a patient’s frailty.

Frailty is common in patients with ILD

Interstitial lung disease refers to a group of respiratory conditions that result in inflammation and/or scarring of the lungs. Frailty, a loss of cognitive or health reserves that contributes to an increased risk of adverse outcomes, is very common among patients with ILD, especially in those with multiple comorbidities. Often, frail patients need to stop treatment for ILD due to a significant adverse event.

Dr. Wong hypothesized that frail patients were less likely to be treated with ILD-specific therapies, because physicians may be more reluctant to prescribe medications to frail patients due to the higher risk of side effects and increased difficulty in recovering from those side effects. 

The study utilized data from the Canadian Registry for Pulmonary Fibrosis (CARE-PF), which is one of the largest registries in the world for patients with ILD. It has eight sites across Canada, of which St. Paul’s Hospital is the lead, and includes around 7000 patients. 

Focusing on the BC-based cohort, Dr. Wong used the Clinical Frailty Score, a comprehensive tool that incorporates mobility, function and cognition to determine degrees of frailty, to identify ILD patients who were either frail, vulnerable to frailty, or fit. She and her team then looked at prescribing patterns and discontinuation rates for medications commonly used to treat ILD, to see if there were differences based on a patient’s frailty. 

Tolerability differs between types of ILD treatment

The two major categories of medications commonly used to treat ILD are antifibrotics and immunosuppressants. The study found that frail patients did not tolerate antifibrotics as well as those who were fit. Frail patients were not being prescribed antifibrotics as often, likely because physicians were more hesitant to prescribe them because of this lower tolerability. 

“We found that people who were frail were not getting prescribed antifibrotics as commonly as people who were fit. We also found that those who did get prescribed antifibrotics were not tolerating the medication as well, so discontinuation rates were higher,” says Dr. Wong.

On the other hand, the study found that there were no differences in the tolerability of immunosuppressants between fit, vulnerable and frail patients. However, there are differences in funding available for different types of immunosuppressant treatment. While one type, azathioprine, is automatically covered for patients, another, mycophenolate, which is often better tolerated, is not funded unless the patient has side effects or experiences disease progression with azathioprine. Dr. Wong’s next study will look at the cost-effectiveness of azathioprine and mycophenolate, with the aim of providing evidence to inform funding decisions that impact patients’ access to treatments that might be better tolerated. 

Award a ‘steppingstone’ to establishing research career

The findings of this study are particularly relevant as new treatments for ILD emerge, highlighting the need, particularly among frail individuals, for antifibrotics that are better tolerated. Further research on strategies to prevent and modify frailty is also essential to ensuring successful ILD treatment. 

This study was made possible by the Carraresi Foundation Early Career Clinician Investigator Award. Receiving this award allowed Dr. Wong to establish her independent research program, gave her time to dedicate to research, and enabled her to build on the work done through this funding to apply for larger grants.

“It was an important steppingstone in establishing a research career,” says Dr. Wong. “It’s a really important award, given limited funding opportunities, and is particularly valuable for early career investigators.”

Providence Research is currently inviting applications for the 2026 Carraresi Foundation Early Career Clinician Investigator Award. To learn more about the award and how to apply, visit our website. 

Providence Research and St. Paul’s Foundation are grateful to the Carraresi Foundation, in memory of Augusto Carraresi, for its interest in supporting early career research at Providence.