Sequential withdrawal – The following order may be followed, while attempting rationalization of treatment, in advanced ILD

Non-essential or duplicate therapies – multivitamins, anti-oxidants, duplicate bronchodilators and proton pump inhibitors.

Long term preventive medications – statins, low-dose aspirin, bisphosphonates, those intended for tight glycemic and strict glycemic control.

Disease-modifying therapies with limited benefit – Immunosuppressants (when no evidence of inflammation) and anti-fibrotics.

Discontinuation of Pirfenidone might be considered mandatory when there is
-significant transaminitis (more than 5 times ULN or More than 3 ULN with symptoms of liver disease),
-severe photosensitivity (blistering or bullous skin lesions, extensive surface area involvement, severe pain or functional impairment, skin necrosis, requirement of systemic steroids),
-intolerable gastrointestinal toxicity.

Presence of ground glass opacities, consolidation, centrilobular nodules on HRCT might correlate with inflammation and might warrant continuation of immunosuppressants.

Chronic therapies with marginal benefit – Long acting bronchodilators, inhaled corticosteroids without Asthma/COPD overlap.

Symptomatic treatment for breathlessness including non-pharmacological measures, anxiolytics, oxygen (where symptom directed benefit has been obtained), antitussives are to be continued in advanced disease.

References

Rai, D. K., Sharma, P., & Kumar, R. (2022). Antifibrotic in interstitial lung diseases: When, where, and how long? Lung India, 39(6), 567–573

Lancaster, L. H. (2017). Safety and adverse event management in patients with idiopathic pulmonary fibrosis treated with pirfenidone. European Respiratory Review, 26(146), 170057.

Santana, A. N. C., et al. (2020). Interstitial lung diseases: The role of HRCT in the era of antifibrotic therapy. Jornal Brasileiro de Pneumologia, 46(3), e20200069.