Articles

Pirfenidone in patients with idiopathic pulmonary brosis

(CAPACITY): two randomised trials
Paul W Noble, Carlo Albera, Williamson Z Bradford, Ulrich Costabel, Marilyn K Glassberg, David Kardatzke, Talmadge E King Jr, Lisa Lancaster,
Steven A Sahn, Javier Szwarcberg, Dominique Valeyre, Roland M du Bois, for the CAPACITY Study Group

Summary
Lancet 2011; 377: 176069 Background Idiopathic pulmonary brosis is a progressive and fatal lung disease with inevitable loss of lung function.
Published Online The CAPACITY programme (studies 004 and 006) was designed to conrm the results of a phase 2 study that
May 14, 2011 suggested that pirfenidone, a novel antibrotic and anti-inammatory drug, reduces deterioration in lung function in
DOI:10.1016/S0140-
6736(11)60405-4
patients with idiopathic pulmonary brosis.
See Comment page 1727
Methods In two concurrent trials (004 and 006), patients (aged 4080 years) with idiopathic pulmonary brosis were
Duke University School of
Medicine, Durham, NC, USA randomly assigned to oral pirfenidone or placebo for a minimum of 72 weeks in 110 centres in Australia, Europe, and
(Prof P W Noble MD); University North America. In study 004, patients were assigned in a 2:1:2 ratio to pirfenidone 2403 mg/day, pirfenidone 1197 mg/day,
of Turin, Department of Clinical or placebo; in study 006, patients were assigned in a 1:1 ratio to pirfenidone 2403 mg/day or placebo. The randomisation
and Biological Sciences, Turin,
code (permuted block design) was computer generated and stratied by region. All study personnel were masked to
Italy (Prof C Albera MD);
InterMune, Brisbane, CA, USA treatment group assignment until after nal database lock. Treatments were administered orally, 801 mg or 399 mg
(W Z Bradford MD, three times a day. The primary endpoint was change in percentage predicted forced vital capacity (FVC) at week 72.
D Kardatzke PhD, Analysis was by intention to treat. The studies are registered with ClinicalTrials.gov, numbers NCT00287729 and
J Szwarcberg MD);
NCT00287716.
Ruhrlandklinik and Medical
Faculty, University of
Duisburg/Essen, Essen, Findings In study 004, 174 of 435 patients were assigned to pirfenidone 2403 mg/day, 87 to pirfenidone 1197 mg/day,
Germany (Prof U Costabel MD); and 174 to placebo. In study 006, 171 of 344 patients were assigned to pirfenidone 2403 mg/day, and 173 to placebo. All
University of Miami Miller
patients in both studies were analysed. In study 004, pirfenidone reduced decline in FVC (p=0001). Mean FVC change
School of Medicine, Miami, FL,
USA (M K Glassberg MD); at week 72 was 80% (SD 165) in the pirfenidone 2403 mg/day group and 124% (185) in the placebo group
University of California, San (dierence 44%, 95% CI 07 to 91); 35 (20%) of 174 versus 60 (35%) of 174 patients, respectively, had a decline of at
Francisco, CA, USA least 10%. A signicant treatment eect was noted at all timepoints from week 24 and in an analysis over all study
(Prof T E King Jr MD); Vanderbilt
University Medical Center,
timepoints (p=00007). Mean change in percentage FVC in the pirfenidone 1197 mg/day group was intermediate to
Nashville, TN, USA that in the pirfenidone 2403 mg/day and placebo groups. In study 006, the dierence between groups in FVC change
(L Lancaster MD); Medical at week 72 was not signicant (p=0501). Mean change in FVC at week 72 was 90% (SD 196) in the pirfenidone
University of South Carolina, group and 96% (191) in the placebo group, and the dierence between groups in predicted FVC change at week 72
Charleston, SC, USA
(Prof S A Sahn MD); Assistance
was not signicant (06%, 35 to 47); however, a consistent pirfenidone eect was apparent until week 48 (p=0005)
Publique-Hpitaux de Paris, and in an analysis of all study timepoints (p=0007). Patients in the pirfenidone 2403 mg/day group had higher
Hpital Avicenne, Bobigny, incidences of nausea (125 [36%] of 345 vs 60 [17%] of 347), dyspepsia (66 [19%] vs 26 [7%]), vomiting (47 [14%] vs
France (Prof D Valeyre MD); and 15 [4%]), anorexia (37 [11%] vs 13 [4%]), photosensitivity (42 [12%] vs 6 [2%]), rash (111 [32%] vs 40 [12%]), and dizziness
Imperial College, London, UK
(Prof R M du Bois MD)
(63 [18%] vs 35 [10%]) than did those in the placebo group. Fewer overall deaths (19 [6%] vs 29 [8%]) and fewer deaths
Correspondence to:
related to idiopathic pulmonary brosis (12 [3%] vs 25 [7%]) occurred in the pirfenidone 2403 mg/day groups than in
Prof Paul W Noble, Division of the placebo groups.
Pulmonary, Allergy and Critical
Care Medicine, Duke University Interpretation The data show pirfenidone has a favourable benet risk prole and represents an appropriate treatment
Medical Center, 106 Research
Drive, Box 103000, Durham,
option for patients with idiopathic pulmonary brosis.
NC 27710, USA
paul.noble@duke.edu Funding InterMune.

Introduction Pirfenidone (5-methyl-1-phenyl-2-[1H]-pyridone) is an

Idiopathic pulmonary brosis is a chronic, progressive, orally bioavailable synthetic molecule. It was shown to
and fatal lung disease with no known cause or cure. It is regulate the activity of transforming growth factor
characterised by progressive dyspnoea and irreversible (TGF) and tumour necrosis factor (TNF) in vitro;59
loss of lung function.1 Disease progression is hetero- and inhibit broblast proliferation and collagen synthesis
geneous; however, the clinical course is ultimately and reduce cellular and histological markers of brosis
deterioration, with an estimated median survival of in animal models of lung brosis.6,912
25 years.24 The uniformly poor prognosis, with paucity of Clinical proof of concept was shown in a randomised,
treatments, provides a strong rationale for the development double-blind, placebo-controlled phase 2 study of
of novel drugs that target the underlying broproliferative 107 Japanese patients with idiopathic pulmonary
process and attenuate decline in pulmonary function. brosis.13 This study was stopped early because an

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interim analysis showed favourable ecacy; nal UK [n=3], and USA [n=64]). All methods apply to both
analysis at 9 months showed a reduced decline in the studies 004 and 006, unless otherwise noted. Eligible
mean change in vital capacity in pirfenidone-treated patients were aged 4080 years with a diagnosis of
patients (p=0037).13 These ndings led to three phase 3 idiopathic pulmonary brosis in the previous 48 months
studies with primary endpoints of change in lung and no evidence of improvement in measures of disease
functionone in Japan and two across North America severity over the preceding year. Inclusion criteria
and Europe. In the Japanese phase 3, randomised, included predicted FVC of at least 50%, predicted carbon
double-blind, placebo-controlled study of 275 patients monoxide diusing capacity (DLco) of at least 35%, either
with idiopathic pulmonary brosis, pirfenidone reduced predicted FVC or predicted DLco of 90% or less, and
mean change in vital capacity at week 52 (absolute 6-min walk test (6MWT) distance of at least 150 m.
dierence 70 mL; relative dierence 44%; p=0042), and Patients younger than 50 years and those not meeting
improved progression-free survival time (p=0028).14 protocol criteria for denite idiopathic pulmonary brosis
These data, with the results of the phase 2 study, led to by use of high-resolution CT (HRCT) were required to
regulatory approval of pirfenidone in Japan for the have a lung biopsy sample showing usual interstitial
treatment of idiopathic pulmonary brosis. pneumonia (webappendix pp 13). Independent expert See Online for webappendix
The CAPACITY (Clinical Studies Assessing Pirfenidone adjudication was obtained for interpretation of HRCT or
in idiopathic pulmonary brosis: Research of Ecacy surgical biopsy sample in instances of uncertainty.
and Safety Outcomes) programme included two similar Exclusion criteria included obstructive airway disease,
multinational trials (studies 004 and 006) designed to connective tissue disease, alternative explanation for
conrm the eect of pirfenidone on reduction of decline interstitial lung disease, and being on a waiting list for a
in lung function. lung transplant.
All patients provided written informed consent, and
Methods the protocol was approved by the institutional review
Patients board or ethics committee at each centre.
The studies were done at 110 centres in 13 countries
(Australia [n=3], Belgium [n=2], Canada [n=9], Randomisation and masking
France [n=5], Germany [n=6], Ireland [n=1], Italy [n=9], Patients were randomly assigned to oral pirfenidone or
Mexico [n=1], Poland [n=2], Spain [n=4], Switzerland [n=1], placebo for 72 weeks from the date the last patient was

Study 004 Study 006

Pirfenidone Pirfenidone Placebo (n=174) Pirfenidone Placebo (n=173)
1197 mg/day 2403 mg/day 2403 mg/day
(n=87) (n=174) (n=171)
Age (years) 680 (76) 657 (82) 663 (75) 668 (79) 670 (78)
Men 65 (75%) 118 (68%) 128 (74%) 123 (72%) 124 (72%)
White 83 (95%) 168 (97%) 168 (97%) 169 (99%) 171 (99%)
Weight (kg)
Men 884 (135) 913 (159) 889 (161) 954 (174) 932 (151)
Women 728 (130) 770 (132) 770 (136) 766 (140) 775 (148)
Non-US enrolment 29 (33%) 60 (34%) 60 (34%) 23 (13%) 23 (13%)
Smoking status
Never 27 (31%) 56 (32%) 51 (29%) 59 (35%) 64 (37%)
Former 57 (66%) 110 (63%) 114 (66%) 112 (65%) 101 (58%)
Current 3 (3%) 8 (5%) 9 (5%) 0 8 (5%)
Denite idiopathic pulmonary brosis (HRCT) 83 (95%) 159 (91%) 164 (94%) 149 (87%) 158 (91%)
Surgical lung biopsy 32 (37%) 86 (49%) 85 (49%) 94 (55%) 94 (54%)
Diagnosis (1 year) of idiopathic pulmonary brosis 46 (53%) 83 (48%) 81 (47%) 100 (58%) 107 (62%)
Predicted FVC (%) 764 (144) 745 (145) 762 (155) 749 (132) 731 (142)
DLco (% predicted) 472 (82) 464 (95) 461 (102) 478 (98) 474 (92)
A-a gradient (mm Hg) 155 (104) 177 (106) 189 (147) 183 (111) 170 (104)
6MWT distance (m) 4175 (1128) 4111 (918) 4100 (909) 3780 (822) 3991 (897)
Use of supplemental oxygen 15 (17%) 29 (17%) 25 (14%) 48 (28%) 49 (28%)

Data are number (%) or mean (SD). HRCT=high-resolution CT. FVC=forced vital capacity. DLco=haemoglobin-corrected carbon monoxide diusing capacity.
A-a gradient=alveolar-arterial oxygen gradient. 6MWT=6-minute walk test.

Table 1: Baseline characteristics of patients

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A
771 patients screened

336 excluded

435 enrolled and

randomly allocated

174 assigned to pirfenidone 87 assigned to pirfenidone 174 assigned to placebo

2403 mg/day 1197 mg/day

13 discontinued study* 5 discontinued study* 8 discontinued study*

4 withdrew consent 2 withdrew consent 5 withdrew consent
8 adverse events 3 adverse events 3 adverse events
1 other reason 17 discontinued treatment 31 discontinued treatment
38 discontinued treatment 11 adverse events 14 adverse events
21 adverse events 2 patients decision 4 patients decision
5 patients decision 4 deaths 4 lung transplant
3 lung transplant 9 deaths
5 deaths
4 other reasons

161 completed study 82 completed study 166 completed study

174 assessed for ecacy 87 assessed for ecacy 174 assessed for ecacy

567 patients screened

223 excluded

344 enrolled and

randomly allocated

Figure 1: Trial prole

(A) Study 004. (B) Study 006.
171 assigned to pirfenidone 173 assigned to placebo
*Does not include death or 2403 mg/day
lung transplantation.
Discontinued study because
of deportation. Includes 13 discontinued study* 9 discontinued study*
unknown interaction with 6 withdrew consent 5 withdrew consent
chemotherapy (n=1), 5 adverse events 4 adverse events
deportation (n=1), 1 sponsors decision 31 discontinued treatment
non-adherence to assigned 1 other reason 14 adverse events
treatment regimen (n=1), and 34 discontinued treatment 3 patients decision
spontaneous discontinuation 24 adverse events 3 lung transplant
3 patients decision 11 deaths
of study drug (n=1).
2 lung transplant
Discontinued study due to 1 sponsors decision
placement on lung 1 death
transplantation schedule. 3 other reasons
Includes placement on lung
transplantation schedule (n=1),
prolonged QTc interval that 158 completed study 164 completed study
was subsequently ascertained 171 assessed for ecacy 173 assessed for ecacy
to be present at baseline (n=1),
and unknown (n=1).

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enrolled. In study 004, patients were assigned in a 2:1:2 ratio discontinuation, and all such assessments were included
to pirfenidone 2403 mg/day, pirfenidone 1197 mg/day, or in the intention-to-treat (ITT) analyses.
placebo; in study 006, patients were assigned in a 1:1 ratio
to pirfenidone 2403 mg/day or placebo. The 2403 mg/day Statistical analysis
dose was derived by normalisation of the 1800 mg/day The primary endpoint was change in percentage of
dose used in the Japanese studies to the predicted predicted FVC from baseline to week 72. The primary
bodyweights of the predominantly US-based study ecacy analysis was by use of a rank analysis of
population. The randomisation code (permuted block covariance (ANCOVA) model, stratied by region, with
design with ve patients per block in study 004 and four standardised rank change in FVC as the outcome and
per block in study 006) was computer generated, stratied standardised rank baseline percentage predicted FVC as
by region, by an independent statistician. Study centres, a covariate, evaluated against a nal adjusted two-tailed
using an interactive voice response system, assigned study p value of 00498. Magnitude of treatment eect was
drug bottles to patients. The independent statistician had estimated by use of dierences in treatment group means
no role other than assignation of the randomisation code and categorical change in FVC. To assess treatment eect
and study drug bottle numbers. All personnel involved in over the full study, a repeated-measures analysis with
the study were masked to treatment group assignment averaging of percentage predicted FVC change over all
until after nal database lock. assessment timepoints was prespecied.
Study drug was administered with food in three daily Secondary ecacy endpoints were categorical FVC
doses (pirfenidone 801 mg or 399 mg) and increased to full (5-level scale), progression-free survival (time to conrmed
dose over 2 weeks. Dose modication guidelines were 10% decline in percentage predicted FVC, 15% decline
provided for expected adverse events, including fatigue, in percentage predicted DLco or death), worsening
gastrointestinal symptoms, skin reactions, and liver idiopathic pulmonary brosis (time to acute exacerbation,
function test abnormalities. Concomitant treatments for death, lung transplantation, or admission to hospital for
idiopathic pulmonary brosis were prohibited, with respiratory problems), dyspnoea (University of California
exceptions for short courses of azathioprine, cyclophos- San Diego Shortness of Breath Questionnaire),15 6MWT
phamide, corticosteroids, or acetylcysteine for protocol- distance, worst peripheral oxygen saturation (SpO2)
dened acute exacerbation of idiopathic pulmonary during the 6MWT, percentage predicted DLco, and
brosis, acute respiratory decompensation, or progression brosis by use of HRCT (study 006 only). Mortality was
of disease (webappendix p 4). prespecied as an exploratory endpoint, and death related
Physical examination and clinical laboratory assess- to idiopathic pulmonary brosis was assigned by
ments were done at weeks 2, 4, 6, and 12, and investigators masked to assignment.
every 12 weeks thereafter. Pulmonary function, exer- In the ecacy analyses, pirfenidone 2403 mg/day was
cise tolerance, and dyspnoea were assessed every compared with placebo in the ITT population by use of
12 weeks. Patients were to continue assessments until SAS (version 9.1.3). The group assigned to pirfenidone
study completion, even after permanent treatment 1197 mg/day in study 004 was summarised descriptively.

A B C
0

2
Mean change from baseline in FVC

4
(1% predicted)

10
Pirfenidone 2403 mg/day (n=174)
12 Pirfenidone 1197 mg/day (n=87) Pirfenidone 2403 mg/day (n=171) Pirfenidone 2403 mg/day (n=345)
Placebo (n=174) Placebo (n=173) Placebo (n=347)
14
0 12 24 36 48 60 72 0 12 24 36 48 60 72 0 12 24 36 48 60 72
Weeks Weeks Weeks
Absolute dierence* 14% 25% 46% 48% 41% 44% 04% 28% 24% 19% 06% 06% 05% 27% 35% 33% 24% 25%
Relative dierence* 535% 652% 637% 523% 383% 353% 315% 621% 482% 273% 76% 65% 285% 636% 575% 416% 251% 228%
p value 0061 0014 00001 00009 00002 0001 0021 00001 0011 0005 0172 0501 0003 <00001 <00001 <00001 00003 0005

Figure 2: Mean change from baseline in percentage predicted FVC in study 004 (A), study 006 (B), and the pooled population (C)
FVC=forced vital capacity. *Pirfenidone 2403 mg/day versus placebo. Rank ANCOVA (pirfenidone 2403 mg/day vs placebo). 95% CIs were only calculated for absolute dierences for the week 72
timepoint in study 004 (07 to 91) and study 006 (35 to 47).

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Study 004 Study 006 Pooled data

Pirfenidone Placebo Absolute p value* Pirfenidone Placebo Absolute p value* Pirfenidone Placebo Absolute p value*
2403 mg/day (n=174) dierence (95% 2403 mg/day (n=173) dierence 2403 mg/day (n=347) dierence
(n=174) CI) (n=171) (95% CI) (n=345) (95% CI)
Categorical change in 35 (20%) 60 (35%) 144 0001 39 (23%) 46 (27%) 38 0440 74 (21%) 106 91 0003
FVC 10% (74 to 213) (27 to 102) (31%) (43 to 139)
Progression-free 064 0023 084 0355 074 0025
survival time (044 to 095) (058 to 122) (057 to 096)
Mean change in 604 768 164 0171 451 769 318 00009 528 768 240 00009
6MWT distance (m) (109 to 437) (32 to 604) (43 to 437)
Mean change in DLco 79 99 20 0145 98 92 05 0996 88 96 07 0301
(% predicted) (04 to 44) (32 to 22) (11 to 25)
Mean change in 121 152 31 0509 119 139 20 0604 120 145 25 0405
dyspnoea score (85 to 23) (76 to 36) (64 to 14)
Mean change in 15 23 08 0087 19 13 05 0893 17 18 01 0261
worst SpO2 during (02 to 18) (17 to 07) (07 to 09)
6MWT (%)
Time to worsening in 084 0515 073 0248 078 0201
idiopathic pulmonary (050 to 142) (043 to 124) (054 to 114)
brosis
Categorical change in NA NA NA NA NA NA NA 0894 NA NA NA NA
HRCT-diagnosed
brosis||

FVC=forced vital capacity. 6MWT=6-minute walk test. DLco=haemoglobin-corrected carbon monoxide diusing capacity. SpO2=peripheral oxygen saturation. HRCT=high-resolution CT. NA=not applicable.
*Rank ANCOVA (pirfenidone 2403 mg/day vs placebo), unless otherwise indicated. Cochran-Mantel-Haenszel row mean score test (pirfenidone 2403 mg/day vs placebo) based on ve categories (severe decline,
20%; moderate decline, <20% but 10%; mild decline; <10% but 0; mild improvement, >0 but <10%; and moderate improvement, 10%). Hazard ratio (95% CI) based on the Cox proportional hazard model
with geographic region (USA vs non-USA) as a stratum. Log-rank test (pirfenidone 2403 mg/day vs placebo). Based on the University of California San Diego Shortness of Breath Questionnaire: total score
ranges from 0 to 120, with larger scores indicating greater shortness of breath. ||Cochran-Mantel-Haenszel row mean score test (pirfenidone 2403 mg/day vs placebo) based on ve categories (much better,
better, same, worse, or much worse); assessed in study 006 only.

Table 2: Secondary ecacy endpoints at week 72

Analyses of pooled data were prespecied to derive precise imbalances between treatment groups within each
estimates of magnitude of treatment eect. Missing values study. The percentages of patients with diagnoses of
as a result of death were assigned the worst rank in idiopathic pulmonary brosis within 1 year, on
ANCOVA analyses, and worst possible outcome in mean supplemental oxygen, and enrolment at US sites were
change analyses (eg, FVC=0) and categorical analyses higher in study 006 than in study 004 (table 1). 713 (92%)
(webappendix p 5). Other missing data were imputed with of 779 patients met criteria for denite idiopathic
the average value from three patients with the smallest pulmonary brosis with HRCT; 391 (50%) underwent
sum of squared dierences at each visit with data that surgical lung biopsy, with 372 (95%) having denite
were not missing. A data monitoring committee reviewed usual interstitial pneumonia.
safety and ecacy data and undertook two interim Figure 1 shows that 409 (94%) of 435 patients in
analyses of all-cause mortality in the pooled dataset against study 004 and 322 (94%) of 344 in study 006 completed
a conservative stopping boundary of p=00001. the study. 109 patients (14%) discontinued treatment
The studies are registered with ClinicalTrials.gov, prematurely: 13 (15%), 30 (17%), and 18 (10%) in the
numbers NCT00287729 and NCT00287716. pirfenidone 1197 mg/day, pirfenidone 2403 mg/day, and
placebo groups, respectively in study 004; and 31 (18%)
Role of the funding source and 17 (10%) in the pirfenidone and placebo groups,
The sponsor participated in the study design, data respectively, in study 006 (gure 1). Treatment
collection, data analysis, and writing the report. After compliance was high: 380 (88%) of 432 patients in the
study completion, the sponsor analysed and maintained pirfenidone groups and 323 (93%) of 347 in the placebo
the data. Authors participated in design, conduct, groups adhered to treatment (ie, received 80% of
analysis, and reporting; had full access to data; and no scheduled doses).
limits were placed on the content of the report. In study 004, at week 72, pirfenidone 2403 mg/day
signicantly reduced mean decline in percentage
Results predicted FVC compared with placebo (80% [SD 165]
Between April, 2006, and November, 2008, 435 patients vs 124% [185], respectively; gure 2A), and the
were enrolled in study 004, and 344 in study 006. Table 1 proportion of patients with FVC decline of 10% or more
shows that there were no pronounced baseline (table 2). Treatment eect was evident by week 24 and

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persisted until week 72 (gure 2). Repeated-measures

analysis of percentage predicted FVC change across all A
assessment timepoints also showed a pirfenidone eect 100
(p=00007; webappendix p 6). Outcomes in the
pirfenidone 1197 mg/day group were intermediate to the 80
pirfenidone 2403 mg/day and placebo groups.
In study 006, no signicant dierence was noted
60

Patients (%)
between the pirfenidone and placebo groups in percentage Hazard ratio 064 (95% CI 044095; p=0023)*
predicted FVC change at week 72 (gure 2B): mean change
was 90% (SD 196) in patients in the pirfenidone 40
2403 mg/day group and 96% (191) in patients in the
placebo group, respectively. The proportions of patients 20 Pirfenidone 2403 mg/day
with a decline in FVC of 10% or more were not signicantly Pirfenidone 1197 mg/day
dierent (table 2). However, a signicant treatment eect Placebo
0
was evident at every timepoint from week 12 until week 48 0 12 24 36 48 60 72 84 96 108 120
(gure 2B), and in the repeated-measures analysis of Number at risk
Week
percentage predicted FVC change over all assessment Pirfenidone 2403 mg/day 171 167 160 157 148 138 55 23 5
timepoints (p=0007; webappendix p 6). Pirfenidone 1197 mg/day 87 86 79 74 68 64 27 11 5
Placebo 173 162 150 136 126 116 44 21 4
The primary endpoint analysis of the pooled
population also showed a pirfenidone treatment eect B
on percentage predicted FVC at week 72 (p=0005; 100
gure 2C): mean change was 85% in the patients in
the pirfenidone 2403 mg/day group and 110% in those 80
in the placebo group, and a smaller proportion of
patients had a decline in FVC of 10% or more in the
60
Patients (%)

pooled pirfenidone group (table 2). Hazard ratio 084 (95% CI 058122; p=0355)*
Pirfenidone 2403 mg/day prolonged progression-free
survival in study 004, with a 36% reduction in risk of 40
death or disease progression (table 2). In study 006, no
signicant eect was noted on progression-free survival 20
(table 2). In the pooled analysis, pirfenidone prolonged Pirfenidone 2403 mg/day
progression-free survival by 26% compared with placebo Placebo
0
(table 2; gure 3C). 0 12 24 36 48 60 72 84 96 108 120
Pirfenidone 2403 mg/day signicantly reduced decline Weeks
Number at risk
in 6MWT distance at week 72 in study 006 but not Pirfenidone 2403 mg/day 170 162 157 149 136 126 61 35 7 2
study 004 (table 2). In the pooled population, a Placebo 172 167 153 144 135 123 51 29 7 1
31% relative dierence was noted between treatment
C
groups at week 72 (gure 4). The minimum clinically 100
important dierence in 6MWT distance in patients with
idiopathic pulmonary brosis has been reported as
2445 m.1618 In a post-hoc analysis, 62 (36%) of 80

170 patients in the pirfenidone group and 80 (47%) of 170

in the placebo group had a 50 m or more decrement in 60
Patients (%)

Hazard ratio 074 (95% CI 057096; p=0025)*

6MWT distance in study 004 (p=0049), and 56 (33%)
of 169 and 79 (47%) of 168, respectively in study 006 40
(p=0010). The Mantel-Haenszel relative risk was 074
(95% CI 062089) for overall relative risk in the post-
20
hoc analysis in the pooled population.
Pirfenidone 2403 mg/day
No signicant treatment group dierences were noted Placebo
in either study in percentage predicted DLco, dyspnoea, 0
0 12 24 36 48 60 72 84 96 108 120
worst SpO2 during the 6MWT, time to worsening Weeks
idiopathic pulmonary brosis, or brosis diagnosed by Number at risk
Pirfenidone 2403 mg/day 341 329 317 306 284 264 116 58 12 2
use of HRCT (table 2). Placebo 345 329 303 280 261 239 95 50 11 1
In the analyses of the pooled population, the hazard
ratios for overall all-cause mortality and mortality related Figure 3: Kaplan-Meier distribution of progression-free survival time in study 004 (A), Study 006 (B), and the
to idiopathic pulmonary brosis at any time during the pooled population (C)
study favoured pirfenidone (table 3). Hazard ratios for *Pirfenidone 2403 mg/day versus placebo.

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0 Pirfenidone Placebo
10 2403 mg/day (n=347)
(n=345)
Mean change from baseline in 6MWT
20
Nausea 125 (36%) 60 (17%)
30 Rash 111 (32%) 40 (12%)
40
distance (m)

Dyspepsia 66 (19%) 26 (7%)

50 Dizziness 63 (18%) 35 (10%)
Vomiting 47 (14%) 15 (4%)
60
Photosensitivity reaction 42 (12%) 6 (2%)
70
Anorexia 37 (11%) 13 (4%)
80 Pirfenidone 2403 mg/day (n=345) Arthralgia 36 (10%) 24 (7%)
Placebo (n=347)
90 Insomnia 34 (10%) 23 (7%)
0 12 24 36 48 60 72
Abdominal distension 33 (10%) 20 (6%)
Weeks
Decreased appetite 30 (9%) 10 (3%)
Absolute dierence* (m) 39 186 187 198 233 240
Relative dierence* 322% 628% 525% 406% 382% 312% Stomach discomfort 29 (8%) 6 (2%)
p value 0760 0042 0053 0004 0002 00009 Weight reduction 28 (8%) 12 (3%)

Figure 4: Mean change from baseline in 6-min walk test distance in the Abdominal pain 26 (8%) 12 (3%)
pooled patient population (studies 004 and 006) Asthenia 24 (7%) 13 (4%)
6MWT=6-min walk test. *Pirfenidone 2403 mg/day versus placebo. Rank Pharyngolaryngeal pain 24 (7%) 16 (5%)
ANCOVA (pirfenidone 2403 mg/day vs placebo).
Pruritus 22 (6%) 14 (4%)
Hot ush 18 (5%) 4 (1%)
Pirfenidone Placebo Hazard ratio* p value
2403 mg/day (n=347) (95% CI) Data are number of patients (%). *Occurring in 5% or more of patients given
(n=345) pirfenidone 2403 mg/day in study 004 and study 006, and with an incidence
Overall 15 times greater than that in patients given placebo.
All-cause mortality 27 (8%) 34 (10%) 077 (047128) 0315 Table 4: Treatment-emergent adverse events*
Idiopathic-pulmonary-brosis-related mortality 18 (5%) 28 (8%) 062 (035113) 0117
On-treatment
All-cause mortality 19 (6%) 29 (8%) 065 (036116) 0141 pooled placebo group; the most common event in both
Idiopathic-pulmonary-brosis-related mortality 12 (3%) 25 (7%) 048 (024095) 0030 groups was idiopathic pulmonary brosis (ten [3%] vs
nine [3%]). The only other adverse events leading to
Data are number (%). *Based on the Cox-proportional hazard model. Log-rank test (pirfenidone 2403 mg/day vs
placebo). Assessed by the investigator, who remained masked to treatment assignment. Dened as the time from treatment discontinuation in more than 1% of patients in
randomisation until 28 days after the last dose of study drug. the pooled pirfenidone groups were rash (ve [1%]) and
nausea (ve [1%]).
Table 3: All-cause and idiopathic-pulmonary-brosis-related mortality in the pooled population
Substantial laboratory abnormalities (grade 4 or a
shift of 3 gradesie, from 0 to 3) occurring more
on-treatment eect also favoured pirfenidone for all-cause frequently in the patients in the pooled pirfenidone
and disease-related mortality (table 3). group were hyperglycaemia (four [1%] of 345 vs
Almost all patients in both studies (765 [98%] of 779) three [<1%] of 347), hyponatraemia (ve [1%] vs 0),
reported at least one treatment-emergent adverse event hypophosphataemia (six [2%] vs three [<1%]), and
(table 4; webappendix p 6). The most commonly reported lymphopenia (ve [1%] vs 0); none were associated with
adverse events in the pooled pirfenidone 2403 mg/day clinical sequelae. More patients in the pooled
group, with at least a 15-times increased incidence pirfenidone group than in the pooled placebo group
relative to placebo, were gastrointestinal events (nausea, had elevations in alanine aminotransferase and
dyspepsia, vomiting, and anorexia), skin disorders (rash, aspartate aminotransferase of more than three times
photosensitivity), and dizziness; a dose-response in the upper limit of normal (14 [4%] vs two [<1%]);
frequency was noted (webappendix p 7). These events however, all were reversible and without clinical
were generally mild or moderate in severity and without sequelae, and there was no imbalance between groups
any clinically signicant consequences. Stevens-Johnson in increases of more than ten times the upper limit of
syndrome or toxic epidermal necrolysis were not normal (one [<1%] and two [<1%] in the pirfenidone
reported. Treatment-emergent serious adverse events 2403 mg/day and placebo groups, respectively).
occurred in 113 (33%) of 345 patients in the pooled
pirfenidone group and 109 (31%) of 347 patients in the Discussion
pooled placebo group (webappendix pp 89). The results of study 004 showed a pirfenidone treatment
Study treatment was discontinued because of adverse eect on the change in percentage predicted FVC at
events in 51 (15%) of 345 patients in the pooled week 72. Signicant treatment eect was also noted at
pirfenidone group and 30 (9%) of 347 patients in the earlier timepoints, in the repeated-measures analysis

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over all study timepoints, and on progression-free

survival and categorical FVC change. An ecacy dose- Panel: Research in context
response relation was noted. In study 006, no signicant Systematic review
dierence was noted between the pirfenidone and We searched Medline from January, 1995, to December, 2010, for full reports of randomised,
placebo groups on percentage predicted FVC change at double-blind, placebo-controlled trials of pirfenidone in the treatment of patients with
week 72. However, a signicant pirfenidone treatment idiopathic pulmonary brosis. We identied Japanese phase 2 and phase 3 studies,13,14 and
eect was noted on percentage predicted FVC at all obtained further results from the sponsor (Shionogi, Osaka, Japan). We undertook
timepoints during the rst year and in the repeated- comparative analyses and meta-analyses of the eect of pirfenidone on lung function by
measures analysis over all study timepoints. Analyses of combining results from all four studies.
pooled data for the two studies supported a pirfenidone
treatment eect on percentage predicted FVC, Interpretation
progression-free survival, and 6MWT distance. The patient populations and general characteristics in the Japanese phase 2 and phase 3
Pirfenidone was safe and generally well tolerated. studies are quite similar to those in study 004 and study 006 despite being geographically
Adherence to treatment was high despite a dosing dierent. More men (mean age ~65 years) were enrolled in all four studies, with a
schedule of three times a day. The type and frequency of diagnosis of idiopathic pulmonary brosis that met the standardised clinical and
adverse events were consistent with the known safety radiographic criteria, and mild-to-moderate impairment of lung function. The Japanese
prole of pirfenidone, including gastrointestinal events, study populations had a greater proportion of current smokers and a lower mean
photosensitivity, and rash. Adverse events were typically bodyweight. In each study, the change from baseline in lung function was measured,
mild or moderate in severity, and few led to treatment represented as either forced vital capacity or vital capacity, and multiple other clinical,
discontinuation. Fewer overall deaths and signicantly physiological, and functional variables.
fewer on-treatment deaths related to idiopathic Results from the two Japanese studies provide additional evidence that pirfenidone reduces
pulmonary brosis occurred in the pirfenidone group decline in lung function and prolongs progression-free survival in patients with idiopathic
than in the placebo group. The dierence in FVC progression-free survival. The meta-analysis of change in lung function that includes each
outcomes in the two studies might be partly attributable study up to its point of completion shows a great consistency of treatment eect in all four
to a lower than expected rate of FVC decline in study 006 studies, with the point estimate and 95% CIs at each assessment timepoint (ie, week 24
after 1 year. Although the magnitude of decline over time or 28, week 36 or 40, week 48 or 52, and week 72) clearly excluding no eect (webappendix
was similar in the two pirfenidone groups, those in the p 11). The totality of the data from four randomised controlled trials (Japanese phase 2 and
two placebo groups diered. Rates of decline in phase 3 trials, and studies 004 and 006) provides compelling evidence for the pirfenidone
percentage predicted FVC at week 72 in the active and treatment eect on lung function.
placebo-treated groups in a large trial of interferon- 1b,19
in which no evidence of treatment eect was noted, were
very similar to the placebo group in study 004 pirfenidone treatment eect. Fourth, an ecacy dose-
(webappendix p 6), further strengthening the hypothesis response relation was noted in study 004.
of attenuated FVC decline in the placebo group in The clinical relevance of the treatment eect is an
study 006. An assessment of baseline characteristics in important issue. Change in FVC was selected as the
studies 004 and 006 showed that study 006 had a greater primary endpoint because of its widespread clinical use
proportion of patients with a recent diagnosis of and the clinical relevance of irreversible loss of lung
idiopathic pulmonary brosis, and the placebo group in function.13 FVC was selected as the primary endpoint
study 006 had a greater proportion of patients with because it is a reliable, valid, and responsive measurement
obstructive airway disease, characteristics associated with of irreversible morbidity in idiopathic pulmonary brosis,
reduced FVC decline. These baseline imbalances, with and is highly predictive of survival.1,2025 An assessment of
the intrinsic variability in rates of FVC decline in patients the proportion of patients with a 10% or more decrement
with idiopathic pulmonary brosis, could partly account a threshold widely accepted as clinically meaningful
for the attenuated rate of FVC decline in the placebo and prognostic of death1,2025 is more directly clinically
group in study 006. meaningful than is the assessment of dierences in
The collective data provide evidence that pirfenidone treatment group means. In the pooled analysis of
reduces decline in lung function in patients with categorical FVC change, pirfenidone reduced the
idiopathic pulmonary brosis. First, in the primary proportion of patients with a 10% or more decrement by
analyses of both studies, the magnitude of treatment 30% compared with placebo. Moreover, pirfenidone was
eect was similar at all assessment timepoints during associated with a 26% reduction in the risk of death or
1 year. At week 72, despite signicant dierences in disease progression in analyses of progression-free
outcome, estimates in both studies favoured pirfenidone survival, a 31% reduced mean decline in 6MWT at
and condence intervals overlapped. Second, the week 72, and a consistently favourable direction of eect
repeated-measures analysis of percentage predicted FVC on mortality, despite the trials not being powered to
change over all study timepoints showed a favourable assess mortality.
pirfenidone treatment eect in both studies. Third, These ndings are supported by their consistency
analyses of pooled FVC data provide evidence for a with those of a third independently sponsored phase 3

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study of pirfenidone in patients with idiopathic Hospital Pontchaillou, Rennes, France), A Dhar (Windsor, ON, Canada),
pulmonary brosis, in which the decline in vital capacity A Duarte (University of Texas, Galveston, TX, USA), K Dushay (Rhode
Island Hospital, Providence, RI, USA), K Flaherty (University of
was signicantly reduced at week 52 with a similar Michigan, Ann Arbor, MI, USA), A Frost (Baylor College of Medicine,
magnitude of eect to that at week 48 in studies 004 Houston, TX, USA), L Ginns (Massachusetts General Hospital, Boston,
and 006 (panel).14 Additionally, an independent Cochrane MA, USA), C Girod (Dallas, TX, USA), I Glaspole (The Alfred Hospital,
meta-analysis of all three phase 3 trials of pirfenidone in Melbourne, VIC, Australia), J Golden (University of California,
San Francisco, San Francisco, CA, USA), M Gottfried (Phoenix, AZ,
patients with idiopathic pulmonary brosis (n=1046) USA), H Haller Jr (Louisville, KY, USA), S Harari (Ospedale
showed signicant improvement in progression-free San Guiseppe, Milano, Italy), D Helmersen (Peter Lougheed Center,
survival (hazard ratio 070, 95% CI 056088; p=0002), Calgary, AB, Canada), R Hodder (Ottawa Hospital, Ottawa, ON, Canada),
an endpoint predominantly driven by large reductions H Hollingsworth (Boston University School of Medicine, Boston, MA,
USA), L Homik (Concordia Hospital, Winnipeg, MB, Canada), N Khalil
in lung function.26 (Vancouver General Hospital, Vancouver, BC, Canada), J Kus (Instytut
Our studies have several limitations. Since we enrolled Gruzlicy I Chorob Pluc, Warsaw, Poland), C Leonard (Whythenshawe
patients with mild to moderate idiopathic pulmonary Hospital, Manchester, UK), M Malouf (St Vincents Hospital,
brosis and few comorbidities, our results cannot Darlinghurst, NSW, Australia), S Mette (Maine Medical Center, Portland,
ME, USA), K Meyer (University of Wisconsin, Madison, WI, USA),
necessarily be generalised to the broader population of H Meziane (CHU Hospital Arnaud de Villeneuve, Montpellier, France),
patients. Because concomitant administration of other S Nathan (Inova Transplant Center, Falls Church, VA, USA), M Padilla
treatments for idiopathic pulmonary brosis was (Mount Sinai Medical Center, New York, NY, USA), R Panos (University of
generally prohibited, the eect of these therapies in Cincinnati, Cincinnati, OH, USA), J Pantano (Elk Grove, IL, USA),
N Patel (New York, NY, USA), V Poletti (Azienda Sanitaria di Forli, Forli,
patients given pirfenidone is not known. Also, the lack of Italy), W Ramesh (Edmonton, AB, Canada), L Richeldi (Azienda
adjustment for multiple statistical testing has the Policlinico di Modena, Modena, Italy), J Rolf (Kelowna, BC, Canada),
potential for overinterpretation of the results. Although P Rottoli (Azienda Ospedaliera Universitaria Policlinico Le Scotte, Siena,
the results of these studies and ongoing open-label Italy), T Russell (Washington University School of Medicine, St Louis,
MO, USA), C Saltini (Azienda Ospedaliera Universitaria Policlinico Tor
extension studies suggest that long-term pirfenidone is Vergata, Rome, Italy), M Selman (Instituto Nacional de Enfermedades
safe and generally well tolerated, the eect of treatment Respiratorias, Mexico City, Mexico), H Shigemitsu (University of
for longer than 72 weeks on pulmonary function and Southern California, Los Angeles, CA, USA), D Sinkowitz (Torrance, CA,
USA), D Stollery (Grey Nuns Community Hospital, Edmonton, AB,
disease status is not known.
Canada), M Strek (University of Chicago, Chicago, IL, USA), G Tino
Idiopathic pulmonary brosis remains a progressive (University of Pennsylvania, Philadelphia, PA, USA), B Wallaert (Hospital
and fatal disorder, and no treatment so far has been Albert Calmette, Lille, France), A Wells (Royal Brompton Hospital,
shown to be ecacious, despite several clinical trials in London, UK), T Whelan (University of Minnesota, Minneapolis, MN,
USA), P Wilcox (St Pauls Hospital, Vancouver, BC, Canada), J Zibrak
the past decade.19,2730 The orphan status of idiopathic
(Beth Israel Deaconess Medical Center, Boston, MA, USA), D Ziora
pulmonary brosis, heterogeneity in rates of disease (Samodzielny Publiczny Szpital, Zabrze, Poland), D Zisman (University
progression, and lack of a precedent for regulatory of California, Los Angeles, Los Angeles, CA, USA).
approval complicate eorts to develop novel treatments. Study 006: O Acosta (Hospital Nuestra Senora de la Candelaria, Santa
Cruz Tenerife, Spain), J Ancochea (Hospital Universita de la Princessa,
The data from these two multinational, double-blind,
Madrid, Spain), R Bonnet (Zentralklinik Bad Berka, Bad Berka,
placebo-controlled phase 3 studies show the clinically Germany), M Brantly (University of Florida, Gainesville, FL, USA),
meaningful benet and favourable safety prole of J Chapman (Cleveland Clinic, Cleveland, OH, USA), G Davis (University
pirfenidone in patients with idiopathic pulmonary of Vermont, Colchester, VT, USA), J de Andrade (University of Alabama
Birmingham, Birmingham, AL, USA), D Doherty (University of
brosis. In conclusion, pirfenidone has a favourable Kentucky, Lexington, KY, USA), J Egan (Mater Misericoriae Hospital,
benet-risk prole and represents a suitable treatment Dublin, Ireland), N Ettinger (Chestereld, MO, USA), P Fairman
option for patients with idiopathic pulmonary brosis. (Richmond, VA, USA), T Geiser (University Hospital of Bern, Bern,
Switzerland), K Gibson (University of Pittsburgh, Pittsburgh, PA, USA),
Contributors
M Habib (VA Healthcare System, Tucson, AZ, USA), T Horiuchi
PWN and RMdB co-chaired the study steering committee. PWN, CA,
(Sarasota Memorial Healthcare System, Sarasota, FL, USA), T Ingrassia
WZB, UC, MKG, DK, TEK, LL, SAS, JS, DV, and RMdB participated in
(OSF Saint Anthony Medical Center, Rockford, IL, USA), M Kallay
the design, conduct, analysis, and reporting the study. PWN, CA, UC,
(Highland Hospital, Rochester, NY, USA), J Landis (Baystate Medical
MKG, TEK, LL, SAS, DV, and RMdB were responsible for
Center, Springeld, MA, USA), J Lasky (Tulane University, New Orleans,
implementation at the study sites. DK was responsible for data
LA, USA), D Lorch (Bradenton, FL, USA), H Magnussen (Pulmonary
management and statistical analyses. All authors participated in the
Research Institute, Grosshansdorf, Germany), F Morrell (Hospital Vall
preparation, review, and critical revision of the report, which has been
dHebron, Barcelona, Spain), L Morrison (Duke University Medical
approved by each author.
Center, Durham, NC, USA), M Musk (Royal Perth Hospital, Perth, WA,
CAPACITY Study Group Australia), M Pfeifer (Krankenhaus Donaustauf, Donaustauf, Germany),
Study 004: C Agostini (Universita degli Studi di Padova, Padova, Italy), J Roman (Emory University School of Medicine, Atlanta, GA, USA),
J Allen (Ohio State University, Columbus, OH), C Andrews (Diagnostics G Rosen (Stanford University Medical Center, Palo Alto, CA, USA),
Research Group, San Antonio, TX, USA), D Antin-Ozerkis (Yale H Sakkhija (University of Arkansas, Little Rock, AR, USA),
University School of Medicine, New Haven, CT, USA), R Baughman T Schaumberg (Oregon Clinic, Portland, OR, USA), M Scholand
(University of Cincinnati, Cincinnati, OH, USA), S Burge (Birmingham (University of Utah Health Sciences Center, Salt Lake City, UT, USA),
Heartlands Hospital, Birmingham, UK), A Chan (UC Davis Medical G Serlippi (Pulmonary and Critical Care Services, Albany, NY, USA),
Center, Sacramento, CA, USA), M Confalonieri (Azienda Ospedaliero H Slabbynck (AZ Middelheim, Antwerpen, Belgium), R Sussman
Univeritaria, Trieste, Italy), J Cordier (Hospital Louis Pradel, Bron, (Pulmonary and Allergy Associates, Summit, NJ, USA), J Swigris
France), F Cordova (Temple University Hospital, Philadelphia, PA, USA), (National Jewish Medical and Research Center, Denver, CO, USA),
A Cuomo (Ospedale Maggiore di Parma, Parma, Italy), P Delaval (CHU M Thomeer (University Hospital Gasthuisberg, Leuven, Belgium),

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A Thompson (University of Nebraska, Omaha, NE, USA), G Verghese 11 Iyer SN, Margolin SB, Hyde DM, et al. Lung brosis is ameliorated
(University of Virginia Medical Center, Charlottesville, VA, USA), by pirfenidone fed in diet after second dose in a three-dose
M Wencel (Wichita Clinic, Wichita, KS, USA), J Wirtz (University of bleomycin-hamster model. Exp Lung Res 1998; 24: 11932.
Leipzig, Germany), L Wesselius (Mayo Clinic, Scottsdale, AZ, USA), 12 Iyer SN, Gurujeyalakshmi G, Giri SN, et al. Eects of pirfenidone
H Worth (Klinikum Frth, Frth, Germany), A Xaubet (Barcelona, on procollagen gene expression at the transcriptional level in
Spain), M Yagan (Midwest Pulmonary Consultants, Kansas City, MO, bleomycin hamster model of lung brosis. J Pharmacol Exp Ther
USA), G Yung (University of California, San Diego, CA, USA). 1999; 289: 21118.
13 Azuma A, Nukiwa T, Tsuboi E, et al. Double-blind,
Conicts of interest placebo-controlled, trial of pirfenidone in patients with idiopathic
PWN has served as a clinical investigator, study steering committee pulmonary brosis. Am J Respir Crit Care Med 2005; 171: 104047.
member, or consultant for Actelion, Boehringer Ingelheim, InterMune, 14 Taniguchi H, Ebina M, Kondoh Y, et al. Pirfenidone in idiopathic
and Novartis. CA has served as a study steering committee member and pulmonary brosis: a phase III clinical trial in Japan. Eur Respir J
a consultant for InterMune. UC has served as a clinical investigator or 2010; 35: 82129.
consultant for Actelion, Boehringer Ingelheim, Centocor, Gilead, and 15 Eakin EG, Resniko PM, Prewitt LM, et al. Validation of a new
InterMune; RMdB has served as a study steering committee co-chair or dyspnea measure: the UCSD Shortness of Breath Questionnaire.
steering committee member for Actelion, Bayer, Boehringer Ingelheim, University of California, San Diego. Chest 1998; 113: 61924.
InterMune, and MondoBiotech. TEK has served as an advisory 16 Holland AE, Hill CJ, Conron M, Munro P, McDonald CF. Small
committee member or consultant for Actelion, Gilead, ImmuneWorks, changes in six-minute walk distance are important in diuse
and InterMune. SAS has served as a clinical investigator or study parenchymal lung disease. Respir Med 2009; 103: 143035.
steering committee member for Actelion, Arresto, Celgene, Gilead, 17 Swigris JJ, Wamboldt FS, Behr J, et al. Six-minute walk test in
InterMune, and the National Institutes of Health Idiopathic Pulmonary idiopathic pulmonary brosis: Longitudinal changes and minimal
Fibrosis Network. DV has served as a clinical investigator for Actelion important dierence. Thorax 2010; 65: 17377.
and as a study steering committee member for InterMune. LL and 18 du Bois RM, Albera C, Bradford WZ, et al. 6-minute walk test
MKG have no nancial conicts of interest to disclose. WZB, DK, and JS distance (6MWD) is a reliable, valid, and responsive outcome
measure that predicts mortality in patients with IPF.
are employees of InterMune.
Am J Respir Crit Care Med 2010; published online Dec 3.
Acknowledgments DOI:10.1164/rccm.201007-1179OC.
This study was funded by InterMune (Brisbane, CA, USA). We are 19 King TE Jr, Albera C, Bradford WZ, et al. Eect of interferon
indebted to Alan Cohen, Kenneth Glasscock, and Sharon Safrin for gamma-1b on survival in patients with idiopathic pulmonary
medical writing and editorial assistance, and to the participating sta brosis (INSPIRE): a multicentre, randomised, placebo-controlled
members and patients at all study centres. trial. Lancet 2009; 374: 22228.
20 Collard HR, King TE Jr, Bartelson BB, et al. Changes in clinical
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