Sunday, November 10, 2013

"Should I take prednisone for my Pulmonary Fibrosis?"

I've received a number of questions about whether or not prednisone should be used to treat pulmonary fibrosis. In this post, I am going to try to help you understand the role of prednisone in the treatment of pulmonary fibrosis. I first want to remind you that you should not make any changes to your current medical treatments without discussing things with your doctor. In particular, if you stop taking a medication like prednisone, you could suffer serious and even life threatening withdrawal symptoms.
Prednisone is a "steroid" medication that is frequently used by doctors to treat inflamed organs and tissues -- and its effect can be pretty remarkable. When inflammation is the cause of the problem, prednisone can pretty much wipe out the inflammation and make people feel a whole lot better. I've been pretty impressed by how effective it is during an "exacerbation" (sudden worsening) of asthma. It is also very effective at treating inflammatory arthritis (joint diseases) and skin conditions (including poison ivy!)

So, does prednisone work for Pulmonary Fibrosis?

There really isn't one single answer to this question. For some people, prednisone will be helpful. For others, prednisone won't do much at all, and for others, prednisone will be downright harmful. So, it's really important to try to figure out how helpful or harmful prednisone might be before deciding to start a course of therapy with prednisone. Let's think it through together…

The first step is to figure out exactly which kind of Pulmonary Fibrosis you have. There are at least 100 different kinds of Pulmonary Fibrosis, and in some (but not all) kinds of Pulmonary Fibrosis, lung inflammation is present and might respond to prednisone. An appropriate evaluation designed to figure out which kind of Pulmonary Fibrosis you have (which I discuss here) requires a bit of work on the part of a doctor, quite a few tubes of blood, a CAT scan done the right way, and about 1 out of 3 people will need to undergo a surgical biopsy of the lung to figure out which type of PF you have -- and then you need someone who can put all of that information together to come up with the right diagnosis. I strongly recommend that you figure all of this out at an ILD center.

Some people at this point might say "well, if there might be lung inflammation that could respond to prednisone, why not just try some prednisone to see if it works instead of going through all of that stuff?" Here's why this is usually not a great idea:

Prednisone can cause serious and even life-threatening side effects. You can find some helpful information about these side effects here and here.

And if it turns out that you have one specific form of Pulmonary Fibrosis called Idiopathic Pulmonary Fibrosis (IPF), we now have pretty convincing evidence that prednisone is likely to be harmful for you. The National Institutes of Health (NIH) sponsored a clinical trial called the PANTHER-IPF trial that studied whether a combination of prednisone, azathioprine (another immunosuppressant medication), and N-acetylcysteine (NAC -- an anti-oxidant) would help slow down the progression of IPF compared to placebo pills. This study found that 1 out of 6 people with IPF given this "triple therapy" for one year died because of the treatment and there was absolutely no benefit -- only harm. People treated with "triple therapy" were also more likely to later be hospitalized and to suffer from a sudden worsening ("acute exacerbation"). You can read about the results of this study here.

There are other reasons that it's a good idea to sort out which kind of Pulmonary Fibrosis you have before starting prednisone. For one, it can be challenging to figure out if prednisone is working. Sure, if you lung function gets better, you stop needing oxygen, and you are less short of breath, then I'd agree that the prednisone is working. But, what if prednisone is only slowing down the progression of your condition. You might not feel better at all, but after some time you will be better off than you would have been if you had not been taking prednisone. That's a really tough thing to figure out because you will have gotten worse whether or not you were taking the prednisone -- but you would have been getting sicker more quickly without prednisone. That's a head scratcher and one that makes doctors and patients plain frustrated.

Seems to me that we should not be doling out prednisone unless we figure out which kind of Pulmonary Fibrosis you have. There are a few exceptions, however. Sometimes we can't figure out which kind of PF you have -- maybe the test results are inconclusive, or maybe you need a biopsy but it is considered to be too risky. In these cases, a "trial" of prednisone might be reasonable. We also still use prednisone to treat sudden worsenings (acute exacerbations), even thought we don't really know if it is helping or not.

So, after figuring out what kind of pulmonary fibrosis you have and weighing the risks and potential benefits, prednisone might be worthwhile for some people. Here are some of the things I typically think about when starting prednisone:
  • Prednisone can lead to a lung infection called "PCP". If I am giving more than 20mg of prednisone a day, I usually talk to my patients about taking an antibiotic to prevent this infection.
  • Prednisone can cause "thrush" -- a yeast infection in the mouth, throat, or esophagus. A lozenge or "swish and swallow" liquid medication can help prevent thrush.
  • Prednisone can contribute to brittle bones and bone fractures. Talk to your doctor about whether you should be taking a calcium supplement, a vitamin D supplement, and other bone protective medication. These medications are not appropriate for everyone. Your doctor might also recommend a bone density test.
  • If you have a medical condition that might be aggravated by prednisone (such as diabetes, anxiety, depression, schizophrenia, or osteoporosis), certain precautions should be taken. Be sure to discuss your medical conditions with your doctor.
  • Prednisone can cause weight gain. If you gain too much weight, you might not be eligible to receive a lung transplant -- which is a life saving therapy for some people with Pulmonary Fibrosis.
It's hard to sum up the message about prednisone for pulmonary fibrosis in a single sentence. Maybe that's the message. Prednisone use is complex and shouldn't be boiled down to a soundbite. Prednisone is not all "good" or all "bad."  Like most medications, it does a little bit of what you want and a little bit of what it wants.

Please share your experiences in the comments section below.

48 comments :

  1. Thank you Dr. Lederer for the blog. I was dx in May with IPF. I try to move forward instead of back but I do wish I had seen all this prior to my VATs biopsy and before prednisone. But it is what it is as they say. I was on prednisone (and NAC) after my biopsy. Thank Goodness I did find your site and other blogs/ support sites when the Pulmonary gave me azathioprine. Needless to say I did NOT take it after some kind IPF people sent me the links. I'm baffled as to why a Pulmonary Doctor would still give this combination. I have since moved on to a Center of Excellence for ILD and will be going to Bringham and Women's soon for evaluation to hopefully test for transplantation. The only medication I'm on now for IPF is NAC. I decreased the prednisone and went off but unfortunately not before I gained 35+ lbs which has to come off prior to any transplant. If my children didn't live closer to Boston I'd be seeing the facility where you work instead, those were the choices Yale gave me. I do have the benefit of both centers, I will be going to B&W and your knowledge here.
    Thanks!
    Laura

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    1. Laura, just had my annual physical today. My primary care physician admits he finds them the most boring part of his practice and admits at one time he wanted to specialize in ER medicine where he could be challenged. He told me today that he looks forward to me coming in with my rare disease and especially since I'm so informed about what's going on. He gets to learn with me. He admitted that his medical training was 30 years ago and isn't really up to date on what's happening in the lung transplant area even with Toronto General Hospital just down the road. He said that they continue to learn but I would imagine that it is mostly either out of necessity because a patient has something or because of a particular interest/curiosity in something.

      So most pulmonologists, the ones outside an ILD/PF clinic or COE, are probably in the same boat. What they learned and know about PF is not up todate and since those pulmonologists primarly see COPD, asthma, cystic fibrosis, they don't get up to date. And that knowledge only needs to be a few years out of date since it's only been in the last few years that the tide has turned on the Prednisone + immuno-suppressants treatment.

      I notice that both Dr Lederer and Dr Swigris over at P3F are sending out the same messge. Get to an ILD Clinic asap! I believe personally, and from what I've been reading, that the multi-disciplinary team approach in diagnosis is one of the biggest benefits -- getting to the correct diagnosis asap (and not just saying we don't know the cause of your PF and therefore it's idiopathic) -- but also that the clinic puts you on a regular 6-month or 3-month monitoring schedule. In my experience, most specialist see you, deal with you, and then see you again next year.

      This regular schedule of monitoring also seems to be benefiting those in clinical trials whether they are receiving the drug or placebo. I've been reading that even those on the placebo seem to do better than those who do not have regular clinic visits.

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    2. Hi Laura, Thanks for sharing your experience. Good luck with the transplant evaluation!

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    3. Hi Laura, Why do you say you wish you had this info. before you had a vats and prednisone? Do you think you would now choose to not have a vats and why? Thanks. ~ Bonnie

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  2. I also have been diagnosed with IPF and have diabetes. My doctor told me right off he would not prescribe prednisone due to increase in weight(I have enough to loose) and because of my blood sugar levels. I was afraid he would give it to me and then I would have more weight to loose before transplant. I was on Nac but had to go off due to enrolling in a blind study for an IPF drug. Thanks so much for your blog as we all can use more knowledge in our own health.

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  3. My husband Larry has a confirmed diagnosis of IPF. He had an open lung biopsy in 2007 which confirmed the IPF, plus some hypersensitivity pneumonitis in the mix. He has been on O2 from the start...first on a PRN basis; now 24/7. His PF doctor, Dr. Ganesh Raghu at UW Med Center, started him on the combo of azothiaprine/prednisone/NAC at that time. In late 2011 he was taken off the azothiaprine as a result of the findings of the PANTHER-IPF study and felt much better. He started at 20 mg on the prednisone but was tapered down to 5 mg which he still takes. Other than the weight gain initially (40 pounds - which he has taken off), he has had very few side effects. He had thrush but that has been eliminated, and he has "prednisone skin" which is frustrating. He's had a DEXA scan to check for osteoporosis - there is none. He gets blood sugar checks monthly and nothing there either - very normal. I guess we're one of the lucky ones that way. So Larry continues on the prednisone and NAC for now. He recently caught his first cold since his diagnosis in 2007. It resulted in bronchitis and a step down in his disease. Larry would like to quit taking the prednisone but we both worry that it would result in a further decline in his IPF. We just kind of figure "if it ain't broke don't fix it". We have the discussion with Dr. Raghu every time we see him but Larry prefers to remain on Prednisone.

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  4. I was diagnosed with IPF, but now we are awaiting the results of a 2nd opinion from Washington University in Saint Louis. I do not take Prednisone, but one statement in your article caught my attention. You said the right kind of CAT scan. I had a high res Cat scan with no contrast. Could you in a future column maybe explain what you mean by right kind. Thanks for your very informative writing!

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    1. Hi Kevin. I think that is the kind of scans I have been getting. The very first time the tech asked are you sure it is to be with no contrast. I said I don't know call my dr. He did and said the scan was to be without contrast. Maybe not having the contrast shows more of the different cell formations. Kind of looking a something that is black / white & levels of gray apposed to something very colorful. Gailinpa

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    2. I believe when the contrast is used you are actually having a pulmonary angiogram that could be checking for blood clots and/or pulmonary hypertension.

      The HRCT (high-resolution catscan) without the contrast is required rather than a normal low-resolution catscan to diagnosis and assessment of Interstitial lung disease but no contrast is required as the lung inherently has very high contrast (soft tissue against air).

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    3. Excellent short video on YouTube explaining the difference between a regular catscan and a high-resolution catscan and depending on what the doctor wants check depends on which one is done.

      http://www.youtube.com/watch?v=oWmAa9YCYDs

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    4. Hi Kevin. Gailinpa and Barbara are correct. The right kind of CAT scan is a high resolution CT (HRCT) scan. I discussed this briefly in an older post (http://www.pfdoc.com/2013/08/should-i-undergo-lung-biopsy-to.html). It's something I will probably discuss in more detail in the future.

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  5. I am a 54 yr old M paraplegic of 31 years and I'd taken prednisone a few times in the past because of allergies to ionic dye. Because I was a buyer for pharma products I always read contraindications.
    When trying to diagnose my IPF I was given prednisone. Overnight my breathing improved. When my Rx ran out 10 days later breathing again became labored. After being referred from first one then a second pulmonologist we discussed my treatment options and I continued my own research it became clear there are few choices if we want some quality of life while we wait. Prednisone looks to be the most universal. However, as a para with thinning bones, prone to decubitis ulcers and UTI's I am not looking forward to relying on prednisone long term. Thanks for confirmation of what I feared.

    It's due to lack of interest from the drug companies and other research organizations over the last 30 or 40 years we have not seen new treatments. Until there is more profit in curing IPF than burying it's victims it appears we are relegated to prednisone, transplant, homeopathic and miracles as our options for a cure. I have no problem with any of the options as long as I am around when my daughter & husband decide to have kids.
    PEACE

    p.s. Recently I applied for two drug studies to treat IPF. but because I am unable to walk I did not qualify. I'd like to thank the ignorance of the medical research facilities for their continued shortsightedness.

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  6. Thank you Dr Lederer. This information is so valuable. It helps me understand the prednisone dilemma.

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  7. Was started on something like the panther study. Imuran, pednisone & Glutathione (NAC). I had a bad reaction to the Imuran, still take a very small dose of prednisone every day (for other reasons) and stopped the Glutathione Apr 2012. My disease was progressing very slowly but has really speed up in the past year. If I could go back I think I would try to stay on the Glutathione/ NAC. I believe it is the only arm of the Panther study that is still being done. Of course it is only natural for me to want there to be a reason my disease has progressed into Pul hypertension and a heart shunt. I will never know if staying on the NAC would have changed anything or made it worse than it is. With so many unknowns with PF it seems to be a roll of the dice. Keep talking to your drs. Use website like this one and facebook pages to form questions for your team. For me knowledge is power and I hate the loss of control this disease give me. Gailinpa

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  8. Thank you Dr. Lederer for the information. I am currently taking the three medicines, started in February 2013, and my Dr. adjusted the dosage to twice a day for Imuran and Pednisone (one in the morning and one at night) plus NAC once a day. I have been feeling well since February but unfortunately I caught a bad cold recently (currently on antibiotics) and my condition seems to worsen quickly (mostly out of breath). I am going back to see my Dr tomorrow so hopefully he can do something for me.

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  9. I have seen people post that they would have to wean themselves off prednisone or at least down to a very minimal daily amount before having a biopsy. Someone even said that they were told that because they had been on prednisone, the chances of having a successful biopsy were nil. Not sure what is meant by "successful".

    What is the connection between prednisone and having a biopsy?

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    1. Hi Barbara. When we do a biopsy of the lung, we rely on the pattern of inflammation and scar tissue to tell us which kind of Pulmonary Fibrosis is present. Prednisone is pretty good at fighting off inflammation in the lung, so a lung biopsy performed during or shortly after prednisone therapy can easily give misleading information.

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  10. I've also seen where people have been told that they must wean off or down to minimal daily dosage of prednisone before transplant. Why is prednisone before transplant contraindicated?

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    1. In the past, lung transplant programs would not offer transplantation to people requiring more than 20mg each day. Doctors were (and still are) concerned about prednisone interfering with the normal healing process where the new lung is sutured (stitched) to the airway (bronchus) inside the chest. Prednisone can also interfere in the healing at the suture sites in the arteries and veins in the chest. Nowadays, most lung transplant programs have eliminated the 20mg upper limit, but we still try to get the prednisone dose as low as possible, and it is still uncommon to see someone on the waiting list who needs more than 20mg each day.

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  11. I have seen people post that they would have to wean themselves off prednisone or at least down to a very minimal daily amount before having a biopsy. Someone even said that they were told that because they had been on prednisone, the chances of having a successful biopsy were nil. Not sure what is meant by "successful".

    What is the connection between prednisone and having a biopsy?

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  13. David,
    After I read your blog. There is a clear point to me. Prednisone is not good for anyone. The side-effects are worst than Pulmonary Fibrosis,plus the weight-gain keep you away from a transplant. Could be good for a short term ( one week) for an exacerbations. Did I understand?
    Pam.

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  14. Hi Pam,

    Thanks for this comment. I went back and re-read my post about prednisone and I think I didn't make one thing clear enough: There are definitely people who do better with prednisone than without prednisone. I did state that "For some people, prednisone will be helpful", but it's buried in the post. So let me make it clear here:

    Prednisone can be helpful for some people with PF. If there is inflammation in the lung, prednisone can sometimes slow down progression, sometimes stabilize the disease, and sometimes even reverse the disease. Knowing the risks of prednisone, however, doctors try to figure out whether prednisone is likely to help (or harm) before starting treatment. Sometimes, though, we need to give prednisone right away even before we figure it out (for reasons discussed in the post).

    Does that help balance the discussion a bit more?

    David

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  15. Dear Dr. Lederer,
    I have PF. The fibrosis started with radiation for a bone marrow transplant that I received 20 years ago. However, symptoms didn't start until 5 years ago. No one knows why or why my symptoms have progressed. A biopsy is deemed too risky. There are a few theories: Hypersensitivity Pneumonitis from mold exposure 5 years ago, or possible chronic Graft Vs. Host Disease. I am now on O2 24/7 and high LPM flows with exertion. Over the last 6 months, I because almost completely debilitated and couldn't move from one place to another bend down or even dress myself or shower without desaturating quickly. I started a course of prednisone 10mg/day for another problem and in 4 hours, I was like a new person! My breathing got easier and I could walk around the house, get in and out of the car normally and generally felt like I could begin to live some semblance of a normal life? My ILD specialist has agreed that I could stay on the prednisone at this dose for a month and see how I do. Today, for my 6 minute walk test I increased my ability to walk from 500 ft (2 months ago) with lots of stress to 825 ft today with no stress at all. I am concerned about being on 10mg a day even though it is a fairly low dose for the long term and would like to see if I can maintain the effects at a gradually reduced dose. My goal is 5 mg every other day. Have you seen results with this low dose? thanks so much!

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    1. I am very happy to hear that low dose prednisone has helped you in this way. While your response to prednisone is unusual, it is not unheard of for some people to respond in this way. Best of luck to you!

      Dave Lederer

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    2. Thank you for your prompt reply! Keeping my fingers crossed.

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  16. My mom is 81 and has PF from rhemotoid arthritis. She has been on 10 and 20 mg of prednisone for years but recently was increased to 40 mg as she was complaining she couldn't breathe. She is on oxygen 24/7. we recently went for a second opinion and he felt the 40mg of prednisone was making her so much weaker and hurting her. She cant even walk, she is so week. He cut her down to 20mg and she has been doing that for 6 days now. Was feeling great the first two days and now and feels worse. Very hard to breathe and sleep. Help, we have left message for the doctor but wondering if that was too drastic to cut the prednisone down, I really feel this prednisone is making her feel worse. Not sure its even helping as she has been on it for years.

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    1. I'm sorry to hear that you mother is suffering with breathlessness and difficulty sleeping. As you've already done, the most important first step is to discuss these symptoms with her physician. I can relate to your sense of frustration with this disease and with the effects of prednisone. Sometimes it is hard to tell if symptoms are due to lung disease or to the side effects of the prednisone. It's been a few days since you posted this -- sorry for the delayed response. I hope things are going well now.

      Dave Lederer

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  17. I was looking into Prednesone articles when I found one that stated this: ""We wanted to show that a shorter period of treatment was not less effective than 14 days," said lead researcher Dr. Jorg Leuppi, with the department of medicine at the University Hospital of Basel.

    The shorter course of treatment had the same outcome as the longer course of treatment, the study found. "There is exactly the same time to recovery and exactly the same number of re-exacerbations," Leuppi said.

    In addition, the shorter course of treatment meant fewer side effects from the drug, such as increased blood pressure and elevated blood sugar, he said.

    The report was published May 21 in the online edition of the Journal of the American Medical Association to coincide with its Tuesday presentation at the American Thoracic Society meeting in Philadelphia."
    Do you know of any other research on this?

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    1. Thanks for pointing this article out. This was a clinical trial that focused on the duration of prednisone use for an acute exacerbation of chronic obstructive pulmonary disease (COPD), which is a different condition than pulmonary fibrosis. I do not believe that these results should be applied to folks with pulmonary fibrosis. The article can be found here: http://jama.jamanetwork.com/article.aspx?articleid=1688035

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  18. I'm a 35 yo Female and I have NOT been diagnosed with IPF. June 2013, a CT scan showed I had "multiple bilateral, thin walled cysts" ALL over my lungs. My only symptoms were moderate chest pains and SOB when active (however I am overweight by 60 lbs). My doc ruled out LAM disease, sarcoidosis, pneumonia, HIV, emphysema, COPD, autoimmune, A1-Antitrypsen diff... Biopsy from left sided VATS in Sept 2013 was non specific but the pathology report noted scarring & honeycomb changes.... I was informed that whatever "this" was, it was stable and I just needed to f/u yearly. 1 year post op, Dec. 2014, my CT scan now showed a VERY large 5cm cyst on the other lung... I was urgently scheduled for another surgery at Methodist Hosp in Houston for a right sided VATS (wedge resection) with BAL. The pathology report was inconclusive AGAIN. my surgeon requested for pathology to review EVERYTHING AGAIN and the 2nd report was just the same. NOTHING. Now, I'm waiting to find out what the "Tumor Board" recommends and if they want to send me to National Jewish or Mayo Clinic..... In the meantime, I'm taking 60mg of Prednisone and Batrim. I do NOT like this prednisone. In 2.5 weeks, my face feels even more blown up, I feel like a HOT MESS (more mess than hot!) I can't sleep anymore and I'm BURNING UP all the time now!!
    My main question is, how do we even know this medication is working? How long should I expect to take this? My health is more important to me right now, but it is taking a toll on my stress level now. I just dont feel right, if that means anything at all!!
    All suggestions or info to put my mind at ease would be GREATLY apprecited!!
    FYI... YES I know I'm way too young for all this... TIA & I'm wishing you all the very best!!!

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    1. Hi Briana,

      I'm so sorry to hear about everything you are going through. No matter who you see first (even if it's the best doc in the world), it is always reasonable to get a 2nd or 3rd opinion. Check out the Pulmonary Fibrosis Foundation's website for a list of ILD centers (http://pulmonaryfibrosis.org/life-with-pf/find-medical-care). Important to get a diagnosis.

      Best of luck.

      Dave Lederer

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    2. Hi, My name is Zana and I am From Malaysia.
      I was dx with IPF about 3yrs ago.
      Thank you so much for all this information because currently in Malaysia, the Doctors here hardly has much info on IPF muchless the treatment for it. Even my Cardiologist advice me to read more on the Net to get much picture of IPF.
      I am currently on NAC (Fluimucil 600) which helps to ease my discomfort in trying to survive longer..

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  25. Hi, My name is Zana and I am From Malaysia.
    I was dx with IPF about 3yrs ago.

    Thank you so much for all this information because currently in Malaysia, the Doctors here hardly has much info on IPF muchless the treatment for it. Even my Cardiologist advice me to read more on the Net to get much picture of IPF.

    I am currently on NAC (Fluimucil 600) which helps to ease my discomfort in trying to survive longer..

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    1. Thanks for sharing your story, Zana!

      Dave Lederer

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  26. Hello! I am hoping to find someone who can help me. I have had chronic lung inflammation for quite some time. I currently buy generic advair online to treat my symptoms, but I'm thinking of changing my medication. It is still very difficult for me to breathe a lot of the time. I have a half off coupon for the site I use (50%off), so it's inexpensive, and please keep in mind with any advice I don't have health coverage. Is there another option that is inexpensive that may work better for me? Please help! Here is what I take now http://canadapharmacyrx.com/generic-advair-diskus.html

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    1. Thanks for sharing your mother's story here. I hope you understand that I can't provide medical care or make specific medical recommendations through this website. I do suggest that you talk to your mother's pulmonologist about her diagnosis and treatment plan. I am not sure where in the world you and your mother live, but you can also consider getting an opinion from a center that specializes in pulmonary fibrosis. you can find a list of centers here: http://www.pulmonaryfibrosis.org/life-with-pf/find-medical-care

      lease give your mother my regards.

      Best wishes
      Dave Lederer

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    2. Hello Dr. Lederer,

      would you have information regarding a pulmonologist in central Florida area? We are looking for a second opinion on path of treatment? PF and Auto immune. I am terrified of current recommendations.

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    3. You can search for medical centers here: http://pulmonaryfibrosis.org/life-with-pf/find-medical-care

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  28. Hello Dr. Lederer, first of all thanks for having this blog with such important information. My father who is 72 years old was diagnosed with IPF on Nov. 2014. At that moment, with the lack of information from our side, his pulmonologist prescribed him prednisone starting from 30mg per day and decreasing to 5mg in a period of 10 months. He stayed with 5mg until Nov. 2015 without the need of oxygen concentrator, although his saturation levels were under 85% (consider the fact that we live in Quito-Ecuador which altitud is 9,186 feet above sea level).
    On Nov. 2015 he was hospitalized due to an infection, supposedly in the upper air ways, which affected his lungs too requiring him to stay at the hospital for 3 days and with the need to use oxygen concentrator since then on 24/7 basis. He decided to see another doctor (younger) who explained us about the problems of taking prednisone so he suspended. He prescribed him NAC and omeoprazol. He cannot prescribed him pirfenidone nor nintedanib as they are not available yet in Ecuador and due to the high price. He sent my father to see a cardiologist who confirmed my father has pulmonar hypertension due the IPF. Pulmonar hypertension is quite controlled now, although since he got out of the hospital and stopped taking prednisone his shortness of breath was very critical even when just walking 6 minutes and with the use of oxygen 24/7.
    He was not happy at all and was not eating. He started respiratory therapies which improve his condition a little bit but still not happy. He had no option to try again with the first doctor who prescribed him prednisone again since a month ago, starting with 30mg, taking into consideration that he did not developed any problems at all after having prednisone for one year (besides that infection that it might be atribuible to this medicine).
    The change in his condition was notorious, as my father says with the prednisone he fells he is back to life again, he had more energy, the shortness of breath has improved, he can walk for longer periods, his saturation levels do not drop very drastically using the oxygen concentrator. He is now on 20mg/day and decided to go to coast to see the difference at sea level. He felt so good there that even did not need the oxygen concentrator as his saturation levels were about 93% in average. He now is looking an apartment for renting to go to live at the coast! I think his IPF is the inflammatory type as you mention in this article. Actually is how I found your blog as I was trying to understand why prednisone is not recommended for most people with IPF and why it is good to my father.
    Today his doctor acknowledge his improvement and has asked him to take 20mg of prednisone along with azathioprine. My father told the doctor about the Panther-IPF study and he said that he should stop taking NAC and go with prednisone and azathioprine that it will not be any problem. The prednisone dose will be decreased in time to the minimum dose possible.
    I would appreciate you thoughts with regards of this long story (sorry for that) and specially with regards of taking prednisone and azathioprine. It is ok not taking NAC?

    Thanks and best regards from Ecuador,
    Andres Salvador

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