Autoantibody Reduction Therapy for Progressive Idiopathic Pulmonary Fibrosis

Patients with progressive pulmonary fibrosis, identified at any of nine participating leading U.S. medical centers, will be randomized (by computer) in a 1:1 ratio to either AART or treatment as usual (TAU). Stratification factors for randomization are sex (self-identified) and whether or not patients are taking any IPF-approved medication. Patients will be observed for six (6) months, with observations and assessments made at baseline, 30 days after randomization, and 90 and 180 days after randomization.

Data will be electronically submitted via electronic case report forms (eCRF) to a Data Coordinating Center.

The University of Alabama Medical Center Institutional Review Board (IRB) will be the central IRB for all sites.

Specimens collected will also be used in experimental B-cell studies conducted in the laboratory of the Principal Investigator.

• Therapeutic Plasma Exchange (Other), also known as Plasmapheresis: Removal of patient's plasma by mechanical means and replacement with saline and albumin or normal plasma
• Rituximab (Drug), also known as ritux: Infusion of humanized mouse monoclonal antibody with specificity for human CD20
• Intravenous immunoglobulin (Drug), also known as IVIg: intravenous infusions of normal human immunoglobulin
• Treatment as Usual (Drug): Continued therapy with conventional, approved, specific IPF medications

Primary outcomes

• Forced Vital Capacity (FVC) [180 days or latest available observation (e.g., at 30, 90, or 180 days after randomization)]: Intergroup comparisons of FVC changes over duration of observations

Secondary outcomes

• Supplemental Oxygen Requirements (O2) [180 days or latest available observation (e.g., at 30, 90, or 180 days after randomization)]: Intergroup comparisons of changing O2 requirements over duration of observations
• Six-minute walk distances (6MWD) [180 days or latest available observation (e.g., at 30, 90, or 180 days after randomization)]: Intergroup comparisons of changes of 6MWD over duration of observations
• Durations of progression-free survival [180 days or latest available observation (e.g., at 30, 90, or 180 days after randomization)]: Intergroup comparisons of number who survive without >5% decrements of FVC as percent of predicted normal values
• Composite outcome measure [180 days or latest available observation (e.g., at 30, 90, or 180 days after randomization)]: Absolute numbers of acute IPF exacerbations or all cause deaths or unscheduled hospitalizations

Sex: All, ages: 40 Years to 85 Years

Inclusion Criteria:

1. Age between 40-85 years old.
2. A diagnosis of IPF that fulfills latest ATS/ERS Consensus Criteria.
3. A diagnosis of Progressive IPF (P-IPF), defined as a relative decrease of FVC%p >10% during the preceding twelve months, and substantiated by replicate values at least three weeks apart.
4. Ability and willingness to give informed consent (no surrogates) and adhere to requirements.
5. Have eligibility confirmed by a consensus of trial investigators.
6. Is not now or has been in experimental regimen for at least 2 weeks (or 5 half-lives of agent) and agrees to not become participants in other experimental regimens (other than solely observational registries) for the duration of their participation in this trial (180 days).
7. Has been immunized with 2025-2026 COVID-19 vaccine (and later versions as they become available) between 1 and 26 weeks prior to randomization.
8. IPF duration <10 years, based on the date of definitive diagnosis.
9. Ratio of forced expiratory volume in 1 second to forced vital capacity (FEV1/FVC) >0.70

Exclusion Criteria:

1. Diagnoses of current infection by clinical or microbial assessments.
2. Diagnoses of an additional or alternative etiology for lung dysfunction based upon clinical assessment, including sepsis, congestive heart failure, thromboembolism, worsened pulmonary artery hypertension, etc. using routine clinical evaluations under direction of the attending physician.
3. History or serologic evidence of hepatitis B or C infection. Positive serology for Hepatitis C will not exclude patients if their circulating HC virus RNA test is negative.
4. Coagulopathy, defined as an INR >1.6, PTT >2x control, fibrinogen <100 mg/dL, or platelet count <50,000 unless these abnormalities can be reversed.
5. Uncontrolled diabetes or hypertension (systolic BP >160 mm Hg and diastolic BP >100 mm Hg) that would contraindicate use of corticosteroids.
6. Hemodynamic instability, defined as an inotrope or vasopressor requirement.
7. History of reactions to blood products, murine-derived products, or prior rituximab use within the last six months.
8. History of malignancy, excluding basal or squamous cell skin cancer and low-risk prostate cancer, the latter defined as stage T1 or T2a, with prostate specific antigen <10 ng/dl. AART is not known to promote cancer, and these criteria are within current guidelines.
9. Unwillingness to accept blood product transfusion.
10. Diagnosis of major comorbidities expected to interfere with study participation.
11. Treatment for >14 days within the preceding month with >20 mg. prednisone (or equivalent) or any treatment during the last month with a cellular immuno-suppressant (e.g., cyclophosphamide, methotrexate, calcineurin inhibitors, etc.), or with rituximab (or other anti-B-cell biological agents) within the last 6 months.
12. Current treatment with an angiotensin converting enzyme inhibitor that cannot be discontinued and/or substituted (to obviate hemodynamic lability during TPE).
13. Fertile women who do not agree to contraception or abstinence. IPF is a disease of older adults, and male predominant, so this will not be a frequent consideration.
14. An alternative, concordant or historical diagnosis of interstitial lung diseases other than IPF, including idiopathic fibrosis with autoimmune features (IPAF) per clinical domain.1
15. IgA deficiency, to preclude IVIg reactions.
16. Listed with the United Network for Organ Sharing (UNOS) for lung transplant at the time of enrollment, to minimize the number of censoring due to very early transplants.
17. Ongoing suspected or known acute exacerbations of IPF (AE-IPF), defined as new onset (within the last 30 days) of dyspnea with increased hypoxemia or oxygen requirement, and new radiographic infiltrates especially with ground glass opacities (GGO).
18. Patients taking antifibrotic agents at randomization who have not been on a stable dose for at least 6 weeks: these therapies could be initiated, at the discretion of their attending physicians, at or after the midpoint of their participation in STRIVE II (i.e., three months after randomization).
19. Patients whose oxygen requirements at rest (per an arterial oxygen saturation \[SaO2\] >0.92) cannot be met with simple nasal cannula at <10L/min.
20. Patients who are not expected to survive 180 days or, in the opinion of the local attending physician, have a high likelihood of not tolerating the trial interventions due to underlying comorbidities or frailties.
21. >10% of whole lung images are emphysematous on High Resolution CT scan

    \-

• Results publication: Donahoe M, Valentine VG, Chien N, Gibson KF, Raval JS, Saul M, Xue J, Zhang Y, Duncan SR. Autoantibody-Targeted Treatments for Acute Exacerbations of Idiopathic Pulmonary Fibrosis. PLoS One. 2015 Jun 17;10(6):e0127771. doi: 10.1371/journal.pone.0127771. eCollection 2015. PMID 26083430
• Results publication: Kulkarni T, Criner GJ, Kass DJ, Rosas IO, Scholand MB, Dilling DF, Summer R, Duncan SR. Design of the STRIVE-IPF trial- study of therapeutic plasma exchange, rituximab, and intravenous immunoglobulin for acute exacerbations of idiopathic pulmonary fibrosis. BMC Pulm Med. 2024 Mar 20;24(1):143. doi: 10.1186/s12890-024-02957-3. PMID 38509495

• Steven R Duncan, MD, Principal investigator, University of Alabama at Birmingham