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Respiratory specialists clashed at the ERS 2026 Congress over whether to start patients with pulmonary fibrosis on combination antifibrotic therapy right away or take a cautious, stepwise approach. Proponents argue early, aggressive treatment yields better outcomes, while skeptics say the evidence for true upfront dual therapy in drug-naive patients simply isn't there yet. After the debate, the audience swung toward caution — 63% voted against upfront combination therapy.
At the European Respiratory Society 2026 International Congress in Barcelona, respiratory clinicians squared off over one of pulmonary fibrosis medicine's hottest questions: should patients with idiopathic pulmonary fibrosis (IPF) start on combination antifibrotic therapy from day one, or should clinicians escalate treatment only when disease progression demands it?
The "pro" camp, led by Dr. François Cottin of the University of Lyon, argued that waiting for irreversible lung function decline before intensifying therapy is a missed opportunity. He pointed to observational data showing that starting antifibrotics within 6 months of diagnosis significantly reduced disease worsening and hospitalizations, and drew parallels to combination therapy successes in lung cancer, COPD, and pulmonary arterial hypertension.
On the other side, Dr. Claudia Valenzuela cautioned that while next-generation agents like nerandomilast have shown impressive results in phase 3 trials (FIBRONEER-IPF, TETON-1/2), those trials enrolled mostly patients already on background monotherapy — not truly drug-naive patients. She flagged real concerns around safety, treatment burden, drug interactions, and cost.
Key Takeaways:
Why it matters: With a new wave of antifibrotics entering the pipeline, the field is at an inflection point. How clinicians resolve this debate will shape treatment guidelines and patient outcomes for millions living with a disease that currently has no cure.
