Ryan Haumschild, PharmD, MS, MBA: There are also some of these economic and clinical considerations as the disease progresses. We’ve talked about these great management [strategies], but ultimately, Dr Noble mentioned it, transplantation can be part of some people’s journey, however, we try to avoid it with proper management. So Dr Noble, I’ll ask you a little further, when do you see lung transplantation indicated in these patients, and what are some of the biggest economic considerations of lung transplants?

Paul Noble, MD: My story with lung transplant is sort of an interesting one, because when I trained in Denver [Colorado], we didn’t have a transplant program yet. Then when I started my first real job 30 years ago at Johns Hopkins [Medicine, in Baltimore, Maryland], they started a lung transplant program, and it seemed like everybody died. Then I went up to Yale [Medicine, in New Haven, Connecticut], and I was there for 9 years. We didn’t have a transplant program, so I sent my patients in New York or Boston. It just seemed like nothing good ever happened. Then I moved to Duke [University Medical Center, in Durham, North Carolina], and I became a believer. My last year we did 150 lung transplants, and I saw miraculous things. I do think it needs to be considered. I’m going to put in a small pitch. We have our program here, it has a minimally invasive lung transplant, I don’t know Dan and Kristin, if you’ve heard of this. We recruited this fellow who came from the United Kingdom, and he learned how to do it in Germany. We did 60 last year, and we’re on a pathway to do more. It’s an incision that’s about that big.

One of the big challenges with lung transplant is it’s a massive operation compared to heart, kidney, and liver [transplants]. This may be a potential game changer in terms of older people because for IPF [idiopathic pulmonary fibrosis], which is still the major reason people get transplanted, most of these people are north of 60 [years old]. Then you get into the whole argument of north of 70 [years old], some places will transplant, some place won’t. The Cleveland Clinic’s very aggressive, and we’re pretty aggressive here, now that we’ve got such a good team. So I do think it’s a conversation, and I’m not a transplant person, but in terms of taking care of folks, I say my job is always to present options, and whatever the patient decides I 100% support. I’ve seen a 74-year-old guy with 1 kidney who I was shocked would have a transplant, live 8 years, and a physician I took care of who was 66 with IPF, who didn’t want a transplant and succumbed to IPF. It’s a very personal decision for the patients, but I really think it’s our job to give them that option. Refer them early, once they’re desaturating significantly, because the acute exacerbation can really take you out, so you’d like to have him in the queue. I’m also biased because we get all the lung tissue from the explants, and we do research on that, which we’re hoping will lead to some new ideas about how to target IPF. So I’ve become somebody who would never have a lung transplant to looking forward to having mine at 83.

Ryan Haumschild, PharmD, MS, MBA: I appreciate the background, and you’re right about that progression; it’s been interesting to see some of the centers have different outcomes when it comes to lung transplant. [We’re] starting to see that improvement in creating that option for patients. If we manage them appropriately, we want to reduce that chance of needing a lung transplant, but when done well, it provides such a therapeutic option for those who are suffering.

This transcript has been edited for clarity.