PICO question 7
In adults with (progressive) CLAD, should antifibrotics be used?

Recommendation

• In adults with (progressive) CLAD phenotype BOS, we suggest not using antifibrotic therapy with pirfenidone. (Conditional recommendation against the intervention, low certainty of evidence) • In adults with (progressive) CLAD phenotype RAS, we suggest either using antifibrotic therapy or not using it. (Conditional recommendation for either the intervention or the comparison, low certainty of evidence)

Remarks
We do not suggest using antifibrotic therapy with pirfenidone in BOS patients given the lack of efficacy. However, antifibrotic therapy might be considered in RAS patients, as – in theory – it might be more effective in this CLAD phenotype demonstrating more extensive fibrosis, although more data are needed to better understand the effect size in this patient population