“Wait and watch” is often advised for chronic breathlessness. In pulmonary fibrosis, that approach is risky. I have seen better outcomes when patients understand their options early and act with a clear plan. This overview sets out the current pulmonary fibrosis treatment pathways in India and where newer therapies may fit. It is basically a practical map for measured decision-making.

Current Pulmonary Fibrosis Treatment Options Available in India

1. Antifibrotic Medications

For idiopathic pulmonary fibrosis, antifibrotics are the clinical backbone. In India, pirfenidone and nintedanib are available through multiple brands, including generics in some centres. I use them to slow functional decline rather than to reverse scarring. That distinction matters. Dose adjustments are common for gastrointestinal side effects or liver enzyme changes, and regular monitoring is prudent.

• Pirfenidone: Typically initiated with a titration schedule to improve tolerability.
• Nintedanib: Often preferred when rapid decline is evident, given its antifibrotic and anti-inflammatory profile.
• Supportive measures: Sun protection with pirfenidone and diarrhoea management with nintedanib are practical details that help adherence.

As part of comprehensive pulmonary fibrosis treatment, I review comorbidities, vaccination status, and drug interactions at baseline and at each follow up.

2. Nerandomilast

Nerandomilast has drawn interest as part of the latest treatments for pulmonary fibrosis. It targets inflammatory signalling that may drive fibrosis progression. Availability in India will likely track regulatory approvals and distribution agreements, which can vary by year and by sponsor. In practice, I advise patients to confirm trial enrolment opportunities with tertiary ILD clinics and to verify any access claims from third parties. Expectations should be measured until robust real world data in Indian cohorts appears.

3. Combination Therapy Options

Combination therapy is sometimes considered when disease progresses despite monotherapy. Two patterns appear in clinics: combining antifibrotics with careful symptom control, and, more selectively, adding agents within research protocols. The first is routine. The second is conditional and should stay within trial governance. My threshold for combination therapy is functional decline over serial spirometry with consistent radiological change. Not a single bad week.

• Standard: Antifibrotic plus inhaled bronchodilator if airflow limitation coexists.
• Conditional: Antifibrotic plus short course of corticosteroid only for acute exacerbations.
• Research settings: Novel add on drugs within protocol oversight.

4. Oxygen Therapy and Support

Oxygen therapy supports activity and sleep when saturation falls below targets on exertion or at rest. I prescribe after a structured assessment that includes a six minute walk test and nocturnal oximetry where feasible. Home concentrators and portable cylinders are widely available in Indian metros, with variable access in smaller towns. A simple rule helps daily living. Keep SpO2 above the threshold set by the treating team during rest and during everyday tasks.

• Delivery formats: Stationary concentrators for home, portable systems for travel.
• Safety: Avoid open flames and ensure reliable power backup during outages.
• Travel: Pre clear airline requirements and arrange in flight oxygen if needed.

5. Pulmonary Rehabilitation Programmes

Pulmonary rehabilitation remains one of the most effective adjuncts for symptom control. I recommend structured programmes that combine endurance training, breathing techniques, and education on energy conservation. Benefits typically include improved exercise tolerance and reduced dyspnoea perception. The effect is not cosmetic. Patients often regain confidence in routine tasks, which stabilises quality of life.

• Core elements: Supervised exercise, breathing retraining, airway clearance if needed.
• Education: Inhaler technique, pacing strategies, and nutrition guidance.
• Outcome tracking: Repeat walk tests and patient reported outcome measures.

Advanced Treatment Options and Lung Transplantation

Lung transplantation is considered for advanced disease when medical therapy no longer maintains function. In India, established programmes operate in several cities.

Programmes evolve, so patients should verify current accreditation, volumes, and waiting list times.

Eligibility Criteria

I discuss transplant early when oxygen needs rise, FVC continues to decline, or pulmonary hypertension complicates the course. Typical criteria include adequate cardiac function, acceptable BMI, optimised infection status, and the ability to adhere to intensive post operative care. Absolute contraindications vary by centre. A frank pre listing assessment prevents late stage surprises.

• Timing: Referral before severe deconditioning improves candidacy.
• Support: Reliable caregiver availability is essential after discharge.
• Preparation: Vaccinations, dental clearance, and nutrition optimisation.

Success Rates and Survival Data

Global registries suggest improving outcomes for lung transplant in fibrotic lung disease, though figures differ by centre and methodology. In my counselling, I present a balanced picture. Survival improves for many, but complications such as rejection, infection, and chronic lung allograft dysfunction remain material risks. The decision is ultimately about values, prognosis, and acceptable trade offs.

Conclusion

Pulmonary fibrosis treatment in India now spans steady antifibrotic foundations, structured rehabilitation, and carefully timed transplant referral. Newer possibilities such as nerandomilast are promising to an extent, yet clinical access will depend on regulatory progress and centre protocols. My advice is consistent. Build a coordinated plan with a specialist team, track function with discipline, and adjust course before decline becomes entrenched.