August 2025
Idiopathic pulmonary fibrosis:
Days 1 to 7: Oral: 267 mg 3 times daily; total daily dose: 801 mg/day.
Days 8 to 14: Oral: 534 mg 3 times daily; total daily dose: 1,602 mg/day.
Day 15 and thereafter: Oral: 801 mg 3 times daily; maximum daily dose: 2,403 mg/day.
Note: Consider slower titration for patients experiencing adverse effects during initial titration (King 2024).
Reinitiation of therapy following interruption: If interruption <14 consecutive days, may reinitiate therapy at previous daily dose without retitration; if interruption ≥14 consecutive days, reinitiate therapy with the initial 2-week titration period up to recommended daily dose.
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
CrCl >80 mL/minute: No dosage adjustment necessary.
CrCl ≥30 to 80 mL/minute: No dosage adjustment necessary (Ref); use with caution. Consider decreasing dose or discontinuing if side effects occur.
CrCl <30 mL/minute: There are no dosage adjustments provided in the manufacturer's labeling, but the AUC of the 5-carboxypirfenidone metabolite is 5.6-fold higher in patients with severe impairment (Ref). Studies have utilized doses up to 2,400 mg/day in patients with severe kidney impairment, although adverse effects (eg, GI) were not uncommon (Ref). Some experts recommend close monitoring and/or a slower titration schedule (ie, dose increases every 2 to 3 weeks) (Ref). Use with caution; consider decreasing dose or discontinuing if side effects occur (Ref).
End-stage kidney disease requiring dialysis: Use is not recommended (has not been studied).
The liver dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Matt Harris, PharmD, MHS, BCPS, FAST, FCCP; Jeong Park, PharmD, MS, BCTXP, FCCP, FAST; Arun Jesudian, MD; Sasan Sakiani, MD.
Note: The following recommendations are derived from pharmacokinetic data extrapolated from patients with liver impairment, using either an IR formulation (available in the US and Canada) or a prolonged-release formulation (available internationally) (Ref).
Liver impairment prior to treatment initiation:
Initial or dose adjustment in patients with preexisting liver cirrhosis:
Child-Turcotte-Pugh class A and B: Oral: Initial: 267 mg 3 times daily for ≥1 week; if tolerated, may increase to 534 mg 3 times daily; maximum dose: 1,602 mg/day (Ref).
Child-Turcotte-Pugh class C: The manufacturer's labeling recommends to avoid use (has not been studied); however, use may be considered in select patients if the benefits are considered to outweigh the risks. Dosing schedules/adjustments may vary depending on disease severity, anticipated or desired response, and concomitant therapies. Refer to institutional protocols and/or consult with hepatologist (Ref).
Liver impairment developing in patient already receiving pirfenidone:
Chronic disease progression (eg, outpatient):
Baseline to Child-Turcotte-Pugh class A and B: No dosage adjustment necessary; however, use with caution along with more frequent monitoring for adverse effects (eg, GI intolerance). Reduce dose or discontinue therapy for intolerable adverse effects (Ref).
Child-Turcotte-Pugh class C: In general, consider discontinuing use; however, continued use may be considered in select patients if the benefits are considered to outweigh the risks. Dosing schedules/adjustments may vary depending on disease severity, anticipated or desired response, and concomitant therapies. Refer to institutional protocols and/or consult with hepatologist (Ref).
Pirfenidone-induced liver injury: Note: Idiosyncratic pirfenidone-induced liver injury is rarely reported (Ref).
ALT/AST >3 to ≤5 times ULN without hyperbilirubinemia or symptoms: As clinically appropriate, may continue current dose, may reduce dose, or may temporarily discontinue therapy. Once aminotransferase elevations have resolved, may be re-titrated to the recommended daily dose (Ref).
ALT/AST >3 to ≤5 times ULN with hyperbilirubinemia or symptoms: Permanently discontinue therapy (Ref).
ALT/AST >5 times ULN (regardless of serum bilirubin concentrations): Permanently discontinue therapy (Ref).
Gastrointestinal (eg, nausea, diarrhea, dyspepsia, vomiting): There are no specific dosage adjustments provided in the manufacturer's labeling; however, consider temporary dosage reduction and/or therapy interruption to allow for resolution of symptoms.
Photosensitivity reaction or rash: There is no specific dosage adjustment provided in the manufacturer's labeling; however, consider temporary dosage reduction and/or therapy interruption to allow for resolution of symptoms. Confirmation of a severe cutaneous adverse drug reaction (eg, Stevens-Johnson syndrome, toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms) warrants discontinuation of treatment (Ref).
Refer to adult dosing.
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Adverse reactions reported in adults.
>10%:
Dermatologic: Skin rash (30%)
Gastrointestinal: Abdominal pain (24%), decreased appetite (21%), diarrhea (26%), dyspepsia (19%), gastroesophageal reflux disease (11%), nausea (36%), vomiting (13%)
Nervous system: Dizziness (18%), fatigue (26%), headache (22%)
Respiratory: Sinusitis (11%), upper respiratory tract infection (27%)
1% to 10%:
Dermatologic: Pruritus (8%), skin photosensitivity (9%)
Endocrine & metabolic: Weight loss (10%)
Gastrointestinal: Dysgeusia (6%)
Hepatic: Increased serum alanine aminotransferase (≥3 × ULN: ≤4%), increased serum aspartate aminotransferase (≥3 × ULN: ≤4%)
Nervous system: Asthenia (6%), insomnia (10%), noncardiac chest pain (5%)
Neuromuscular & skeletal: Arthralgia (10%)
Postmarketing:
Dermatologic: Severe cutaneous adverse reaction (including drug reaction with eosinophilia and systemic symptoms, Stevens-Johnson syndrome, toxic epidermal necrolysis)
Hematologic & oncologic: Agranulocytosis
Hepatic: Hepatoxicity
Hypersensitivity: Angioedema
There are no contraindications listed in the manufacturer's US labeling.
Canadian labeling: Additional contraindications (not in US labeling): Hypersensitivity to pirfenidone or any component of the formulation; history of angioedema with pirfenidone; concomitant use of fluvoxamine; severe hepatic impairment or end-stage liver disease; severe renal impairment (CrCl <30 mL/minute) or end-stage renal disease requiring dialysis.
Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Concerns related to adverse effects:
• CNS effects: May cause dizziness and/or fatigue which may impair physical or mental abilities; patients must be cautioned about performing tasks which require mental alertness (eg, operating machinery or driving). Incidence of dizziness may be reduced by administering with food. Dose reduction or discontinuation may be necessary if symptoms fail to improve or worsen.
• GI effects: Adverse effects including nausea/vomiting, diarrhea, dyspepsia, gastroesophageal reflux disease, and abdominal pain have been reported; incidence may be reduced by administering with food. The incidence of gastrointestinal events was highest early in the course of treatment (initial 3 months) and decreased over time. Consider dose reduction or discontinuation of therapy if lack of improvement or worsening of symptoms.
• Hepatic effects: Serious and nonserious cases of drug-induced liver injury (including severe liver injury with fatal outcome) have been reported. Elevations of ALT and AST were reversible with dose modification or discontinuation of therapy.
• Photosensitivity: Photosensitivity reactions and rash have been reported with the majority of reactions occurring during the initial 6 months of therapy (severe reactions are uncommon); instruct patients to avoid or minimize exposure to the sun and/or sun lamps, to apply sunscreen (SPF ≥50 against UVA and UVB), wear protective clothing/hats, and to avoid concurrent use of other photosensitizing drugs. Patients should promptly report symptoms, reaction, or rash; dose reduction or therapy interruption may be necessary. If appropriate, may reinitiate therapy with re-escalation of dose as tolerated.
• Severe cutaneous adverse reactions: Severe cutaneous adverse reactions (eg, Stevens-Johnson syndrome, toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms) have been reported. Confirmation of these reactions warrants permanent discontinuation of therapy (King 2024).
• Weight loss: Weight loss/anorexia have been reported with use; monitor weight during therapy.
Disease-related concerns:
• Kidney impairment: Use with caution in patients with kidney impairment; consider dose reduction and/or discontinuation as necessary; use in patients with end-stage kidney disease requiring dialysis is not recommended.
• Liver impairment: Use with caution in patients with mild to moderate liver impairment; dosage adjustment may be necessary. Use should generally be avoided in severe impairment.
Special populations:
• Cigarette smokers: Clearance may be increased, and systemic exposure decreased in cigarette smokers due to hepatic enzyme (ie, CYP1A2) induction. Patients should be instructed to quit smoking prior to initiation of therapy; cigarette smoking should be avoided during therapy.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Capsule, Oral:
Esbriet: 267 mg
Generic: 267 mg
Tablet, Oral:
Esbriet: 267 mg, 801 mg
Generic: 267 mg, 534 mg, 801 mg
Yes
Capsules (Esbriet Oral)
267 mg (per each): $46.44
Capsules (Pirfenidone Oral)
267 mg (per each): $13.34 - $44.12
Tablets (Esbriet Oral)
267 mg (per each): $46.44
801 mg (per each): $139.33
Tablets (Pirfenidone Oral)
267 mg (per each): $5.84 - $44.12
534 mg (per each): $132.36
801 mg (per each): $17.87 - $132.36
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Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Capsule, Oral:
Esbriet: 267 mg [DSC] [contains fd&c blue #2 (indigotine,indigo carmine)]
Generic: 267 mg
Tablet, Oral:
Esbriet: 267 mg, 801 mg
Generic: 267 mg, 801 mg
Oral: Administer with food at the same time each day.
Idiopathic pulmonary fibrosis: Treatment of idiopathic pulmonary fibrosis.
Substrate of CYP1A2 (Major), CYP2C19 (Minor), CYP2C9 (Minor), CYP2D6 (Minor), CYP2E1 (Minor); Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential;
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program by clicking on the “Launch drug interactions program” link above.
Aminolevulinic Acid (Systemic): Photosensitizing Agents may increase photosensitizing effects of Aminolevulinic Acid (Systemic). Risk X: Avoid
Aminolevulinic Acid (Topical): Photosensitizing Agents may increase photosensitizing effects of Aminolevulinic Acid (Topical). Risk C: Monitor
Broccoli: May decrease serum concentration of CYP1A2 Substrates (High risk with Inducers). Risk C: Monitor
Cannabis: May decrease serum concentration of CYP1A2 Substrates (High risk with Inducers). Risk C: Monitor
Ciprofloxacin (Systemic): May increase serum concentration of Pirfenidone. Management: Avoid this combination if possible. With ciprofloxacin doses of 1,500 mg/day, the pirfenidone dose should be reduced to 1,602 mg per (534 mg three times a day). With lower daily doses of ciprofloxacin, use pirfenidone with caution. Risk D: Consider Therapy Modification
CYP1A2 Inducers (Moderate): May decrease serum concentration of Pirfenidone. Risk C: Monitor
CYP1A2 Inhibitors (Moderate): May increase serum concentration of Pirfenidone. Management: Avoid concomitant use of pirfenidone and moderate CYP1A2 inhibitors whenever possible. If combined, decrease the pirfenidone dose to 1,602 mg per day (534 mg three times daily) and monitor for increased pirfenidone toxicities. Risk D: Consider Therapy Modification
CYP1A2 Inhibitors (Strong): May increase serum concentration of Pirfenidone. Management: Avoid concomitant use of pirfenidone and strong CYP1A2 inhibitors whenever possible. If combined, decrease the pirfenidone dose to 801 mg per day (267 mg three times daily) and monitor for increased pirfenidone toxicities. Risk D: Consider Therapy Modification
Diazoxide Choline (Extended Release): May increase serum concentration of CYP1A2 Substrates (High risk with Inhibitors). Risk X: Avoid
Porfimer: Photosensitizing Agents may increase photosensitizing effects of Porfimer. Risk X: Avoid
Primaquine: May increase serum concentration of CYP1A2 Substrates (High risk with Inhibitors). Risk C: Monitor
Temoporfin: Photosensitizing Agents may increase photosensitizing effects of Temoporfin. Risk X: Avoid
Tobacco (Smoked): May decrease serum concentration of Pirfenidone. Risk X: Avoid
Verteporfin: Photosensitizing Agents may increase photosensitizing effects of Verteporfin. Risk C: Monitor
Food decreased Cmax ~50% and AUC by ~15% to 20% compared to the fasted state. However, incidence of certain adverse events (eg, nausea, dizziness) was decreased when administered with food. Grapefruit products may inhibit the CYP-mediated metabolism of pirfenidone and increase its exposure. Management: Administer with food. Limit or avoid grapefruit products during therapy.
Adverse events have been observed in animal reproduction studies.
It is not known if pirfenidone is present in breast milk. According to the manufacturer, the decision to continue or discontinue breastfeeding during therapy should take into account the risk of infant exposure, the benefits of breastfeeding to the infant, and benefits of treatment to the mother.
Take with food to decrease frequency of dizziness or nausea. Limit or avoid grapefruit juice.
Hepatic function tests (ALT, AST, bilirubin; prior to initiation, monthly for first 6 months, then every 3 months thereafter and as clinically indicated based on symptoms of hepatic injury [eg, fatigue, anorexia, right upper abdominal discomfort, dark urine, jaundice]); signs of photosensitivity; GI symptoms (eg, diarrhea, nausea, vomiting); weight loss.
Precise mechanisms of action have not been fully elucidated; however, pirfenidone may exert antifibrotic properties by decreasing fibroblast proliferation and the production of fibrosis-associated proteins and cytokines; may decrease the formation and accumulation of extracellular matrix (ie, collagen) in response to transforming growth factor-beta and platelet derived growth factor. Pirfenidone is also believed to exert anti-inflammatory properties by decreasing the accumulation of inflammatory cells resulting from a variety of stimuli.
Distribution: ~59 to 71 L
Protein binding: Mean: 58% (primarily to albumin)
Metabolism: Hepatic primarily via CYP1A2 and to a lesser extent via CYP2C9, 2C19, 2D6, and 2E1; major metabolite (5-carboxy-pirfenidone) is partially active (Togami 2013).
Half-life elimination: ~3 hours
Time to peak, plasma: Median: 0.5 hours (fasting); 3 hours (with food)
Excretion: Urine (~80%; >99% as metabolite)
Altered kidney function: Systemic exposure (AUC0 to ∞) increased ~1.4, 1.5, and 1.2-fold in mild, moderate, and severe kidney impairment, respectively. The corresponding AUC0 to ∞ of 5-carboxy-pirfenidone increased 1.7, 3.4, and 5.6-fold. The kidney clearance of 5-carboxy-pirfenidone decreased significantly in patients with moderate to severe impairment.
Hepatic function impairment: In patients with moderate impairment (Child Pugh class B), mean exposure, AUC0 to ∞ and Cmax increased ~1.6- and ~1.4-fold in moderate hepatic impairment, respectively.
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