From the Guidelines
For a patient with Idiopathic Pulmonary Fibrosis (IPF) and Chronic Kidney Disease (CKD), nintedanib is generally preferred over pirfenidone due to its more favorable pharmacokinetic profile in renal impairment and lack of requirement for dose adjustment in mild to moderate CKD. Nintedanib is typically started at 150 mg twice daily, and can be reduced to 100 mg twice daily if side effects occur, as suggested by the INPULSIS trials 1. Pirfenidone, on the other hand, requires dose adjustment in CKD and is contraindicated in severe renal impairment. The choice between these drugs should consider the specific type of ILD, as nintedanib has broader approval across ILD subtypes, and individual patient factors, comorbidities, and potential side effects, as recommended by the ATS/ERS/JRS/ALAT clinical practice guideline 1. Additionally, the most recent guideline from 2022 suggests that nintedanib can be used for the treatment of progressive pulmonary fibrosis in patients who have failed standard management for fibrotic ILD, other than IPF 1. It is also important to note that nintedanib has shown efficacy across a broader range of ILD subtypes, as discussed in the 2023 review of state-of-the-art evidence in the treatment of systemic sclerosis 1. Monitor liver function tests and for gastrointestinal side effects with nintedanib, and be aware of potential drug interactions, particularly with anticoagulants. Key points to consider when choosing between nintedanib and pirfenidone include:
- Nintedanib's lack of requirement for dose adjustment in mild to moderate CKD
- Nintedanib's more favorable pharmacokinetic profile in renal impairment
- Nintedanib's broader approval across ILD subtypes
- Individual patient factors, comorbidities, and potential side effects.
From the Research
Comparison of Nintedanib and Pirfenidone in IPF and CKD
- Nintedanib and pirfenidone are two anti-fibrotic therapies available for the treatment of Idiopathic Pulmonary Fibrosis (IPF) 2, 3, 4, 5, 6.
- Both drugs have been shown to slow disease progression in IPF patients, but there is a lack of comparative trials between the two 5.
- Nintedanib has been found to be safe and effective in patients with IPF, with a favorable long-term safety profile 3, 5.
- Pirfenidone has anti-fibrotic, anti-oxidant, and anti-inflammatory properties, while nintedanib is a tyrosine kinase inhibitor with selectivity for vascular endothelial growth factor, platelet-derived growth factor, and fibroblast growth factor receptors 4.
- In patients with IPF and Chronic Kidney Disease (CKD), nintedanib may be a viable option, as it has been shown to be safe in a patient with concomitant kidney failure 2.
- However, more studies are necessary to fully understand the safety and efficacy of nintedanib in patients with IPF and CKD 2.
Safety and Efficacy in CKD
- Nintedanib is contraindicated in patients with severe renal impairment (creatinine clearance < 30 mL/min) due to a lack of studies on its safety and efficacy in this population 2.
- However, a case report has shown that nintedanib can be safely used in a patient with IPF and stage 3/4 CKD, with careful monitoring of liver and kidney function 2.
- Pirfenidone has not been specifically studied in patients with IPF and CKD, but it has been shown to be safe and effective in patients with IPF in general 4, 6.
Treatment Considerations
- The choice of treatment between nintedanib and pirfenidone is left to the physician's judgement, as there is a lack of comparative trials between the two 5.
- Non-pharmacologic approaches, such as long-term oxygen therapy, pulmonary rehabilitation, and lung transplantation, should also be considered as additional treatment modalities 6.