From the Guidelines
Nintedanib is conditionally recommended as a first-line ILD treatment option for people with SSc-ILD, but not for those with SjD-ILD, IIM-ILD, or MCTD-ILD, according to the 2023 American College of Rheumatology (ACR)/American College of Chest Physicians (CHEST) guideline 1. The standard dosage of nintedanib is 150 mg taken twice daily with food, though some patients may require dose reduction to 100 mg twice daily if side effects become problematic. Nintedanib works by blocking multiple growth factor receptors involved in fibrosis development, including vascular endothelial growth factor, fibroblast growth factor, and platelet-derived growth factor. This mechanism helps slow the progression of lung scarring by inhibiting fibroblast proliferation and extracellular matrix deposition. Common side effects include diarrhea (affecting about 60% of patients), nausea, abdominal pain, and elevated liver enzymes. Diarrhea can typically be managed with loperamide as needed. Liver function tests should be monitored regularly, especially during the first three months of treatment. Nintedanib is contraindicated in patients with severe liver disease and should be used cautiously in those with increased bleeding risk, as it can interfere with blood clotting. The medication has demonstrated efficacy in slowing the decline in lung function in patients with progressive fibrosing interstitial lung diseases, though it does not reverse existing fibrosis. Some key points to consider when prescribing nintedanib include:
- Monitoring for adverse effects, such as diarrhea and elevated liver enzymes
- Adjusting the dose as needed to minimize side effects
- Regularly assessing liver function and bleeding risk
- Considering alternative treatment options for patients with certain types of ILD, such as SjD-ILD or IIM-ILD. It's also important to note that the evidence for the efficacy of nintedanib in certain types of ILD is limited, and the medication may not be effective for all patients 1. Therefore, the decision to prescribe nintedanib should be made on a case-by-case basis, taking into account the individual patient's needs and medical history. In addition, nintedanib may be considered as a treatment option for patients with progressive fibrosing disease on HRCT chest, particularly those with SSc-ILD 1. Overall, nintedanib is a valuable treatment option for certain patients with ILD, but its use should be carefully considered and monitored.
From the Research
Nintedanib Overview
- Nintedanib is a tyrosine kinase inhibitor used in the treatment of idiopathic pulmonary fibrosis (IPF) and certain types of non-small cell lung cancer (NSCLC) 2, 3.
- It has been shown to slow the progression of IPF and improve survival in patients with NSCLC and IPF 3, 4.
Efficacy in NSCLC with IPF
- A case report found that nintedanib monotherapy was effective in treating NSCLC in a patient with IPF who was unable to tolerate cytotoxic chemotherapy 2.
- A randomized phase 3 trial found that nintedanib plus chemotherapy improved overall survival in patients with NSCLC and IPF, particularly those with nonsquamous histology 3.
Safety and Tolerability
- Nintedanib has a manageable safety profile, with common adverse events including diarrhea, nausea, and vomiting 4, 5.
- Dose adjustments and symptomatic therapies can help minimize the impact of adverse events and allow patients to remain on treatment 4, 5.
Use in Combination with Other Therapies
- Nintedanib may be used in combination with immune checkpoint inhibitors (ICIs) to reduce the risk of ICI-induced pneumonitis in patients with IPF and NSCLC 6.
- However, further research is needed to confirm the efficacy and safety of this combination 6.
Management of Adverse Events
- Practical recommendations for managing nintedanib treatment, including gastrointestinal side effects, have been developed by a multidisciplinary panel of experts 5.
- These recommendations emphasize the importance of individualized treatment and careful monitoring to minimize adverse events and optimize treatment outcomes 5.