Should nintedanib be held before a left‑heart catheterisation?

Should Nintedanib Be Held Before Left Heart Catheterization?

No, nintedanib does not need to be held before left heart catheterization, but ensure the patient receives standard procedural anticoagulation with unfractionated heparin (UFH) at least 100 U/kg, and monitor closely for bleeding given nintedanib's potential to increase bleeding risk.

Rationale and Evidence-Based Approach

Standard Procedural Anticoagulation Requirements

• All patients undergoing left heart catheterization require procedural anticoagulation with UFH, regardless of concurrent medications 1.
• The standard dose is at least 100 U/kg UFH for procedures involving arterial access and left-sided heart catheterization 1.
• This anticoagulation protocol is mandatory to prevent thrombotic complications during the procedure 1.

Nintedanib-Specific Considerations

Bleeding Risk Profile:

• Nintedanib has a "potential increased risk of bleeding" as noted in rheumatology guidelines, though this is not classified as a black box warning 1.
• Clinical trial data demonstrates that nintedanib can be safely used in patients with cardiovascular disease and does not require routine discontinuation for cardiovascular procedures 2.
• Research specifically examining nintedanib-anticoagulant interactions suggests that concomitant use is feasible with appropriate monitoring, particularly when drug-monitored therapy is employed 3.

Cardiovascular Safety:

• Nintedanib has been studied in patients with pre-existing cardiovascular disease, showing similar rates of major adverse cardiovascular events compared to placebo 2.
• The drug does not appear on standard lists of medications requiring discontinuation before cardiac catheterization 1.

Practical Management Algorithm

Pre-Procedure (Day of Catheterization):

• Continue nintedanib as scheduled 1, 2.
• Check baseline platelet count and coagulation parameters if not recently obtained 1.
• Ensure electrolytes (potassium, magnesium) are within normal limits, as nintedanib monitoring already includes these parameters 1.

During Procedure:

• Administer standard UFH dosing (at least 100 U/kg) as per institutional protocol 1.
• Maintain activated clotting time (ACT) >250 seconds if transseptal access is required 1.
• Use meticulous hemostasis techniques given the theoretical additive bleeding risk 3.

Post-Procedure:

• Apply standard vascular access site management and monitoring 4.
• Resume nintedanib at the next scheduled dose without interruption 1.
• Monitor access site more vigilantly for bleeding complications in the first 24 hours 3.

Critical Caveats and Pitfalls to Avoid

Do Not Confuse with Oral Anticoagulants:

• Unlike warfarin or DOACs, nintedanib is not a systemic anticoagulant and does not require bridging or interruption 3.
• The bleeding risk with nintedanib is substantially lower than with therapeutic anticoagulation 3, 2.

Avoid Unnecessary Delays:

• Holding nintedanib unnecessarily may compromise treatment of the underlying interstitial lung disease without providing meaningful procedural safety benefit 1, 2.
• There is no guideline recommendation or FDA labeling requirement to discontinue nintedanib before invasive cardiovascular procedures 1.

Monitor for Drug Interactions:

• If the patient is on concurrent antiplatelet agents (aspirin, clopidogrel) or anticoagulants for other indications, the combined bleeding risk requires heightened vigilance but still does not mandate nintedanib discontinuation 1, 3.

Special Consideration for Radial Access:

• If radial artery access is used instead of femoral, the bleeding risk is further minimized, making nintedanib continuation even more straightforward 4.