Nintedanib Administration Before Left-Heart Catheterization
Nintedanib should be held on the morning of left-heart catheterization and can be resumed after the procedure once adequate hemostasis is established. While the medication is recommended to be taken with food, the primary concern is procedural bleeding risk rather than gastrointestinal tolerability.
Rationale for Holding Nintedanib
Bleeding Risk Considerations
- Nintedanib inhibits P-gp and BCRP transporters, which can increase exposure to anticoagulants and antiplatelet agents commonly used during cardiac catheterization 1
- The combination of nintedanib with rivaroxaban and betrixaban is contraindicated due to increased bleeding risk 1
- When combined with apixaban, dose reduction by 25% is required; with dabigatran, timing adjustments are necessary (administered 2 hours before nintedanib in fasted state) 1
Cardiac Catheterization Anticoagulation Protocol
- Patients undergoing left-heart catheterization typically receive unfractionated heparin (UFH) with target ACT 200-250 seconds with GP IIb/IIIa inhibitors or 250-350 seconds without GP IIb/IIIa inhibitors 1
- Antiplatelet therapy with aspirin and P2Y12 inhibitors (clopidogrel, prasugrel, or ticagrelor) is standard during PCI procedures 1
- The interaction between nintedanib's P-gp/BCRP inhibition and procedural anticoagulation creates unpredictable bleeding risk 1
Practical Management Algorithm
Pre-Procedure (Morning of Catheterization)
- Hold the morning dose of nintedanib 1
- This creates approximately 12 hours since the last dose (assuming evening dosing the night before)
- The fasting requirement for the procedure aligns with avoiding food intake needed for nintedanib administration 1
During Procedure
- Proceed with standard anticoagulation protocols as nintedanib does not interfere with ACT monitoring or heparin dosing 1
- Continue aspirin and administer P2Y12 inhibitors per standard protocols 1
Post-Procedure Resumption
- Resume nintedanib 3-5 hours after sheath removal once adequate hemostasis is confirmed 1
- This timing parallels recommendations for resuming NOACs after catheter ablation procedures 1
- Ensure no evidence of access site bleeding or pericardial effusion before restarting 1
- The patient can take nintedanib with food at this point 1, 2
Critical Pitfalls to Avoid
Do Not Continue Nintedanib Through the Procedure
- The unpredictable interaction between nintedanib's transporter inhibition and procedural anticoagulation outweighs any theoretical benefit of maintaining continuous therapy 1
- A 12-24 hour interruption does not compromise long-term efficacy for progressive pulmonary fibrosis 3, 4
Avoid Confusion with Chronic Antianginal Medications
- Unlike nitrates (such as Imdur), which should be continued through catheterization, nintedanib is not an antianginal agent and has bleeding-related concerns 5
- The guidelines addressing continuation of chronic medications before catheterization apply to antianginal agents, not tyrosine kinase inhibitors 5
Monitor for Gastrointestinal Tolerance Upon Resumption
- Diarrhea occurs in 66.9-77.2% of nintedanib-treated patients and is the most common adverse event 4, 6
- Ensure the patient resumes nintedanib with food to minimize GI side effects 2
- Have anti-diarrheal medications available if needed 2
Special Considerations
If Patient on Concurrent Anticoagulation
- If the patient requires chronic anticoagulation with a DOAC, edoxaban is the preferred agent with nintedanib as it requires no dose adjustment 1
- Apixaban requires 25% dose reduction; dabigatran requires specific timing (2 hours before nintedanib in fasted state) 1
- Rivaroxaban and betrixaban are contraindicated with nintedanib 1