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Nintedanib

Pronunciation

(nin TED a nib)

Index Terms

  • BIBF1120
  • Nintedanib Esylate

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Capsule, Oral:

Ofev: 100 mg, 150 mg

Brand Names: U.S.

  • Ofev

Pharmacologic Category

  • Tyrosine Kinase Inhibitor

Pharmacology

Inhibits multiple receptor tyrosine kinases (RTKs) and nonreceptor tyrosine kinases (nRTKs), including platelet-derived growth factor (PDGFR alpha and PDGFR beta); fibroblast growth factor receptor (FGFR1, FGFR2, FGFR3); vascular endothelial growth factor (VEGFR1, VEGFR2, and VEGFR3); and Fms-like tyrosine kinase-3 (FLT3). Nintedanib binds competitively to the adenosine triphosphate (ATP) binding pocket of these receptors and blocks the intracellular signaling which is crucial for the proliferation, migration, and transformation of fibroblasts.

Absorption

Food increases exposure ~20% and delays absorption

Distribution

Vss: 1050 L

Metabolism

Hydrolytic cleavage by esterases to free acid moiety BIBF 1202, which is then glucuronidated by UGT 1A1, UGT 1A7, UGT 1A8, and UGT 1A10 to BIBF 1202 glucuronide; CYP 3A4 (minor)

Excretion

Feces (~93%); urine (<1%)

Time to Peak

2 hours (4 hours with food)

Half-Life Elimination

9.5 hours

Protein Binding

~98%

Special Populations: Hepatic Function Impairment

In patients with mild hepatic impairment (Child-Pugh class A) and moderate impairment (Child-Pugh class B), the AUC is increased 2.2 fold and 7.6 fold, respectively, compared to patients with normal hepatic function.

Special Populations Note

Cigarette smoking: Exposure was 21% lower in smokers.

Use: Labeled Indications

Idiopathic pulmonary fibrosis: Treatment of idiopathic pulmonary fibrosis (IPF).

Contraindications

There are no contraindications listed in the manufacturer's labeling.

Canadian labeling: Additional contraindications (not in US labeling): Hypersensitivity to nintedanib, peanut, or soya or any component of the formulation; pregnancy

Dosing: Adult

Idiopathic pulmonary fibrosis (IPF): Oral: 150 mg every 12 hours (maximum: 300 mg/day)

Missed dose: If a dose is missed, the next dose should be taken at the next scheduled time. Do not make up a missed dose.

Dosing: Geriatric

Refer to adult dosing.

Dosing: Renal Impairment

CrCl ≥30 mL/minute: No initial dosage adjustment necessary.

CrCl <30 mL/minute: There are no dosage adjustments provided in the manufacturer’s labeling (has not been studied).

ESRD: There are no dosage adjustments provided in the manufacturer’s labeling (has not been studied).

Dosing: Hepatic Impairment

Hepatic impairment at baseline:

Mild impairment (Child-Pugh class A): 100 mg every 12 hours.

Moderate to severe impairment (Child-Pugh class B or C): Use is not recommended (exposure is increased in moderate impairment; has not been studied in severe impairment).

Hepatotoxicity during treatment:

AST or ALT >3 times to <5 times ULN (without signs of severe liver damage): Interrupt treatment or reduce dosage to 100 mg every 12 hours. Once liver enzymes have returned to baseline values after treatment interruption, reintroduce therapy at 100 mg every 12 hours; may be subsequently increased to 150 mg every 12 hours. If a patient does not tolerate 100 mg every 12 hours, consider treatment interruption or discontinue treatment to manage adverse reactions.

AST or ALT >5 times ULN or >3 times ULN with signs or symptoms of severe liver damage: Discontinue therapy.

Dosing: Adjustment for Toxicity

Gastrointestinal toxicity (eg, diarrhea, nausea, vomiting) or other adverse reactions/toxicity: Dose reduction or temporary interruption may be needed. Treatment may be resumed at 150 mg every 12 hours or 100 mg every 12 hours, which may subsequently be increased to 150 mg every 12 hours. If a patient does not tolerate 100 mg every 12 hours, discontinue treatment.

Administration

Oral: Administer with food. Swallow capsules whole with liquid; do not chew or crush (bitter taste).

Storage

Store at 25°C (77°F); excursions permitted between 15°C and 30°C (59°F and 86°F). Protect from high humidity and avoid excessive heat.

Drug Interactions

Anticoagulants: May enhance the adverse/toxic effect of Nintedanib. Specifically, the risk for bleeding may be increased. Monitor therapy

Combined Inducers of CYP3A4 and P-glycoprotein: May decrease the serum concentration of Nintedanib. Avoid combination

Combined Inhibitors of CYP3A4 and P-glycoprotein: May increase the serum concentration of Nintedanib. Monitor therapy

Lumacaftor: May decrease the serum concentration of P-glycoprotein/ABCB1 Substrates. Lumacaftor may increase the serum concentration of P-glycoprotein/ABCB1 Substrates. Monitor therapy

P-glycoprotein/ABCB1 Inhibitors: May increase the serum concentration of P-glycoprotein/ABCB1 Substrates. P-glycoprotein inhibitors may also enhance the distribution of p-glycoprotein substrates to specific cells/tissues/organs where p-glycoprotein is present in large amounts (e.g., brain, T-lymphocytes, testes, etc.). Monitor therapy

Pirfenidone: May decrease the serum concentration of Nintedanib. Monitor therapy

Ranolazine: May increase the serum concentration of P-glycoprotein/ABCB1 Substrates. Monitor therapy

Adverse Reactions

>10%:

Gastrointestinal: Diarrhea (62%), nausea (24%), abdominal pain (15%), vomiting (12%), decreased appetite (11%)

Hepatic: Increased liver enzymes (14%)

1% to 10%:

Cardiovascular: Hypertension (5%), arterial thrombosis (3%), myocardial infarction (2%)

Central nervous system: Headache (8%)

Endocrine & metabolic: Weight loss (10%), hypothyroidism (1%)

Hematologic and oncologic: Hemorrhage (10%)

Respiratory: Bronchitis (1%)

<1% (Limited to important or life-threatening): Gastrointestinal perforation, hepatotoxicity, major hemorrhage, pancreatitis, thrombocytopenia

Warnings/Precautions

Concerns related to adverse effects:

• Bleeding: May increase the risk of bleeding. Use in patients with known risk of bleeding only if the benefit outweighs the risk.

• Cardiovascular effects: Arterial thromboembolic events, including MI, have been reported. Use caution in patients at high cardiovascular risk, including in patients with known coronary artery disease. Consider treatment interruption in patients who develop signs or symptoms of acute myocardial ischemia.

• GI effects: Diarrhea, nausea, and vomiting may occur. Diarrhea occurred in over 50% of nintedanib-treated patients, and was generally of mild to moderate intensity and occurred within the first 3 months of treatment. Treat with appropriate supportive care (eg, adequate hydration, antidiarrheals, antiemetics); dose reduction and/or treatment interruption may be required. If GI effects do not resolve, discontinue treatment. In addition, nintedanib may increase the risk of GI perforation; only use in patients at risk of perforation if the benefit outweighs the risk. Use caution in patients with recent abdominal surgery. It has been recommended to wait at least 4 weeks following abdominal surgery before initiating therapy (OFEV Canadian product labeling 2017). Discontinue if perforation develops.

• Hepatic effects: Drug-induced liver injury has been observed. Elevations of ALT, AST, GGT, alkaline phosphatase, and bilirubin were reversible with dose modification or interruption. Obtain liver function tests prior to treatment then as clinically indicated. Dosage modifications or interruption may be necessary; if serious liver injury with clinical symptoms and/or hyperbilirubinemia or jaundice occurs, promptly interrupt therapy.

Concurrent drug therapy issues:

• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.

Special populations:

• Hepatic impairment: Nintedanib is primarily eliminated through biliary/fecal excretion; use is not recommended in patients with moderate or severe hepatic impairment. Dose reduction is recommended in patients with mild impairment; if adverse reactions occur, consider treatment interruption or discontinuation.

• Smokers: Smoking may decrease exposure to nintedanib; patients should stop smoking prior to treatment and avoid smoking during therapy.

Monitoring Parameters

Obtain liver function tests prior to treatment and as clinically indicated; obtain pregnancy test prior to treatment. Monitor for gastrointestinal events (eg, diarrhea, nausea, vomiting), arterial thromboembolic events, bleeding, and gastrointestinal perforation.

Pregnancy Considerations

Based on the mechanism of action and adverse events observed in animal reproduction studies, nintedanib may be expected to cause fetal harm if used during pregnancy. Women of reproductive potential should use adequate contraception during therapy; pregnancy status should be obtained before treatment and pregnancy should be avoided; effective contraception should be used during therapy and for at least 3 months after the last dose. Based on animal studies, nintedanib may reduce female fertility.

Patient Education

• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)

• Patient may experience lack of appetite or weight loss. Have patient report immediately to prescriber signs of bleeding (vomiting blood or vomit that looks like coffee grounds; coughing up blood; hematuria; black, red, or tarry stools; bleeding from the gums; abnormal vaginal bleeding; bruises without a reason or that get bigger; or any severe or persistent bleeding), signs of severe cerebrovascular disease (change in strength on one side is greater than the other, difficulty speaking or thinking, change in balance, or vision changes), signs of a heart attack (angina; pain in arms, back, neck, jaw, or abdomen; shortness of breath; cold sweats; severe dizziness; passing out; or severe nausea or vomiting), signs of liver problems (dark urine, fatigue, lack of appetite, nausea, abdominal pain, light-colored stools, vomiting, or jaundice), severe diarrhea, persistent diarrhea, severe nausea, vomiting, severe abdominal pain, abdominal edema, severe headache, severe dizziness, passing out, or vision changes (HCAHPS).

• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.

Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.

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