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Pirfenidone and Nintedanib for IPF
1. Pirfenidone and Nintedanib
DR. MD. SHAFIQUL ISLAM DEWAN
RESIDENT (PULMONOLOGY)
RESPIRATORY MEDICINE DEPARTMENT
DHAKA MEDICAL COLLEGE HOSPITAL
4/27/2023
2. 4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH
Pirfenidone
3. Mechanism of Action
Precise mechanism by which pirfenidone may work in pulmonary fibrosis has not been
established.
Inhibits transforming growth factor (TGF)-beta, a chemical mediator that controls many cell
functions including proliferation and differentiation.
Also inhibits the synthesis of TNF-alpha, a cytokine that is known to have an active role in
inflammation.
Metabolized by Liver and Excreted by Kidney.
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH
4. Initial dose titration
Take with food
Doses should be taken at the same time each day.
Days 1-7: 267 mg PO TID (801 mg/day)
Days 8-14: 534 mg PO TID (1602 mg/day)
Day 15 and thereafter (maintenance): 801 mg PO TID; not to exceed 2403
mg/day.
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH
5. Treatment interruption
Following treatment interruption of ≥14 days: Titrate dosage upward using the
initial 2-week dosage titration regimen.
Following treatment interruption of <14 days: Therapy can be resumed at
dosage received prior to treatment interruption.
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH
6. Dosage Modifications
If patients experience significant adverse reactions (ie, gastrointestinal,
photosensitivity reaction, rash);
Consider temporary dosage reductions or therapy interruptions of pirfenidone
to allow for resolution of symptoms;
Discontinue if symptoms persist despite these interventions.
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH
7. CYP1A2 inhibitors
Strong inhibitors (eg, fluvoxamine, enoxacin): Reduce maintenance
dose to 267 mg (1 capsule) TID
Moderate inhibitors (eg, ciprofloxacin): Reduce maintenance dose
to 534 mg (2 capsules) TID (with ciprofloxacin 750 mg BID)
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH
8. Hepatic impairment
Mild-to-moderate (Child Pugh A or B): Use caution; monitor and consider
dosage modification or discontinuation as needed
Severe (Child Pugh C): Not recommended (not studied)
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH
9. Renal impairment
Mild, moderate, or severe: Use caution; monitor and consider dosage
modification or discontinuation as needed.
ESRD requiring dialysis: No recommended (not studied)
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH
12. Post marketing Reports
Blood and lymphatic system disorders: Agranulocytosis
Immune system disorders: Angioedema
Hepatobiliary disorders: Drug-induced liver injury
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH
13. Recommended liver monitoring
Perform liver function tests (ALT, AST, and bilirubin) before initiating treatment
with pirfenidone.
Monthly intervals for the first 6 months.
Then every 3 months thereafter.
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH
14. Dose adjustments due to liver enzyme abnormalities
3–5-times ULN without bilirubin elevation
◦ Exclude other causes
◦ Monitor the patient closely
◦ Consider discontinuing other medicines associated with liver toxicity
◦ Consider possible drug interactions if the patient is taking inhibitors of CYP isoenzymes
involved in the metabolism of pirfenidone.
◦ Reduce or interrupt the dose of pirfenidone if clinically appropriate
◦ Re-escalate pirfenidone to the recommended daily dose if tolerated once liver function
tests are within normal limits.
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH
15. Dose adjustments due to liver enzyme abnormalities
3–5-times ULN accompanied by hyperbilirubinaemia or clinical signs or symptoms indicative
of liver injury
◦ Permanently discontinue pirfenidone therapy; do not reinitiate
treatment
Higher than 5-times ULN
◦ Permanently discontinue pirfenidone therapy; do not reinitiate
treatment
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH
16. Pregnancy & Lactation
Pregnancy: Data in pregnant women are insufficient to inform on drug
associated risks for major birth defects and miscarriage.
Lactation: No information is available on presence of pirfenidone in human
milk, effects of drug on breastfed infant, or effects of drug on milk production.
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH
17. 4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH
Nintedanib
18. Indication
Idiopathic pulmonary fibrosis
Chronic fibrosing interstitial lung disease with A progressive phenotype
Systemic sclerosis-associated interstitial lung disease
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH
19. Mechanism of Action
Tyrosine kinase inhibitor; targets growth factors, which have been shown to be
potentially involved in pulmonary fibrosis (eg, vascular endothelial growth
factor receptor [VEGFR], fibroblast growth factor receptor [FGFR], platelet-
derived growth factor receptor [PDGF])
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, representing
essential mechanisms of the IPF pathology.
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH
20. Metabolism and Elimination
Metabolized by Liver
Excretion: 93.4% feces/biliary; 0.65% urine
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH
21. Doses
Administer 150mg tab orally twice daily (approximately 12 hours apart) with
food.
Swallow capsules whole with liquid; do not chew or crush.
If a dose is missed, take the next dose at the regularly scheduled time. Do not
double the dose or take extra doses.
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH
22. Dosage Modification for Toxicity
Hepatic Toxicity
◦ ALT or AST elevations >3 times but <5 times the ULN without signs or
symptoms of severe liver damage: Temporarily interrupt therapy or reduce
dosage to 100 mg twice daily. When liver function tests return to baseline
values, may resume nintedanib at 100 mg twice daily and may subsequently
increase dosage to 150 mg twice daily.
◦ ALT or AST elevations >5 times the ULN, or >3 times the ULN with signs or
symptoms of severe liver damage: Discontinue therapy.
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH
23. Dosage Modification for Toxicity
Other Adverse Effects
◦ If adverse reactions occur and are intolerable, despite symptomatic
treatment, temporarily interrupt therapy or reduce dosage to 100 mg
twice daily until the adverse reaction improves or resolves.
◦ May resume nintedanib 150 mg twice daily; alternatively, initially
reduce dosage to 100 mg twice daily and may subsequently increase
dosage to 150 mg twice daily.
◦ Discontinue therapy if intolerable adverse reactions occur or persist at
a dosage of 100 mg twice daily.
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH
24. Hepatic Impairment
No initial dosage adjustment required in patients with mild hepatic impairment
(Child-Pugh class A); monitor closely and reduce dosage or temporarily interrupt
therapy if not tolerated.
Not studied in patients with moderate or severe hepatic impairment (Child-
Pugh class B or C).
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH
25. Renal Impairment
No initial dosage adjustment required in patients with mild to moderate renal
impairment (Clcr 30–90 mL/minute).
Not studied in patients with severe renal impairment (Clcr <30 mL/minute) or
end-stage renal disease.
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH
29. Monitoring
Monitor liver function tests prior to initiation,
Monthly for the first 3 months,
Then every 3 months, and as clinically indicated.
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH
30. 4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH
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