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Gastrointestinal perforation during nintedanib therapy — SCE Respiratory MCQ

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HardInterstitial Lung DiseaseGastrointestinal perforation during nintedanib therapySCE Respiratory

A 71-year-old man with multidisciplinary team-confirmed idiopathic pulmonary fibrosis has an FVC of 69% predicted and has tolerated nintedanib 150 mg twice daily for 18 months. He also takes prednisolone 5 mg daily for polymyalgia rheumatica and intermittently uses naproxen. He is admitted with perforated sigmoid diverticulitis and undergoes an emergency Hartmann's procedure. Nintedanib is withheld on admission. Five weeks later, the abdominal wound has healed, the stoma is functioning normally and liver biochemistry is normal. His respiratory symptoms and lung function are unchanged from before admission. What is the most appropriate management of nintedanib?

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Correct answer: B — Permanently discontinue nintedanib

The decisive feature is not simply that the patient has undergone abdominal surgery, but that he developed a gastrointestinal perforation while receiving nintedanib. The UK Summary of Product Characteristics states that nintedanib must be permanently discontinued in patients who develop gastrointestinal perforation. His diverticular disease, corticosteroid exposure and NSAID use are recognised risk factors that further strengthen concern but are not required to establish the stopping decision. A is inappropriate because monitoring does not mitigate the requirement for permanent withdrawal after perforation. B incorrectly applies the 100 mg dose-reduction strategy used for manageable intolerance, such as diarrhoea or reversible hepatic enzyme elevation. C uses the superficially relevant rule that nintedanib should not be initiated until at least four weeks after abdominal surgery; that rule does not permit rechallenge after an actual perforation. D similarly misapplies the wound-healing precaution, under which treatment interrupted for uncomplicated surgery may be resumed once healing is adequate. The exceptional possibility of reintroduction described in the product information applies after complete resolution of ischaemic colitis and individual risk assessment, not after gastrointestinal perforation. His stable IPF and previous antifibrotic benefit do not override this specific safety requirement.

Reference: Nintedanib soft capsules 150 mg — Summary of Product Characteristics (21 April 2026) — https://www.medicines.org.uk/emc/product/102105/smpc