DILD- Pulmonary Fibrosis, Pneumonitis Patho, Drugs, Treatment Flashcards
Pulmonary fibrosis, pneumonitis pathology
Usual or nonspecific interstitial pneumonia, can be drug-induced or idiopathic
Pulmonary fibrosis, pneumonitis: can fibrosis occur with these drugs?
Yes, and can be preceded by an acute pneumonitis, fibrosis can lead to pulmonary HTN
Pulmonary fibrosis, pneumonitis: onset
acute, subacute, chronic
Pulmonary fibrosis, pneumonitis: symptoms
nonproductive cough and sudden onset dyspnea (hours), fever, rash, eosinophilia
chronic Sx: slowly progressing breathlessness, decreased physical activity
Pulmonary fibrosis, pneumonitis chest CT
fibrosis- decreased lung volumes, BL diffuse ground-glass opacities
(Diagnosis of exclusion- I don’t think we need to know this)
Pulmonary fibrosis, pneumonitis PE
crackles on expiration, clubbing
Pulmonary fibrosis, pneumonitis: purpose of BAL
distinguishes between cell differential, rules out malignancy or infection
(Used to rule out other causes- I don’t think we need to know this)
Nitrofurantoin DILD mechanism
Imbalance of oxidant/antioxidant
Nitrofurantoin DILD presentation
Acute eosinophilic pneumonia
Chronic pulmonary fibrosis: 8 months-16 years
Leflunomide, methotrexate DILD mechanism
Hypersensitivity
Leflunomide, methotrexate DILD presentation
onset of days-years
Bleomycin DILD mechanism
Cytokine, inflammatory cells, free O2 radial induction
Belomycin DILD presentation
Weeks-months, can progress to fibrosis
Well known side effect of bleomycin!
Busulfan DILD mechanism
Direct alveolar injury
Busulfan DILD presentation
4 years after monotherapy or months after a high dose
Carmustine DILD presentation
Months-years after initiation
Can progress to fibrosis after years
Cyclophosphamide DILD mechanism
Direct alveolar injury
Cyclophosphamide DILD presentation
Months of initiation (early)
Months-years (late)
Gemcitabine DILD mechanism
Endothelial dysfunction after cytokine release
EGFRIs DILD presentation
Within 1 month
ICPIs DILD presentation
Onset within 3 months but may be faster if used in combination with other medications
mTORIs DILD mechanism
DAD or hypersensitivity
mTORIs DILD presentation
51-104 days, daily regimens more likely than weekly ones
Taxanes DILD mechanism
Hypersensitivity, direct toxicity to organ, pneumonia
Taxanes DILD presentation
During Cycle 2 of treatment or within 18 days after last cycle ends
Amiodarone DILD mechanism
Direct toxic effect
Amiodarone DILD presentation
4 weeks-6 years
Is amiodarone DILD dose-dependent?
YES! Smaller doses over years (>2 years) or larger doses over a shorter period of time (400mg/day for >2 months) are at risk
Patients over 60 have a 3x increased risk of toxicity each subsequent decade
Treatment of DIILD: Immunotherapy Check-Point Inhibitors (ICPis), Grade 1 event
consider holding meds and reassess in 1-2 weeks
Treatment of DIILD: Immunotherapy Check-Point Inhibitors (ICPis), Grade 2 event
hold meds, prednisone/methylprednisone 1-2mg/kg/day
if you improve to grade 1, taper over 4-6 weeks, if no improvement in 48-72 hours, treat as grade 3
Treatment of DIILD: Immunotherapy Check-Point Inhibitors (ICPis), Grade 3 or 4 event
permanent D/C, methylprednisone 1-2mg/kg/day
Taper over 4-6 weeks
no improvement in 48 hours- infliximab, IVIG, MMF
Treatment of DIILD: mTORIs, Grade 1 event
Nothing, it’s fine
Treatment of DIILD: mTORIs, Grade 2 event
Dose reduce or hold medication
Treatment of DIILD: mTORIs, Grade 3 event
hold med
Treatment of DIILD: mTORIs, Grade 4 event
permanently D/C medication
For ALL Grade events (except for 1) of mTORI treatment, what else do you give them?
Prednisone 0.75-1mg/kg/day and treat until they’re a Grade 1
Bleomycin treatment
Prednisone 0.75mg/kg/day for 4-6 days, then taper
Carmustine treatmentt
Prednisone 60mg PO BID, then 30mg PO QD then tapered by 10mg PO QW, then 5mg PO QW
Amiodarone treatment
Prednisone 0.5-1mg/kg/day, continue for several months up to 1 year
