Drug Induced Pulmonary Toxicity

Question 1

4 Mechanisms of Lung Injury

Answer 1

• oxidant injury
• immune complex mediated injury
• interference w/ matrix formation
• interference w/ lipid metabolism

Question 2

Naranjo Scale

Answer 2

10 question test to determine that the injury is drug related

Questions to know:
- Did the ADE occur after the drug was administered?
- Was the rxn more severe when the dose increased or less severe when the dose decreased?

Question 3

Risk factors for DIPI

Answer 3

Drug related:
- dose/admin/rate
- treatment duration
- O2 therapy
- Radiation
- Cumulative dose

Patient related:
- Age (extremes)
- RA
- pre-existing lung disease
- impaired renal/hepatic function
- genetics

Question 4

DI Interstitial Pneumonitis/Fibrosis Symptoms

Answer 4

• nonproductive cough
• sudden onset dyspnea
• fever
• rash
• eosinophilia
• PE: crackles on expiration, clubbing
• Chest CT: decreased lung volume, BL diffuse ground glass opacities (honeycombing)

Question 5

DI Interstitial Pneumonitis/Fibrosis (Drugs)

Answer 5

• Nitrofurantoin
• Leflunomide
• Methotrexate
• Bleomycin
• Busulfan
• Carmustine
• Cyclophosphamide
• Gemcitabine
• EGFRIs
• CPis
• mTORIs
• Taxanes
• Amiodarone

Question 6

DI Interstitial Pneumonitis/Fibrosis treatment

Answer 6

Caused by immunotherapy checkpoint inhibitors:
- Prednisone/Methylprednisolone 1-2 mg/kg/day

Caused by mTORIs
- Prednisone 0.75mg/kg/day

Bleomycin: Prednisone 0.75mg/kg/d x 4-6 weeks
Carmustine: Prednisone 60mg PO BID -> taper
Amiodarone: Prednisone 0.5-1mg/kg/d x up to 1 year

Question 7

Prevention of DIILD

Answer 7

• baseline spirometry
• DLCO
• CXR

Question 8

Pneumonias: BOOP

Answer 8

inflammatory response
Sx:
- nonproductive cough
- dyspnea
- BL crackles
- occasional fever/rash
- CXR: BL patchy infiltrates

Agents:
- Minocycline/Nitrofurantoin
- Bleomycin
- Amiodarone
- Sulfasalazine
- Carbamazepine
- Cocaine

Treatment:
- DC agent
- Steroids

Question 9

Pneumonia: Eosinophilic

Answer 9

eosinophils infiltrate pulmonary interstitium
Sx:
- dry cough
- dyspnea
- chest pain
- fever
- BL ground glass opacities

Drugs:
- daptomycin
- nitrofurantoin
- minocycline
- mesalamine
- sulfasalazine

Treatment:
- steroids

Question 10

Hypersensitivity Pneumonitis

Answer 10

Sx:
- urticaria (hives)
- angioedema
- rhinitis
- dyspnea

Agents:
- NSAIDs
- methotrexate

Treatment:
- DC agent
- antihistamines
- consider steroids

Question 11

DI Pulmonary Edema

Answer 11

Sx:
- cough
- crackles
- cyanosis/hypoxemia
- acinar infiltrate + normal heart size
- onset: minutes - 2hrs

Agents:
- Narcotics

Treatment:
- naloxone
- O2
- ventilator support

Question 12

Drug Induced Lupus

Answer 12

Sx:
- fever
- myalgia
- rash
- arthralgia
- arthritis
- serositis
- pleuritic pain
- pleural effusion
- diffuse interstitial pneumonitis
- alveolar infiltrates
- onset: up to 3 years

Agents:
- Procainamide **
- hydralazine *
- isoniazid
- anti-TNFa

Treatment:
- DC agent