部份中文尼达尼布处方资料（仅供参考）
商品名称：OFEV
通用名称：尼达尼布胶囊
英文名称：nintedanib
药理药效
尼达尼布是一种小分子多受体酪氨酸激酶（RTKs）和非受体酪氨酸激酶（nRTKs）抑制剂。尼达尼布抑制以下RTKs：血小板衍生生长因子受体（PDGFR-α和PDGFR-β），成纤维细胞生长因子受体（FGFR）1-3，血管内皮细胞生长因子受体（VEGFR）1-3, Fms样酪氨酸激酶-3（FLT3），其中，FGFR，PDGFR和VEGFR与IPF发病机制有关。尼达尼布竞争性地与这些受体的三磷酸腺苷（ATP）结合，阻断细胞内纤维细胞（代表IPF重要发病机制）的增殖、迁移和转运信号的传导。另外，尼达尼布抑制以下nRTKs：Lck，Lyn和Src激酶。尚不清楚FLT3和nRTK抑制作用对IPF治疗的影响。
适应症
用于治疗特发性肺纤维化（IPF）
用法用量
⑴ 推荐剂量：150mg每天2次间隔约12小时与食物服用。
⑵ 考虑暂时剂量减低至100mg，治疗中断，或终止为处理不良反应。
⑶ 治疗前，进行肝功能检验。
不良反应
最常见不良反应(≥5%)是：腹泻，恶心，腹痛，呕吐，肝酶升高，食欲减退，头痛，体重减轻，和高血压。
注意事项
⑴ 肝酶升高：用OFEV曾发生ALT，AST，和胆红素升高。治疗前和期间监视ALT，AST，和胆红素。可能需要暂时减低剂量或终止。
⑵ 胃肠道疾病：用OFEV曾发生腹泻，恶心，和呕吐。第一个征象用充分水化和止泻药(如，洛哌丁胺[loperamide])或抗吐药治疗患者。如尽管对症治疗严重腹泻，恶心，或呕吐持续终止OFEV。
⑶ 胚胎胎儿毒性：应劝告育龄妇女对胎儿潜在危害和避免成为妊娠。
⑷ 曾报道动脉血栓栓塞事件。当治疗患者处于较高心血管风险包括已知冠状动脉疾病谨慎使用。
⑸ 曾报道出血事件。只有已知出血风险患者期望获益胜过潜在风险时使用FEV。
⑹ 曾报道胃肠道穿孔。最近腹部手术治疗患者谨慎使用OFEV。发生胃肠道穿孔患者终止OFEV。只有有已知胃肠道穿孔风险如期望获益胜过潜在风险才使用OFEV。
专利情况：尼达尼布 化合物专利2020年到期，晶型专利2023年到期。
国内外上市的情况
2014年10月15日，在美国上市，2014年11月20日，欧盟（EC）批准，用于治疗特发性肺纤维化（IPF），商品名：OFEV，规格：100mg和150mg
尼达尼布软胶囊 JXHL1500079国化药进口2015年4月10日勃林格殷格翰（中国）投资有限公司在审评国内上市情况.

Ofev 100 mg and 150 mg soft capsules
1. Name of the medicinal product
Ofev 100 mg soft capsules
Ofev 150 mg soft capsules
2. Qualitative and quantitative composition
One capsule contains 100 mg nintedanib (as esilate)
One capsule contains 150 mg nintedanib (as esilate)
Excipient(s) with known effect:
Each capsule contains 1.2 mg of soya lecithin.
Each capsule contains 1.8 mg of soya lecithin.
For the full list of excipients, see section 6.1.
3. Pharmaceutical form
Soft capsule.
Ofev 100 mg soft capsules are peach-coloured, opaque, oblong soft-gelatin capsules imprinted on one side in black with the Boehringer Ingelheim company symbol and “100”.
Ofev 150 mg soft capsules are brown-coloured, opaque, oblong soft-gelatin capsules imprinted on one side in black with the Boehringer Ingelheim company symbol and “150”.
4. Clinical particulars
4.1 Therapeutic indications
Ofev is indicated in adults for the treatment of Idiopathic Pulmonary Fibrosis (IPF).
4.2 Posology and method of administration
Treatment with Ofev should be initiated by physicians experienced in the diagnosis and treatment of IPF.
Posology
The recommended dose is 150 mg nintedanib twice daily administered approximately 12 hours apart.
The 100 mg twice daily dose is only recommended to be used in patients who do not tolerate the 150 mg twice daily dose.
If a dose is missed, administration should resume at the next scheduled time at the recommended dose. If a dose is missed the patient should not take an additional dose. The recommended maximum daily dose of 300 mg should not be exceeded.
Dose adjustments
In addition to symptomatic treatment if applicable, the management of adverse reactions to Ofev (see sections 4.4 and 4.8) could include dose reduction and temporary interruption until the specific adverse reaction has resolved to levels that allow continuation of therapy. Ofev treatment may be resumed at the full dose (150 mg twice daily) or a reduced dose (100 mg twice daily). If a patient does not tolerate 100 mg twice daily, treatment with Ofev should be discontinued.
In case of interruptions due to aspartate aminotransferase (AST) or alanine aminotransferase (ALT) elevations > 3x upper limit of normal (ULN), once transaminases have returned to baseline values, treatment with Ofev may be reintroduced at a reduced dose (100 mg twice daily) which subsequently may be increased to the full dose (150 mg twice daily) (see sections 4.4 and 4.8).
Special populations
Elderly patients (≥ 65 years)
No overall differences in safety and efficacy were observed for elderly patients. No a-priori dose adjustment is required on the basis of a patient's age. Patients ≥75 years may be more likely to require dose reduction to manage adverse effects (see section 5.2).
Renal impairment
Less than 1% of a single dose of nintedanib is excreted via the kidney (see section 5.2). Adjustment of the starting dose in patients with mild to moderate renal impairment is not required. The safety, efficacy, and pharmacokinetics of nintedanib have not been studied in patients with severe renal impairment (<30 ml/min creatinine clearance).
Hepatic impairment
Nintedanib is predominantly eliminated via biliary/faecal excretion (> 90%). Exposure increased in patients with hepatic impairment (Child Pugh A, Child Pugh B; see section 5.2). No adjustment of the starting dose is needed for patients with mild hepatic impairment based on clinical data (Child Pugh A; see section 4.4). The safety and efficacy of nintedanib have not been investigated in patients with hepatic impairment classified as Child Pugh B and C. Treatment of patients with moderate (Child Pugh B) and severe (Child Pugh C) hepatic impairment with Ofev is not recommended (see section 5.2).
Paediatric population
The safety and efficacy of Ofev in children aged 0-18 years have not been established. No data are available.
Method of administration
Ofev is for oral use. The capsules should be taken with food, swallowed whole with water, and should not be chewed or crushed.
4.3 Contraindications
Hypersensitivity to nintedanib, to peanut or soya, or to any of the excipients listed in section 6.1.
4.4 Special warnings and precautions for use
Gastrointestinal disorders
Diarrhoea
In the INPULSIS trials (see section 5.1), diarrhoea was the most frequent gastro-intestinal adverse reaction reported in 62.4% versus 18.4% of patients treated with Ofev and placebo, respectively (see section 4.8). In most patients the adverse reaction was of mild to moderate intensity and occurred within the first 3 months of treatment. Diarrhoea led to dose reduction in 10.7% of the patients and to discontinuation of nintedanib in 4.4% of the patients.
Diarrhoea should be treated at first signs with adequate hydration and anti-diarrhoeal medicinal products, e.g. loperamide, and may require treatment interruption. Ofev treatment may be resumed at a reduced dose (100 mg twice daily) or at the full dose (150 mg twice daily). In case of persisting severe diarrhoea despite symptomatic treatment, therapy with Ofev should be discontinued.
Nausea and vomiting
Nausea and vomiting were frequently reported gastrointestinal adverse reactions (see section 4.8). In most patients with nausea and vomiting, the event was of mild to moderate intensity. Nausea led to discontinuation of nintedanib in 2.0% of patients. Vomiting led to discontinuation in 0.8% of the patients.
If symptoms persist despite appropriate supportive care (including anti-emetic therapy), dose reduction or treatment interruption may be required. The treatment may be resumed at a reduced dose (100 mg twice daily) or at the full dose (150 mg twice daily). In case of persisting severe symptoms therapy with Ofev should be discontinued.
Hepatic function
The safety and efficacy of Ofev has not been studied in patients with moderate (Child Pugh B) or severe (Child Pugh C) hepatic impairment. Therefore treatment with Ofev is not recommended in such patients (see section 4.2). Based on increased exposure, the risk for adverse events may be increased in patients with mild hepatic impairment (Child Pugh A; see sections 4.2 and 5.2).
Administration of nintedanib was associated with elevations of liver enzymes (ALT, AST, alkaline phosphatase (ALKP), gamma-glutamyl-transferase (GGT)) with a potentially higher risk for female patients. Transaminase increases were reversible upon dose reduction or interruption. Administration of nintedanib was also associated with elevations of bilirubin. Hepatic transaminase and bilirubin levels should be investigated before the initiation of treatment with Ofev, and periodically thereafter (e.g. at each patient visit) or as clinically indicated. If transaminase (AST or ALT) elevations > 3x ULN are measured, dose reduction or interruption of the therapy with Ofev is recommended and the patient should be monitored closely. Once transaminases have returned to baseline values, treatment with Ofev may be resumed at the full dose (150 mg twice daily) or reintroduced at a reduced dose (100 mg twice daily) which subsequently may be increased to the full dose (see section 4.2). If any liver test elevations are associated with clinical signs or symptoms of liver injury, e.g. jaundice, treatment with Ofev should be permanently discontinued. Alternative causes of the liver enzyme elevations should be investigated.
Haemorrhage
Vascular endothelial growth factor receptor (VEGFR) inhibition might be associated with an increased risk of bleeding. In the INPULSIS trials with Ofev, the frequency of patients who experienced bleeding AEs was slightly higher in the Ofev arm (10.3%) than in the placebo arm (7.8%). Non-serious epistaxis was the most frequent bleeding event. Serious bleeding events occurred with low and similar frequencies in the 2 treatment groups (placebo: 1.4%; Ofev: 1.3%).
Patients at known risk for bleeding including patients with inherited predisposition to bleeding or patients receiving a full dose of anticoagulative treatment were not included in the INPULSIS studies. Cases of haemorrhage have been reported in postmarketing period (including patients with or without anticoagulant therapy or other drugs that could cause bleeding). Therefore these patients should only be treated with Ofev if the anticipated benefit outweighs the potential risk.
Arterial thromboembolic events
Patients with a recent history of myocardial infarction or stroke were excluded from the INPULSIS trials. Arterial thromboembolic events were infrequently reported: in 0.7% of patients in the placebo and 2.5% in the nintedanib treated group. While adverse events reflecting ischaemic heart disease were balanced between the nintedanib and placebo groups, a higher percentage of patients experienced myocardial infarctions in the nintedanib group (1.6%) compared to the placebo group (0.5%). Caution should be used when treating patients at higher cardiovascular risk including known coronary artery disease. Treatment interruption should be considered in patients who develop signs or symptoms of acute myocardial ischemia.
Venous thromboembolism
In the INPULSIS trials no increased risk of venous thromboembolism was observed in nintedanib treated patients. Due to the mechanism of action of nintedanib patients might have an increased risk of thromboembolic events.
Gastrointestinal perforations
In the INPULSIS trials no increased risk of gastrointestinal perforation was observed in nintedanib treated patients. Due to the mechanism of action of nintedanib patients might have an increased risk of gastrointestinal perforation. Particular caution should be exercised when treating patients with previous abdominal surgery. Ofev should only be initiated at least 4 weeks after abdominal surgery. Therapy with Ofev should be permanently discontinued in patients who develop gastrointestinal perforation.
Hypertension
Administration of Ofev may increase blood pressure. Systemic blood pressure should be measured periodically and as clinically indicated.
Wound healing complication
No increased frequency of impaired wound healing was observed in the INPULSIS trials. Based on the mechanism of action nintedanib may impair wound healing. No dedicated studies investigating the effect of nintedanib on wound healing were performed. Treatment with Ofev should therefore only be initiated or - in case of perioperative interruption - resumed based on clinical judgement of adequate wound healing.
Co-administration with pirfenidone
Concomitant treatment of nintedanib with pirfenidone was investigated in a parallel group design study in Japanese patients with IPF. Twenty four patients were treated for 28 days with 150 mg nintedanib twice daily (13 patients received nintedanib on top of chronic treatment with standard doses of pirfenidone; 11 patients received nintedanib alone). Due to the short duration of concomitant exposure and low number of patients the benefit/risk of the co-administration with pirfenidone has not been established.
Effect on QT interval
No evidence of QT prolongation was observed for nintedanib in the clinical trial programme (Section 5.1). As some other tyrosine kinase inhibitors are known to exert an effect on QT, caution should be exercised when administered nintedanib in patients who may develop QTc prolongation.
Allergic reaction
Dietary soya products are known to cause allergic reactions including severe anaphylaxis in persons with soya allergy. Patients with known allergy to peanut protein carry an enhanced risk for severe reactions to soya preparations.
4.5 Interaction with other medicinal products and other forms of interaction
P-glycoprotein (P-gp)
Nintedanib is a substrate of P-gp (see section 5.2). Co-administration with the potent P-gp inhibitor ketoconazole increased exposure to nintedanib 1.61-fold based on AUC and 1.83-fold based on Cmax in a dedicated drug-drug interaction study. In a drug-drug interaction study with the potent P-gp inducer rifampicin, exposure to nintedanib decreased to 50.3% based on AUC and to 60.3% based on Cmax upon co-administration with rifampicin compared to administration of nintedanib alone. If co-administered with Ofev, potent P-gp inhibitors (e.g. ketoconazole, erythromycin or cyclosporine) may increase exposure to nintedanib. In such cases, patients should be monitored closely for tolerability of nintedanib. Management of side effects may require interruption, dose reduction, or discontinuation of therapy with Ofev (see section 4.2).
Potent P-gp inducers (e.g. rifampicin, carbamazepine, phenytoin, and St. John's Wort) may decrease exposure to nintedanib. Selection of an alternate concomitant medicinal product with no or minimal P-gp induction potential should be considered.
Cytochrome (CYP)-enzymes
Only a minor extent of the biotransformation of nintedanib consisted of CYP pathways. Nintedanib and its metabolites, the free acid moiety BIBF 1202 and its glucuronide BIBF 1202 glucuronide, did not inhibit or induce CYP enzymes in preclinical studies (see section 5.2). The likelihood of drug-drug interactions with nintedanib based on CYP metabolism is therefore considered to be low.
Co-administration with other medicinal products
The potential for interactions of nintedanib with hormonal contraceptives was not explored.
4.6 Fertility, pregnancy and lactation
Women of childbearing potential / Contraception
Nintedanib may cause foetal harm in humans (see section 5.3). Women of childbearing potential should be advised to avoid becoming pregnant while receiving treatment with Ofev. They should be advised to use adequate contraception during and at least 3 months after the last dose of Ofev. Since the effect of nintedanib on the metabolism and efficacy of hormonal contraceptives has not been investigated, barrier methods should be applied as a second form of contraception, to avoid pregnancy.
Pregnancy
There is no information on the use of Ofev in pregnant women, but pre-clinical studies in animals have shown reproductive toxicity of this active substance (see section 5.3). As nintedanib may cause foetal harm also in humans, it must not be used during pregnancy.
Female patients should be advised to notify their doctor or pharmacist if they become pregnant during therapy with Ofev.
If the patient becomes pregnant while receiving Ofev, she should be apprised of the potential hazard to the foetus. Termination of the treatment with Ofev should be considered.
Breast-feeding
There is no information on the excretion of nintedanib and its metabolites in human milk.
Pre-clinical studies showed that small amounts of nintedanib and its metabolites (≤ 0.5% of the administered dose) were secreted into milk of lactating rats. A risk to the newborns/infants cannot be excluded. Breast-feeding should be discontinued during treatment with Ofev.
Fertility
Based on preclinical investigations there is no evidence for impairment of male fertility (see section 5.3). From subchronic and chronic toxicity studies, there is no evidence that female fertility in rats is impaired at a systemic exposure level comparable with that at the maximum recommended human dose (MRHD) of 150 mg twice daily (see section 5.3).
4.7 Effects on ability to drive and use machines
Ofev has minor influence on the ability to drive and use machines. Patients should be advised to be cautious when driving or using machines during treatment with Ofev.
4.8 Undesirable effects
Summary of the safety profile
Nintedanib has been studied in clinical trials of 1,529 patients suffering from IPF. The safety data provided in the following are based on the two Phase III, randomised, double-blind, placebo-controlled studies in 1,061 patients comparing treatment with nintedanib 150 mg twice daily to placebo for 52 weeks (INPULSIS-1 and INPULSIS-2).
The most frequently reported adverse reactions associated with the use of nintedanib included diarrhoea, nausea and vomiting, abdominal pain, decreased appetite, weight decreased and hepatic enzyme increased.
For the management of selected adverse reactions please also refer to section 4.4.
Tabulated list of adverse reactions
The below table provides a summary of the adverse reactions by MedDRA System Organ Class (SOC) and frequency category.
Table 1 summarizes the frequencies of adverse drug reactions (ADRs) that were reported in the nintedanib group (638 patients) pooled from the two placebo-controlled Phase III clinical trials of 52 weeks duration or from the postmarketing period.
Frequency categories are defined using the following convention:
very common (≥ 1/10), common (≥ 1/100 to < 1/10), uncommon (≥ 1/1,000 to < 1/100), rare (≥ 1/10,000 to < 1/1,000), very rare (< 1/10,000), not known (cannot be estimated from the available data).
Within each frequency grouping adverse reactions are presented in order of decreasing seriousness.
Table 1: Summary of ADRs per frequency category

Frequency System Organ Class	Very common (≥ 1/10)	Common (≥ 1/100 < 1/10)	Uncommon (≥ 1/1,000 < 1/100)
Metabolism and nutrition disorders		Weight decreased, Decreased appetite
Vascular disorders		Bleeding	Hypertension
Gastrointestinal Disorder	Diarrhoea, Nausea, Abdominal pain	Vomiting	Pancreatitis
Hepatobiliary disorders	Hepatic enzyme increased	Alanine aminotransferase (ALT) increased, Aspartate aminotransferase (AST) increased, Gamma glutamyl transferase (GGT) increased	Hyperbilirubinaemia, Blood alkaline phosphatase (ALKP) increased

Description of selected adverse reactions
Diarrhoea
Diarrhoea was reported in 62.4% of patients treated with nintedanib. The event was reported to be of severe intensity in 3.3% of nintedanib treated patients. More than two thirds of patients experiencing diarrhoea reported its first onset already during the first three months of treatment. Diarrhoea led to permanent treatment discontinuation in 4.4% of patients; otherwise the events were managed by anti-diarrhoeal therapy, dose reduction or treatment interruption (see section 4.4).
Hepatic enzyme increased
Liver enzyme elevations (see section 4.4) were reported in 13.6% of nintedanib treated patients. Elevations of liver enzymes were reversible and not associated with clinically manifest liver disease.
For further information about special populations, recommended measures and dosing adjustments in case of diarrhoea and hepatic enzyme increased, refer additionally to sections 4.4 and 4.2, respectively.
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via:
United Kingdom
Yellow Card Scheme
Website: www.mhra.gov.uk/yellowcard
Ireland
HPRA Pharmacovigilance
Earlsfort Terrace
IRL - Dublin 2
Tel: +353 1 6764971
Fax: +353 1 6762517
Website: www.hpra.ie
e-mail: medsafety@hpra.ie
Malta
ADR Reporting
Website: www.medicinesauthority.gov.mt/adrportal
4.9 Overdose
There is no specific antidote or treatment for Ofev overdose. Two patients in the oncology programme had an overdose of maximum 600 mg twice daily up to eight days. Observed adverse reactions were consistent with the known safety profile of nintedanib, i.e. increased liver enzymes and gastrointestinal symptoms. Both patients recovered from these adverse reactions. In the INPULSIS trials, one patient was inadvertently exposed to a dose of 600 mg daily for a total of 21 days. A non-serious adverse event (nasopharyngitis) occurred and resolved during the period of incorrect dosing, with no onset of other reported events. In case of overdose, treatment should be interrupted and general supportive measures initiated as appropriate.
5. Pharmacological properties
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Antineoplastic agents, protein kinase inhibitors, ATC code: L01XE31
Mechanism of action
Nintedanib is a small molecule tyrosine kinase inhibitor including the receptors platelet-derived growth factor receptor (PDGFR) α and β, fibroblast growth factor receptor (FGFR) 1-3, and VEGFR 1-3. Nintedanib binds competitively to the adenosine triphosphate (ATP) binding pocket of these receptors and blocks the intracellular signalling. In addition nintedanib inhibits Flt-3 (Fms-like tyrosine-protein kinase), Lck (lymphocyte-specific tyrosine-protein kinase), Lyn (tyrosine-protein kinase lyn) and Src (proto-oncogene tyrosine-protein kinase src) kinases.
Pharmacodynamic effects
Nintedanib inhibits the activation of FGFR and PDGFR signalling cascades which are critically involved in proliferation, migration and differentiation of lung fibroblasts/myofibroblasts, the hallmark cells in the pathology of idiopathic pulmonary fibrosis. The potential impact of VEGFR inhibition by nintedanib and the anti-angiogenic activity of nintedanib on IPF pathology are currently not fully elucidated. In preclinical disease models of lung fibrosis nintedanib exerts potent anti-fibrotic and anti-inflammatory activity. Nintedanib inhibits proliferation, migration and fibroblast to myofibroblast transformation of human lung fibroblasts from patients with IPF.
Clinical efficacy and safety
The clinical efficacy of nintedanib has been studied in patients with IPF in two phase III, randomised, double-blind, placebo-controlled studies with identical design (INPULSIS-1 (1199.32) and INPULSIS-2 (1199.34)). Patients with FVC baseline < 50% predicted or carbon monoxide diffusing capacity (DLCO, corrected for haemoglobin) < 30% predicted at baseline were excluded from the trials. Patients were randomized in a 3:2 ratio to treatment with Ofev 150 mg or placebo twice daily for 52 weeks.
The primary endpoint was the annual rate of decline in Forced Vital Capacity (FVC). The key secondary endpoints were change from baseline in Saint George's Respiratory Questionnaire (SGRQ) total score at 52 weeks and time to first acute IPF exacerbation.
Annual rate of decline in FVC
The annual rate of decline of FVC (in mL) was significantly reduced in patients receiving nintedanib compared to patients receiving placebo. The treatment effect was consistent in both trials. See Table 2 for individual and pooled study results.
Table 2: Annual rate of decline in FVC (mL) in trials INPULSIS-1, INPULSIS-2 and their pooled data - treated set

INPULSIS-1		INPULSIS-2		INPULSIS-1 and INPULSIS-2 Pooled
	Placebo	Ofev 150 mg twice daily	Placebo	Ofev 150 mg twice daily	Placebo	Ofev 150 mg twice daily
Number of analysed patients	204	309	219	329	423	638
Rate1 (SE) of decline over 52 weeks	−239.9 (18.71)	−114.7 (15.33)	−207.3 (19.31)	−113.6 (15.73)	−223.5 (13.45)	−113.6 (10.98)
Comparison vs placebo
Difference1		125.3		93.7		109.9
95% CI		(77.7, 172.8)		(44.8, 142.7)		(75.9, 144.0)
p-value		<0.0001		0.0002		<0.0001
1 Estimated based on a random coefficient regression model. CI: confidence interval

The robustness of the effect of nintedanib in reducing the annual rate of decline in FVC was confirmed in all pre-specified sensitivity analyses. In patients with missing data, the primary analysis assumes that the decline in FVC after the last observed value would be similar to the decline in other patients in the same treatment group. In a sensitivity analysis which assumed that in patients with missing data at week 52 the FVC decline after the last observed value would be the same as in all placebo patients, the adjusted difference in the annual rate of decline between nintedanib and placebo was 113.9 mL/year (95% CI 69.2, 158.5) in INPULSIS-1 and 83.3 mL/year (95% CI 37.6, 129.0) in INPULSIS-2.
In addition, similar effects were observed on other lung function endpoints e.g. change from baseline in FVC at week 52 and FVC responder analyses providing further substantiation of the effects of nintedanib on slowing disease progression. See Figure 1 for the evolution of change from baseline over time in both treatment groups, based on the pooled analysis of studies INPULSIS-1 and INPULSIS-2.
Figure 1: Mean (SEM) observed FVC change from baseline (mL) over time, studies INPULSIS-1 and INPULSIS-2 pooled
FVC responder analysis
In both INPULSIS trials, the proportion of FVC responders, defined as patients with an absolute decline in FVC % predicted no greater than 5% (a threshold indicative of the increasing risk of mortality in IPF), was significantly higher in the nintedanib group as compared to placebo. Similar results were observed in analyses using a conservative threshold of 10%. See Table 3 for individual and pooled study results.
Table 3: Proportion of FVC responders at 52 weeks in trials INPULSIS-1, INPULSIS-2 and their pooled data - treated set

	INPULSIS-1		INPULSIS-2		INPULSIS-1 and INPULSIS-2 pooled
	Placebo	Ofev 150 mg twice daily	Placebo	Ofev 150 mg twice daily	Placebo	Ofev 150 mg twice daily
Number of analysed patients	204	309	219	329	423	638
5% threshold
Number (%) of FVC responders1	78 (38.2)	163 (52.8)	86 (39.3)	175 (53.2)	164 (38.8)	338 (53.0)
Comparison vs placebo
Odds ratio		1.85		1.79		1.84
95% CI		(1.28, 2.66)		(1.26, 2.55)		(1.43, 2.36)
p-value2		0.0010		0.0011		<0.0001
10% threshold
Number (%) of FVC responders1	116 (56.9)	218 (70.6)	140 (63.9)	229 (69.6)	256 (60.5)	447 (70.1)
Comparison vs placebo
Odds ratio		1.91		1.29		1.58
95% CI		(1.32, 2.79)		(0.89, 1.86)		(1.21, 2.05)
p-value2		0.0007		0.1833		0.0007

1Responder patients are those with no absolute decline greater than 5% or greater than 10% in FVC % predicted, depending on the threshold and with an FVC evaluation at 52 weeks.
2Based on a logistic regression.
Time to progression (≥ 10% absolute decline of FVC % predicted or death)
In both INPULSIS trials, the risk of progression was statistically significantly reduced for patients treated with nintedanib compared with placebo. In the pooled analysis, the HR was 0.60 indicating a 40% reduction in the risk of progression for patients treated with nintedanib compared with placebo.
Table 4: Frequency of patients with ≥ 10% absolute decline of FVC % predicted or death over 52 weeks and time to progression in trials INPULSIS-1, INPULSIS-2, and their pooled data - treated set

INPULSIS-1		INPULSIS-2		INPULSIS-1 and INPULSIS-2 pooled
	Placebo	Ofev 150 mg twice daily	Placebo	Ofev 150 mg twice daily	Placebo	Ofev 150 mg twice daily
Number at risk	204	309	219	329	423	638
Patients with events, N (%)	83 (40.7)	75 (24.3)	92 (42.0)	98 (29.8)	175 (41.4)	173 (27.1)
Comparison vs placebo1
p-value2		0.0001		0.0054		<0.0001
Hazard ratio3		0.53		0.67		0.60
95% CI		(0.39, 0.72)		(0.51, 0.89)		(0.49, 0.74)
1 Based on data collected up to 372 days (52 weeks + 7 day margin). 2 Based on a Log-rank test. 3 Based on a Cox's regression model.

Change from baseline in SGRQ total score at week 52
SGRQ total score measuring health related quality of life (HRQoL) was analysed at 52 weeks. In INPULSIS-2, patients receiving placebo had a larger increase from baseline SGRQ total score as compared to patients receiving nintedanib 150 mg twice daily. The deterioration of HRQoL was smaller in the nintedanib group; the difference between the treatment groups was statistically significant (-2.69; 95% CI: -4.95, -0.43; p=0.0197).
In INPULSIS-1, the increase from baseline in SGRQ total score at week 52 was comparable between nintedanib and placebo (difference between treatment groups: -0.05; 95% CI: -2.50, 2.40; p=0.9657). In the pooled analysis of the INPULSIS trials, the estimated mean change from baseline to week 52 in SGRQ total score was smaller in the nintedanib group (3.53) than in the placebo group (4.96), with a difference between the treatment groups of -1.43 (95% CI: -3.09, 0.23; p=0.0923). Overall, the effect of nintedanib on health-related quality of life as measured by the SGRQ total score is modest, indicating less worsening compared to placebo.
Time to first acute IPF exacerbation
In the INPULSIS-2 trial, the risk of first acute IPF exacerbation over 52 weeks was significantly reduced in patients receiving nintedanib compared to placebo, in the INPULSIS-1 trial there was no difference between the treatment groups. In the pooled analysis of the INPULSIS trials, a numerically lower risk of first acute exacerbation was observed in patients receiving nintedanib compared to placebo. See Table 5 for individual and pooled study results.
Table 5: Frequency of patients with acute IPF exacerbations over 52 weeks and time to first exacerbation analysis based on investigator-reported events in trials INPULSIS-1, INPULSIS-2, and their pooled data - treated set

INPULSIS-1		INPULSIS-2		INPULSIS-1 and INPULSIS-2 pooled
	Placebo	Ofev 150 mg twice daily	Placebo	Ofev 150 mg twice daily	Placebo	Ofev 150 mg twice daily
Number at risk	204	309	219	329	423	638
Patients with events, N (%)	11 (5.4)	19 (6.1)	21 (9.6)	12 (3.6)	32 (7.6)	31 (4.9)
Comparison vs placebo1
p-value2		0.6728		0.0050		0.0823
Hazard ratio3		1.15		0.38		0.64
95% CI		(0.54, 2.42)		(0.19, 0.77)		(0.39, 1.05)
1 Based on data collected up to 372 days (52 weeks + 7 day margin). 2 Based on a Log-rank test. 3 Based on a Cox's regression model.

All adverse events of acute IPF exacerbation reported by the investigator were adjudicated by a blinded adjudication committee. A pre-specified sensitivity analysis of the time to first 'confirmed' or 'suspected' adjudicated acute IPF exacerbation was performed on the pooled data. The frequency of patients with at least 1 adjudicated exacerbation occurring within 52 weeks was lower in the nintedanib group (1.9% of patients) than in the placebo group (5.7% of patients). Time to event analysis of the adjudicated exacerbation events using pooled data yielded a hazard ratio (HR) of 0.32 (95% CI 0.16, 0.65; p=0.0010). This indicates that the risk of having a first acute adjudicated IPF exacerbation was statistically significantly lower in the nintedanib group than in the placebo group at any time point.
Survival analysis
In the pre-specified pooled analysis of survival data of the INPULSIS trials, overall mortality over 52 weeks was lower in the nintedanib group (5.5%) compared with the placebo group (7.8%). The analysis of time to death resulted in a HR of 0.70 (95% CI 0.43, 1.12; p=0.1399). The results of all survival endpoints (such as on-treatment mortality and respiratory mortality) showed a consistent numerical difference in favour of nintedanib.
Table 6: All-cause mortality over 52 weeks in trials INPULSIS-1, INPULSIS-2, and their pooled data - treated set

INPULSIS-1		INPULSIS-2		INPULSIS-1 and INPULSIS-2 Pooled
	Placebo	Ofev 150 mg twice daily	Placebo	Ofev 150 mg twice daily	Placebo	Ofev 150 mg twice daily
Number at risk	204	309	219	329	423	638
Patients with events, N (%)	13 (6.4)	13 (4.2)	20 (9.1)	22 (6.7)	33 (7.8)	35 (5.5)
Comparison vs placebo1
p-value2		0.2880		0.2995		0.1399
Hazard ratio3		0.63		0.74		0.70
95% CI		(0.29, 1.36)		(0.40, 1.35)		(0.43, 1.12)
1 Based on data collected up to 372 days (52 weeks + 7 day margin). 2 Based on a Log-rank test. 3 Based on a Cox's regression model.

Supportive evidence from the phase II trial (1199.30) Ofev 150 mg twice daily results
Additional evidence of efficacy is provided by the randomised, double-blind, placebo-controlled, dose finding phase II trial including a nintedanib 150 mg twice daily dose group.
The primary endpoint, rate of decline in FVC over 52 weeks was lower in the nintedanib arm (-0.060 L/year, N=84) than the placebo arm (-0.190 L/year, N=83). The estimated difference between the treatment groups was 0.131 L/year (95% CI 0.027, 0.235). The difference between the treatment groups reached nominal statistical significance (p=0.0136).
The estimated mean change from baseline in SGRQ total score at 52 weeks was 5.46 for placebo, indicating worsening of the health-related quality of life and -0.66 for nintedanib, indicating stable health-related quality of life. The estimated mean difference for nintedanib compared with placebo was -6.12 (95% CI: -10.57, -1.67; p=0.0071).
The number of patients with acute IPF exacerbations over 52 weeks was lower in the nintedanib group (2.3%, N=86) compared to placebo (13.8%, N=87). The estimated hazard ratio of nintedanib versus placebo was 0.16 (95% CI 0.04, 0.71; p=0.0054).
QT interval
In a dedicated study in renal cell cancer patients, QT/QTc measurements were recorded and showed that a single oral dose of 200 mg nintedanib as well as multiple oral doses of 200 mg nintedanib administered twice daily for 15 days did not prolong the QTcF interval.
Paediatric population
The European Medicines Agency has waived the obligation to submit the results of studies with Ofev in all subsets of the paediatric population in IPF (see section 4.2 for information on paediatric use).
5.2 Pharmacokinetic properties
Absorption
Nintedanib reached maximum plasma concentrations approximately 2 - 4 h after oral administration as soft gelatine capsule under fed conditions (range 0.5 - 8 h). The absolute bioavailability of a 100 mg dose was 4.69% (90% CI: 3.615 - 6.078) in healthy volunteers. Absorption and bioavailability are decreased by transporter effects and substantial first-pass metabolism. Dose proportionality was shown by increase of nintedanib exposure (dose range 50 - 450 mg once daily and 150 - 300 mg twice daily). Steady state plasma concentrations were achieved within one week of dosing at the latest.
After food intake, nintedanib exposure increased by approximately 20% compared to administration under fasted conditions (CI: 95.3 - 152.5%) and absorption was delayed (median tmax fasted: 2.00 h; fed: 3.98 h).
Distribution
Nintedanib follows at least bi-phasic disposition kinetics. After intravenous infusion, a high volume of distribution (Vss: 1,050 L, 45.0% gCV) was observed.
The in vitro protein binding of nintedanib in human plasma was high, with a bound fraction of 97.8%. Serum albumin is considered to be the major binding protein. Nintedanib is preferentially distributed in plasma with a blood to plasma ratio of 0.869.
Biotransformation
The prevalent metabolic reaction for nintedanib is hydrolytic cleavage by esterases resulting in the free acid moiety BIBF 1202. BIBF 1202 is subsequently glucuronidated by uridine 5'-diphospho-glucuronosyltransferase enzymes (UGT) enzymes, namely UGT 1A1, UGT 1A7, UGT 1A8, and UGT 1A10 to BIBF 1202 glucuronide.
Only a minor extent of the biotransformation of nintedanib consisted of CYP pathways, with CYP 3A4 being the predominant enzyme involved. The major CYP-dependent metabolite could not be detected in plasma in the human ADME study. In vitro, CYP-dependent metabolism accounted for about 5% compared to about 25% ester cleavage. Nintedanib, BIBF 1202, and BIBF 1202 glucuronide did not inhibit or induce CYP enzymes in preclinical studies, either. Drug-drug interactions between nintedanib and CYP substrates, CYP inhibitors, or CYP inducers are therefore not expected.
Elimination
Total plasma clearance after intravenous infusion was high (CL: 1,390 mL/min, 28.8% gCV). Urinary excretion of the unchanged active substance within 48 h was about 0.05% of the dose (31.5% gCV) after oral and about 1.4% of the dose (24.2% gCV) after intravenous administration; the renal clearance was 20 mL/min (32.6% gCV). The major route of elimination of drug related radioactivity after oral administration of [14C] nintedanib was via faecal/biliary excretion (93.4% of dose, 2.61% gCV). The contribution of renal excretion to the total clearance was low (0.649% of dose, 26.3% gCV). The overall recovery was considered complete (above 90%) within 4 days after dosing. The terminal half-life of nintedanib was between 10 and 15 h (gCV % approximately 50%).
Linearity/non-linearity
The pharmacokinetics (PK) of nintedanib can be considered linear with respect to time (i.e. single-dose data can be extrapolated to multiple-dose data). Accumulation upon multiple administrations was 1.04-fold for Cmax and 1.38-fold for AUC. Nintedanib trough concentrations remained stable for more than one year.
Transport
Nintedanib is a substrate of P-gp. For the interaction potential of nintedanib with this transporter, see section 4.5. Nintedanib was shown to be not a substrate or inhibitor of OATP-1B1, OATP-1B3, OATP-2B1, OCT-2, or MRP-2 in vitro. Nintedanib was also not a substrate of BCRP. Only a weak inhibitory potential on OCT-1, BCRP, and P-gp was observed in vitro which is considered to be of low clinical relevance. The same applies for nintedanib being a substrate of OCT-1.
Population pharmocokinetic analysis in special populations
The PK properties of nintedanib were similar in healthy volunteers, patients with IPF, and cancer patients. Based on results of a Population PK (PopPK) analysis in patients with IPF and non small cell lung cancer (NSCLC) (N=1,191) and descriptive investigations, exposure to nintedanib was not influenced by sex (body weight corrected), mild and moderate renal impairment (estimated by creatinine clearance), alcohol consumption, or P-gp genotype. PopPK analyses indicated moderate effects on exposure to nintedanib depending on age, body weight, and race (see below). Based on the high inter-individual variability of exposure observed moderate effects are considered not clinically relevant (see section 4.4).
Age
Exposure to nintedanib increased linearly with age. AUC,ss decreased by 16% for a 45-year old patient and increased by 13% for a 76-year old patient relative to a patient with the median age of 62 years. The age range covered by the analysis was 29 to 85 years; approximately 5% of the population were older than 75 years. Based on a PopPK model, an increase in nintedanib exposure of approximately 20 - 25% was observed in patients ≥ 75 years compared with patients under 65 years.
Studies in paediatric populations have not been performed.
Body weight
An inverse correlation between body weight and exposure to nintedanib was observed. AUC,ss increased by 25% for a 50 kg patient (5th percentile) and decreased by 19% for a 100 kg patient (95th percentile) relative to a patient with the median weight of 71.5 kg.
Race
The geometric mean exposure to nintedanib was 33% higher in Chinese, Taiwanese, and Indian patients while it was 22% lower in Koreans compared to Caucasians (body weight corrected). Data from Black individuals was very limited but in the same range as for Caucasians.
Hepatic impairment
In a dedicated single dose phase I study and compared to healthy subjects, exposure to nintedanib based on Cmax and AUC was 2.2-fold higher in volunteers with mild hepatic impairment (Child Pugh A; 90% CI 1.3 – 3.7 for Cmax and 1.2 – 3.8 for AUC, respectively). In volunteers with moderate hepatic impairment (Child Pugh B), exposure was 7.6-fold higher based on Cmax (90% CI 4.4 – 13.2) and 8.7-fold higher (90% CI 5.7 – 13.1) based on AUC, respectively, compared to healthy volunteers. Subjects with severe hepatic impairment (Child Pugh C) have not been studied.
Concomitant treatment with pirfenidone
In a small parallel group design study in Japanese patients with IPF (13 patients received nintedanib on top of chronic treatment with standard doses of pirfenidone; 11 patients received nintedanib alone), exposure to nintedanib decreased to 68.3% based on AUC and to 59.2% based on Cmax upon co-administration with pirfenidone pirfenidone compared to administration of nintedanib alone. Nintedanib had no effect on the PK of pirfenidone (see section 4.4).
5.3 Preclinical safety data
General toxicology
Single dose toxicity studies in rats and mice indicated a low acute toxic potential of nintedanib. In repeat dose toxicology studies in rats, adverse effects (e.g. thickening of epiphyseal plates, lesions of the incisors) were mostly related to the mechanism of action (i.e. VEGFR-2 inhibition) of nintedanib. These changes are known from other VEGFR-2 inhibitors and can be considered class effects.
Diarrhoea and vomiting accompanied by reduced food consumption and loss of body weight were observed in toxicity studies in non-rodents.
There was no evidence of liver enzyme increases in rats, dogs, and Cynomolgus monkeys. Mild liver enzyme increases, which were not due to serious adverse effects such as diarrhoea were only observed in Rhesus monkeys.
Reproduction toxicity
In rats, embryo-foetal lethality and teratogenic effects were observed at exposure levels below human exposure at the MRHD of 150 mg twice daily. Effects on the development of the axial skeleton and on the development of the great arteries were also noted at subtherapeutic exposure levels.
In rabbits, embryo-foetal lethality and teratogenic effects were observed at an exposure approximately 3 times higher than at the MRHD but equivocal effects on the embryo-foetal development of the axial skeleton and the heart were noted already at an exposure below that at the MRHD of 150 mg twice daily.
In a pre- and postnatal development study in rats, effects on pre- and post-natal development were seen at an exposure below the MRHD.
A study of male fertility and early embryonic development up to implantation in rats did not reveal effects on the male reproductive tract and male fertility.
In rats, small amounts of radiolabelled nintedanib and/or its metabolites were excreted into the milk (≤ 0.5% of the administered dose).
From the 2-year carcinogenicity studies in mice and rats, there was no evidence for a carcinogenic potential of nintedanib.
Genotoxicity studies indicated no mutagenic potential for nintedanib.
6. Pharmaceutical particulars
6.1 List of excipients
Capsule content
triglycerides, medium-chain
hard fat
lecithin (soya) (E322)
Capsule shell
gelatin
glycerol (85%)
titanium dioxide (E171)
iron oxide red (E172)
iron oxide yellow (E172)
Printing ink
shellac glaze
iron oxide black (E172)
propylene glycol (E1520)
6.2 Incompatibilities
Not applicable.
6.3 Shelf life
3 years
6.4 Special precautions for storage
Do not store above 25°C.
Store in the original package in order to protect from moisture.
6.5 Nature and contents of container
Ofev 100 mg soft capsules/ Ofev 150 mg soft capsules are available in the following pack-sizes:
- 30 x 1 soft capsules in Aluminium/aluminium perforated unit dose blisters
- 60 x 1 soft capsules in Aluminium/aluminium perforated unit dose blisters
Not all pack sizes may be marketed.
6.6 Special precautions for disposal and other handling
Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
7. Marketing authorisation holder
Boehringer Ingelheim International GmbH
Binger Strasse 173
55216 Ingelheim am Rhein
Germany
8. Marketing authorisation number(s)
EU/1/14/979/001
EU/1/14/979/002
EU/1/14/979/003
EU/1/14/979/004
9. Date of first authorisation/renewal of the authorisation
Date of first authorisation: 15 January 2015
10. Date of revision of the text
22 July 2016
Detailed information on this medicinal product is available on the website of the European Medicines Agency http://www.ema.europa.eu.
尼达尼布（Nintedanib）是勃林格殷格翰公司开发的一种口服三联血管激酶抑制剂，2014年10月经FDA批准OFEV® (尼达尼布) 用于治疗特发性肺纤维化 (IPF)，成为首个获准用于治疗IPF的 酪氨酸激酶抑制剂 (TKI) 。
尼达尼布（Nintedanib）针对已被证实在肺纤维化病理机制中具有潜在影响的生长因子受体发挥作用，其中最为重要的就是血小板源性生长因子受体（PDGFR）、成纤维细胞生长因子受体（FGFR）和血管内皮生长因子受体（VEGFR）。通过阻断这些参与纤维化进程的信号转导通路，尼达尼布（Nintedanib）能够通过减少肺功能下降速度、从而减缓IPF疾病进展。
特发性肺纤维化是一种病因不明，以肺部的进行性纤维化损害为特征的慢性进展性疾病，是最为常见的特发性间质性肺炎 。
目前尚无预防方法或除肺移植外国际公认的有确切疗效的治疗方法。该在全球范围的患病率达到14-43例/每100000人 。
2014年6月EMA宣布尼达尼布（Nintedanib）治疗特发性肺纤维化（IPF）的上市许可申请获得确认、并被EMA纳入加速审批名单。
9月欧盟宣布尼达尼布（Nintedanib）联合多西他赛在一线化疗之后应用于组织学诊断为腺癌的、局部晚期或转移性或局部复发性非小细胞肺癌（NSCLC）成年患者的支持性意见。公司目前还在针对尼达尼布（Nintedanib）作为癌症治疗选择开展临床研发工作，包括非小细胞肺癌、卵巢癌、结直肠癌和肝细胞肝癌。
OFEV® (nintedanib*) approved in the EU for the treatment of IPF
• Nintedanib* slows disease progression by reducing the decline in lung function by 50% in a broad range of IPF patient types
• Nintedanib* significantly reduced the risk of adjudicated acute exacerbations‡ by 68%
• EC approval is based on results from the replicate Phase III INPULSIS® trials, involving 1,066 patients from 24 countries
Boehringer Ingelheim today announced that the European Commission (EC) has approved nintedanib* for the treatment of idiopathic pulmonary fibrosis (IPF), following an expedited review and positive CHMP opinion on 20 November 2014. Nintedanib* will be marketed in the EU under the brand name OFEV®. IPF is a debilitating and fatal lung disease – with a median survival of 2-3 years after diagnosis.
“Approval of this treatment for patients in the EU is a significant step towards meeting the substantial unmet need in IPF. Patients suffering from this chronic, debilitating disease can now be offered a new treatment option that has been shown to have a clinically meaningful effect on their disease,” said Professor Klaus Dugi, Chief Medical Officer, Boehringer Ingelheim. “This approval is another milestone in Boehringer Ingelheim’s ongoing efforts with regard to innovation in rare diseases in general and our continuing research for the benefit of patients affected by such a dreadful disease as IPF in particular.”
EC approval is based on results from the replicate Phase III INPULSIS® trials, involving ,066 patients from 24 countries. INPULSIS® results showed that nintedanib* slowed disease progression by reducing the annual rate of decline in lung function by 50% in a broad range of IPF patient types including patients with early disease (forced vital capacity (FVC) >90% pred), limited radiographic fibrosis (no honeycombing) on high resolution computed tomography (HRCT) and those with emphysema.2 Nintedanib*, only one capsule twice a day, is the first targeted treatment for IPF to consistently meet the primary endpoint in two identically designed Phase III trials. Nintedanib* has been shown to significantly reduce the risk of adjudicated acute exacerbations‡ by 68%.2
Study investigator Professor Luca Richeldi, Professor of Respiratory Medicine, Chair of Interstitial Lung Disease at the University of Southampton, United Kingdom said, “Until recently, treatment options for patients with IPF were limited. The approval of nintedanib* in the EU gives patients with a life threatening illness a choice of therapy with proven efficacy. Clinical data demonstrate that nintedanib* reduces the annual decline of lung function by approximately half. Data also showed that nintedanib* reduced the risk of acute exacerbations, which can lead to hospitalisation and death.”
Worldwide IPF affects as many as 14–43 people per 100,000.3,4 It most commonly affects people over the age of 50.5 IPF causes permanent scarring of the lungs and decreases the amount of oxygen the lungs can supply to major organs of the body.6,7
“It’s great that there is now a choice of treatments for IPF patients. This approval provides important hope for patients and caregivers living with this awful disease,” said Dr Toby Maher, Consultant Respiratory Physician at the Royal Brompton Hospital in London, United Kingdom.
Nintedanib is approved under the brand name OFEV® in the US and EU for use in patients with IPF. Nintedanib is under regulatory review by health authorities in other countries
INPULSIS® recruited a broad range of patient types – similar to those seen in clinical practice including patients with early disease (FVC > 90% pred), no honeycombing on HRCT and/or concomitant emphysema
Adjudicated exacerbations was a pre-specified sensitivity analysis in the pooled data set. Time to first investigator-reported exacerbation was a secondary endpoint which was met in TOMORROW and INPULSIS®-2 but not in INPULSIS®