Gastric perforation related to concurrent use of nintedanib and ramucirumab

The prevalence of lung cancer in idiopathic pulmonary fibrosis (IPF) patients ranges from 9.8 to 38%. Nintedanib, a small molecule receptor tyrosine kinase inhibitor (TKI) of platelet-derived growth factor receptor (PDGFR), fibroblast growth factor receptor (FGFR), and vascular endothelial growth factor receptor (VEGFR), has been approved for IPF after phase III INPULSIS trials in 2014. Ramucirumab, a monoclonal antibody for VEGFR-2, combined with docetaxcel, has been approved for advanced non-small cell lung cancer (NSCLC) after the phase III REVEL trail in 2014. Physicians will have more IPF patients being treated with nintedanib, who subsequently develop NSCLC, and therefore will likely be treated with ramucirumab plus docetaxel. We report the first case of 70-year-old man taking nintedanib for his IPF and treated with ramucirumab plus docetaxel as a seventh-line therapy for his pulmonary adenocarcinoma. On day 15 of his chemotherapy treatment cycle 2, after taking nintedanib for nine days, he developed gastric perforation.