Ofev is indicated in adults for the treatment of idiopathic pulmonary fibrosis (IPF).
Ofev is also indicated in adults for the treatment of other chronic fibrosing interstitial lung diseases
(ILDs) with a progressive phenotype (see section 5.1).
Ofev is indicated in adults for the treatment of systemic sclerosis associated interstitial lung disease
(SSc-ILD).

Treatment should be initiated by physicians experienced in the management of diseases for which
Ofev is approved.
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.
3
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.
If diarrhoea, nausea and/or vomiting 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
diarrhoea, nausea and/or vomiting despite symptomatic treatment, therapy with Ofev should be
discontinued (see section 4.4).
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
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
In patients with mild hepatic impairment (Child Pugh A), the recommended dose of Ofev is 100 mg
twice daily approximately 12 hours apart. In patients with mild hepatic impairment (Child Pugh A),
treatment interruption or discontinuation for management of adverse reactions should be considered.
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. The capsule should not be opened or crushed (see section 6.6).

Gastrointestinal disorders
Diarrhoea
In the clinical trials (see section 5.1), diarrhoea was the most frequent gastro-intestinal adverse
reaction reported (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.
Serious cases of diarrhoea leading to dehydration and electrolyte disturbances have been reported in
the post-marketing. Patients should be treated at first signs with adequate hydration and anti-diarrhoeal
medicinal products, e.g. loperamide, and may require dose reduction or 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. In clinical trials,
nausea led to discontinuation of Ofev in up to 2.1% of patients and vomiting led to discontinuation of
Ofev in up to 1.4% of 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 reactions may be
increased in patients with mild hepatic impairment (Child Pugh A). Patients with mild hepatic
impairment (Child Pugh A) should be treated with a reduced dose of Ofev (see sections 4.2 and 5.2).
Cases of drug-induced liver injury have been observed with nintedanib treatment, including severe
liver injury with fatal outcome. The majority of hepatic events occur within the first three months of
treatment. Therefore, hepatic transaminase and bilirubin levels should be investigated before treatment
initiation and during the first month of treatment with Ofev. Patients should then be monitored at
regular intervals during the subsequent two months of treatment and periodically thereafter, e.g. at
each patient visit or as clinically indicated.
Elevations of liver enzymes (ALT, AST, blood alkaline phosphatase (ALKP), gamma-glutamyltransferase
(GGT), see section 4.8) and bilirubin were reversible upon dose reduction or interruption in
the majority of cases. 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.
Patients with low body weight (< 65 kg), Asian and female patients have a higher risk of elevations of
liver enzymes. Nintedanib exposure increased linearly with patient age, which may also result in a
higher risk of developing liver enzyme elevations (see section 5.2). Close monitoring is recommended
in patients with these risk factors.
5
Renal function
Cases of renal impairment/failure, in some cases with fatal outcome, have been reported with
nintedanib use (see section 4.8).
Patients should be monitored during nintedanib therapy, with particular attention to those patients
exhibiting risk factors for renal impairment/failure. In case of renal impairment/failure, therapy
adjustment should be considered (see section 4.2 Dose adjustments).
Haemorrhage
Vascular endothelial growth factor receptor (VEGFR) inhibition might be associated with an increased
risk of bleeding.
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 clinical trials. Nonserious
and serious bleeding events, some of which were fatal, have been reported in the postmarketing
period (including patients with or without anticoagulant therapy or other medicinal products
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 clinical trials.
In the clinical trials, arterial thromboembolic events were infrequently reported (Ofev 2.5% versus
placebo 0.7% for INPULSIS; Ofev 0.9% versus placebo 0.9% for INBUILD; Ofev 0.7% versus
placebo 0.7% for SENSCIS). In the INPULSIS trials, a higher percentage of patients experienced
myocardial infarctions in the Ofev group (1.6%) compared to the placebo group (0.5%), while adverse
events reflecting ischaemic heart disease were balanced between the Ofev and placebo groups. In the
INBUILD trial, myocardial infarction was observed with low frequency: Ofev 0.9% versus placebo
0.9%. In the SENSCIS trial, myocardial infarction was observed with low frequency in the placebo
group (0.7%) and not observed in the Ofev group. 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.
Aneurysms and artery dissections
The use of VEGF pathway inhibitors in patients with or without hypertension may promote the
formation of aneurysms and/or artery dissections. Before initiating Ofev, this risk should be carefully
considered in patients with risk factors such as hypertension or history of aneurysm.
Venous thromboembolism
In the clinical 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 and ischaemic colitis
In the clinical trials, the frequency of patients with perforation was up to 0.3% in both treatment
groups. Due to the mechanism of action of nintedanib, patients might have an increased risk of
gastrointestinal perforations. Cases of gastrointestinal perforations and cases of ischaemic colitis,
some of which were fatal, have been reported in the post-marketing period. Particular caution should
be exercised when treating patients with previous abdominal surgery, previous history of peptic
ulceration, diverticular disease or receiving concomitant corticosteroids or NSAIDs. 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 or ischaemic colitis. Exceptionally,
Ofev can be reintroduced after complete resolution of ischaemic colitis and careful assessment of
patient’s condition and other risk factors.
Nephrotic range proteinuria and thrombotic microangiopathy
Very few cases of nephrotic range proteinuria with or without renal function impairment have been
reported post-marketing. Histological findings in individual cases were consistent with glomerular
microangiopathy with or without renal thrombi. Reversal of the symptoms has been observed after
6
Ofev was discontinued, with residual proteinuria in some cases. Treatment interruption should be
considered in patients who develop signs or symptoms of nephrotic syndrome.
VEGF pathway inhibitors have been associated with thrombotic microangiopathy (TMA), including
very few case reports for nintedanib. If laboratory or clinical findings associated with TMA occur in a
patient receiving nintedanib, treatment with nintedanib should be discontinued and thorough
evaluation for TMA should be completed.
Hypertension
Administration of Ofev may increase blood pressure. Systemic blood pressure should be measured
periodically and as clinically indicated.
Pulmonary hypertension
Data on the use of Ofev in patients with pulmonary hypertension is limited.
Patients with significant pulmonary hypertension (cardiac index ≤ 2 L/min/m², or parenteral
epoprostenol/treprostinil, or significant right heart failure) were excluded from the INBUILD and
SENSCIS trials.
Ofev should not be used in patients with severe pulmonary hypertension. Close monitoring is
recommended in patients with mild to moderate pulmonary hypertension.
Wound healing complication
No increased frequency of impaired wound healing was observed in the clinical 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
In a dedicated pharmacokinetic study, concomitant treatment of nintedanib with pirfenidone was
investigated in patients with IPF. Based on these results, there is no evidence of a relevant
pharmacokinetic drug-drug interaction between nintedanib and pirfenidone when administered in
combination (see section 5.2). Given the similarity in safety profiles for both medicinal products,
additive adverse reactions, including gastrointestinal and hepatic adverse events, may be expected.
The benefit-risk balance of concomitant treatment 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 nintedanib is administered 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.

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 coadministered
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 adverse reactions may require interruption, dose reduction, or
discontinuation of therapy with Ofev (see section 4.2).
7
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 Pgp
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
Co-administration of nintedanib with oral hormonal contraceptives did not alter the pharmacokinetics
of oral hormonal contraceptives to a relevant extent (see section 5.2).
Co-administration of nintedanib with bosentan did not alter the pharmacokinetics of nintedanib (see
section 5.2).

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 and to use highly
effective contraceptive methods at initiation of, during and at least 3 months after the last dose of
Ofev. Nintedanib does not relevantly affect the plasma exposure of ethinylestradiol and levonorgestrel
(see section 5.2). The efficacy of oral hormonal contraceptives may be compromised by vomiting
and/or diarrhoea or other conditions where the absorption may be affected. Women taking oral
hormonal contraceptives experiencing these conditions should be advised to use an alternative highly
effective contraceptive measure.
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 (see section 4.3) and pregnancy testing
must be conducted prior to treatment with Ofev and during treatment as appropriate.
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, treatment must be discontinued and she should
be apprised of the potential hazard to the foetus.
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).

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.

Summary of the safety profile
In clinical trials and during the post-marketing experience, 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 see section 4.4.
Tabulated list of adverse reactions
Table 1 provides a summary of the adverse drug reactions (ADRs) by MedDRA System Organ Class
(SOC) and frequency category 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).
Table 1: Summary of ADRs per frequency category
Frequency
System Organ Class
preferred term
Idiopathic
pulmonary
fibrosis
Other chronic
fibrosing ILDs with a
progressive
phenotype
Systemic sclerosis
associated interstitial
lung disease
Blood and lymphatic system disorders
Thrombocytopenia Uncommon Uncommon Uncommon
Metabolism and nutrition disorders
Weight decreased Common Common Common
Decreased appetite Common Very common Common
Dehydration Uncommon Uncommon Not known
Cardiac disorders
Myocardial
infarction
Uncommon Uncommon Not known
Vascular disorders
Bleeding (see
section 4.4)
Common Common Common
Hypertension Uncommon Common Common
Aneurysms and
artery dissections
Not known Not known Not known
Gastrointestinal disorder
Diarrhoea Very common Very common Very common
Nausea Very common Very common Very common
Abdominal pain Very common Very common Very common
Vomiting Common Very common Very common
Pancreatitis Uncommon Uncommon Not known
Colitis Uncommon Uncommon Uncommon
Hepatobiliary disorders
Drug induced liver
injury
Uncommon Common Uncommon
Hepatic enzyme
increased
Very common Very common Very common
Alanine
aminotransferase
Common Very common Common
9
Frequency
System Organ Class
preferred term
Idiopathic
pulmonary
fibrosis
Other chronic
fibrosing ILDs with a
progressive
phenotype
Systemic sclerosis
associated interstitial
lung disease
(ALT) increased
Aspartate
aminotransferase
(AST) increased
Common Common Common
Gamma glutamyl
transferase (GGT)
increased
Common Common Common
Hyperbilirubinaemia Uncommon Uncommon Not known
Blood alkaline
phosphatase (ALKP)
increased
Uncommon Common Common
Skin and subcutaneous tissue disorders
Rash Common Common Uncommon
Pruritus Uncommon Uncommon Uncommon
Alopecia Uncommon Uncommon Not known
Renal and urinary disorders
Renal failure (see
section 4.4)
Not known Not known Uncommon
Proteinuria Uncommon Uncommon Not known
Nervous system disorders
Headache Common Common Common
Description of selected adverse reactions
Diarrhoea
In clinical trials (see section 5.1), diarrhoea was the most frequent gastro-intestinal event reported. In
most patients, the event was of mild to moderate intensity. More than two thirds of patients
experiencing diarrhoea reported its first onset already during the first three months of treatment. In
most patients, the events were managed by anti-diarrhoeal therapy, dose reduction or treatment
interruption (see section 4.4). An overview of the reported diarrhoea events in the clinical trials is
listed in Table 2:
Table 2: Diarrhoea in clinical trials over 52 weeks
INPULSIS INBUILD SENSCIS
Placebo Ofev Placebo Ofev Placebo Ofev
Diarrhoea 18.4% 62.4% 23.9% 66.9% 31.6% 75.7%
Severe diarrhoea 0.5% 3.3% 0.9% 2.4% 1.0% 4.2%
Diarrhoea
leading to Ofev
dose reduction
0%
10.7%
0.9%
16.0%
1.0%
22.2%
Diarrhoea
leading to Ofev
discontinuation
0.2%
4.4%
0.3%
5.7%
0.3%
6.9%
Hepatic enzyme increased
In the INPULSIS trials, liver enzyme elevations (see section 4.4) were reported in 13.6% versus 2.6%
of patients treated with Ofev and placebo, respectively. In the INBUILD trial, liver enzyme elevations
were reported in 22.6% versus 5.7% of patients treated with Ofev and placebo, respectively. In the
SENSCIS trial, liver enzyme elevations were reported in 13.2% versus 3.1% of patients treated with
10
• The National Pharmacovigilance Centre (NPC):
- Fax: +966 11 205 7662
- Call NPC at +966-11-2038222, Ext 2317-2356-2340
- SFDA Call Center: 19999
- E-mail: npc.drug@sfda.gov.sa
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Ofev and placebo, respectively. 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.
Bleeding
In clinical trials, the frequency of patients who experienced bleeding was slightly higher in patients
treated with Ofev or comparable between the treatment arms (Ofev 10.3% versus placebo 7.8% for
INPULSIS; Ofev 11.1% versus placebo 12.7% for INBUILD; Ofev 11.1% versus placebo 8.3% for
SENSCIS). Non-serious epistaxis was the most frequent bleeding event reported. Serious bleeding
events occurred with low frequencies in the 2 treatment groups (Ofev 1.3% versus placebo 1.4% for
INPULSIS; Ofev 0.9% versus placebo 1.5% for INBUILD; Ofev 1.4% versus placebo 0.7% for
SENSCIS).
Post-marketing bleeding events include but are not limited to gastrointestinal, respiratory and central
nervous organ systems, with the most frequent being gastrointestinal (see section 4.4).
Proteinuria
In clinical trials, the frequency of patients who experienced proteinuria was low and comparable
between the treatment arms (Ofev 0.8% versus placebo 0.5% for INPULSIS; Ofev 1.5% versus
placebo 1.8% for INBUILD; Ofev 1.0% versus placebo 0.0% for SENSCIS). Nephrotic syndrome has
not been reported in clinical trials. Very few cases of nephrotic range proteinuria with or without renal
function impairment have been reported post-marketing. Histological findings in individual cases were
consistent with glomerular microangiopathy with or without renal thrombi. Reversal of the symptoms
has been observed after Ofev was discontinued, with residual proteinuria in some cases. Treatment
interruption should be considered in patients who develop signs or symptoms of nephrotic syndrome
(see section 4.4).
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 the national reporting system
• Saudi Arabia
• Other GCC States:
- Please contact the relevant competent authority.

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
11
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.

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. In addition, nintedanib inhibits Lck (lymphocyte-specific tyrosine-protein kinase), Lyn
(tyrosine-protein kinase lyn), Src (proto-oncogene tyrosine-protein kinase src), and CSF1R (colony

stimulating factor 1 receptor) kinases. Nintedanib binds competitively to the adenosine triphosphate
(ATP) binding pocket of these kinases and blocks the intracellular signalling cascades, which have
been demonstrated to be involved in the pathogenesis of fibrotic tissue remodelling in interstitial lung
diseases.
Pharmacodynamic effects
In in vitro studies using human cells nintedanib has been shown to inhibit processes assumed to be
involved in the initiation of the fibrotic pathogenesis, the release of pro-fibrotic mediators from
peripheral blood monocytic cells and macrophage polarisation to alternatively activated macrophages.
Nintedanib has been demonstrated to inhibit fundamental processes in organ fibrosis, proliferation and
migration of fibroblasts and transformation to the active myofibroblast phenotype and secretion of
extracellular matrix. In animal studies in multiple models of IPF, SSc/SSc-ILD, rheumatoid arthritisassociated-(
RA-)ILD and other organ fibrosis, nintedanib has shown anti-inflammatory effects and
anti-fibrotic effects in the lung, skin, heart, kidney, and liver. Nintedanib also exerted vascular activity.
It reduced dermal microvascular endothelial cell apoptosis and attenuated pulmonary vascular
remodelling by reducing the proliferation of vascular smooth muscle cells, the thickness of pulmonary
vessel walls and percentage of occluded pulmonary vessels.
Clinical efficacy and safety
Idiopathic pulmonary fibrosis (IPF)
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 3
for individual and pooled study results.
13
Table 3: 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
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.
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
14
bid = twice daily
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 4 for individual
and pooled study results.
Table 4: 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.
15
Table 5: 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
In the pooled analysis of the INPULSIS trials, the baseline SGRQ scores were 39.51 in the nintedanib
group and 39.58 in the placebo group. 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 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 6 for individual and pooled
study results.
Table 6: 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.
In a pre-specified sensitivity analysis, 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
16
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).
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 7: 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.
Long-term treatment with Ofev in patients with IPF (INPULSIS-ON)
An open-label extension trial of Ofev included 734 patients with IPF. Patients who completed the 52-
week treatment period in an INPULSIS trial received open-label Ofev treatment in the extension trial
INPULSIS-ON. Median exposure time for patients treated with Ofev in both the INPULSIS and
INPULSIS-ON trials was 44.7 months (range 11.9 – 68.3). The exploratory efficacy endpoints
included the annual rate of decline in FVC over 192 weeks which was −135.1 (5.8) mL/year in all
patients treated and were consistent with the annual rate of FVC decline in patients treated with Ofev
in the INPULSIS phase III trials (−113.6 mL per year). The adverse event profile of Ofev in
INPULSIS-ON was consistent to that in the INPULSIS phase III trials.
IPF patients with advanced lung function impairment (INSTAGE)
INSTAGE was a multicentre, multinational, prospective, randomised, double-blind, parallel-group
clinical trial in IPF patients with advanced lung function impairment (DLCO ≤ 35% predicted) for 24
weeks. 136 patients were treated with Ofev monotherapy. Primary endpoint result showed a reduction
of St Georges Respiratory Questionnaire (SGRQ) total score by -0.77 units at week W12, based on
adjusted mean change from baseline. A post hoc comparison demonstrated that the decline in FVC in
these patients was consistent with the decline in FVC in patients with less advanced disease and
treated with Ofev in the INPULSIS phase III trials.
The safety and tolerability profile of Ofev in IPF patients with advanced lung function impairment was
consistent with that seen in the INPULSIS phase III trials.
Additional data from the phase IV INJOURNEY trial with Ofev 150 mg twice daily and add-on
pirfenidone
Concomitant treatment with nintedanib and pirfenidone has been investigated in an exploratory openlabel,
randomised trial of nintedanib 150 mg twice daily with add-on pirfenidone (titrated to 801 mg
three times a day) compared to nintedanib 150 mg twice daily alone in 105 randomised patients for 12
17
weeks. The primary endpoint was the percentage of patients with gastrointestinal adverse events from
baseline to week 12. Gastrointestinal adverse events were frequent and in line with the established
safety profile of each component. Diarrhoea, nausea and vomiting were the most frequent adverse
events reported in patients, treated with pirfenidone added to nintedanib versus nintedanib alone,
respectively.
Mean (SE) absolute changes from baseline in FVC at week 12 were −13.3 (17.4) mL in patients
treated with nintedanib with add-on pirfenidone (n=48) compared to −40.9 (31.4) mL in patients
treated with nintedanib alone (n=44).
Other chronic fibrosing interstitial lung diseases (ILDs) with a progressive phenotype
The clinical efficacy of Ofev has been studied in patients with other chronic fibrosing ILDs with a
progressive phenotype in a double-blind, randomised, placebo-controlled phase III trial (INBUILD).
Patients with IPF were excluded. Patients with a clinical diagnosis of a chronic fibrosing ILD were
selected if they had relevant fibrosis (greater than 10% fibrotic features) on HRCT and presented
with clinical signs of progression (defined as FVC decline ≥10%, FVC decline ≥ 5% and <10%
with worsening symptoms or imaging, or worsening symptoms and worsening imaging all in the
24 months prior to screening). Patients were required to have an FVC greater than or equal to 45%
of predicted and a DLCO 30% to less than 80% of predicted. Patients were required to have
progressed despite management deemed appropriate in clinical practice for the patient’s relevant
ILD.
A total of 663 patients were randomised in a 1:1 ratio to receive either Ofev 150 mg bid or matching
placebo for at least 52 weeks. The median Ofev exposure over the whole trial was 17.4 months and the
mean Ofev exposure over the whole trial was 15.6 months. Randomisation was stratified based on
HRCT fibrotic pattern as assessed by central readers. 412 patients with HRCT with usual interstitial
pneumonia (UIP)-like fibrotic pattern and 251 patients with other HRCT fibrotic patterns were
randomised. There were 2 co-primary populations defined for the analyses in this trial: all patients (the
overall population) and patients with HRCT with UIP-like fibrotic pattern. Patients with other HRCT
fibrotic patterns represented the ‘complementary’ population.
The primary endpoint was the annual rate of decline in forced vital capacity (FVC) (in mL) over
52 weeks. Main secondary endpoints were absolute change from baseline in King's Brief Interstitial
Lung Disease Questionnaire (K-BILD) total score at week 52, time to first acute ILD exacerbation or
death over 52 weeks, and time to death over 52 weeks.
Patients had a mean (standard deviation [SD, Min-Max]) age of 65.8 (9.8, 27-87) years and a mean
FVC percent predicted of 69.0% (15.6, 42-137). The underlying clinical ILD diagnoses in groups
represented in the trial were hypersensitivity pneumonitis (26.1%), autoimmune ILDs (25.6%),
idiopathic nonspecific interstitial pneumonia (18.9%), unclassifiable idiopathic interstitial pneumonia
(17.2%), and other ILDs (12.2%).
The INBUILD trial was not designed or powered to provide evidence for a benefit of nintedanib in
specific diagnostic subgroups. Consistent effects were demonstrated in subgroups based on the ILD
diagnoses. The experience with nintedanib in very rare progressive fibrosing ILDs is limited.
Annual rate of decline in FVC
The annual rate of decline in FVC (in mL) over 52 weeks was significantly reduced by 107.0 mL in
patients receiving Ofev compared to patients receiving placebo (Table 8) corresponding to a relative
treatment effect of 57.0%.
18
Table 8: Annual rate of decline in FVC (mL) over 52 weeks
Placebo Ofev
150 mg twice daily
Number of analysed patients 331 332
Rate1 (SE) of decline over
52 weeks
-187.8 (14.8)
-80.8 (15.1)
Comparison vs placebo
Difference1 107.0
95% CI (65.4, 148.5)
p-value < 0.0001
1Based on a random coefficient regression with fixed categorical effects of treatment, HRCT pattern, fixed
continuous effects of time, baseline FVC [mL], and including treatment-by-time and baseline-by-time
interactions
Similar results were observed in the co-primary population of patients with HRCT with UIP-like
fibrotic pattern. The treatment effect was consistent in the complementary population of patients with
other HRCT fibrotic patterns (interaction p-value 0.2268) (Figure 2).
Figure 2 Forest plot of the annual rate of decline in FVC (mL) over 52 weeks in the
patient populations
bid = twice daily
The results of the effect of Ofev in reducing the annual rate of decline in FVC were confirmed by all
pre-specified sensitivity analyses and consistent results were observed in the pre-specified efficacy
subgroups: gender, age group, race, predicted baseline FVC %, and original underlying clinical ILD
diagnosis in groups.
Figure 3 shows the evolution of change in FVC from baseline over time in the treatment groups.
19
Figure 3 Mean (SEM) observed FVC change from baseline (mL) over 52 weeks
bid = twice daily
In addition, favourable effects of Ofev were observed on the adjusted mean absolute change from
baseline in FVC % predicted at week 52. The adjusted mean absolute change from baseline to week 52
in FVC % predicted was lower in the nintedanib group (-2.62%) than in the placebo group (-5.86%).
The adjusted mean difference between the treatment groups was 3.24 (95% CI: 2.09, 4.40, nominal
p<0.0001).
FVC responder analysis
The proportion of FVC responders, defined as patients with a relative decline in FVC % predicted no
greater than 5%, was higher in the Ofev group as compared to placebo. Similar results were observed
in analyses using a threshold of 10% (Table 9).
20
Table 9: Proportion of FVC responders at 52 weeks in INBUILD
Placebo Ofev
150 mg twice daily
Number of analysed patients 331 332
5% threshold
Number (%) of FVC
responders1
104 (31.4)
158 (47.6)
Comparison vs placebo
Odds ratio² 2.01
95% CI (1.46, 2.76)
Nominal p-value < 0.0001
10% threshold
Number (%) of FVC
responders1
169 (51.1)
197 (59.3)
Comparison vs placebo
Odds ratio² 1.42
95% CI (1.04, 1.94)
Nominal p-value 0.0268
1Responder patients are those with no relative decline greater than 5% or greater than 10% in FVC % predicted,
depending on the threshold and with an FVC evaluation at 52 weeks (patients with missing data at week 52 were
considered as non-responders).
2Based on a logistic regression model with continuous covariate baseline FVC % predicted and binary covariate
HRCT pattern
Time to first acute ILD exacerbation or death
Over the whole trial, the proportion of patients with at least one event of first acute ILD exacerbation
or death was 13.9% in the Ofev group and 19.6% in the placebo group. The HR was 0.67 (95% CI:
0.46, 0.98; nominal p=0.0387), indicating a 33% reduction in the risk of first acute ILD exacerbation
or death in patients receiving Ofev compared to placebo (Figure 4).
21
Figure 4 Kaplan–Meier plot of time to first acute ILD exacerbation or death over the
whole trial
bid = twice daily
Survival analysis
The risk of death was lower in the Ofev group compared to the placebo group. The HR was 0.78 (95%
CI: 0.50, 1.21; nominal p=0.2594), indicating a 22% reduction in the risk of death in patients receiving
Ofev compared to placebo.
Time to progression (≥ 10% absolute decline of FVC % predicted) or death
In the INBUILD trial, the risk of progression (≥ 10% absolute decline of FVC % predicted) or death
was reduced for patients treated with Ofev. The proportion of patients with an event was 40.4% in the
Ofev group and 54.7% in the placebo group. The HR was 0.66 (95% CI: 0.53, 0.83; p=0.0003),
indicating a 34% reduction of the risk of progression (≥ 10% absolute decline of FVC % predicted) or
death in patients receiving Ofev compared to placebo.
Quality of life
The adjusted mean change from baseline in K-BILD total score at week 52 was -0.79 units in the
placebo group and 0.55 in the Ofev group. The difference between the treatment groups was 1.34
(95% CI: -0.31, 2.98; nominal p=0.1115).
The adjusted mean absolute change from baseline in Living with Pulmonary Fibrosis (L-PF)
symptoms dyspnoea domain score at week 52 was 4.28 in the Ofev group compared with 7.81 in the
placebo group. The adjusted mean difference between the groups in favour of Ofev was -3.53 (95%
CI: -6.14, -0.92; nominal p=0.0081). The adjusted mean absolute change from baseline in L-PF
Symptoms cough domain score at week 52 was -1.84 in the Ofev group compared with 4.25 in the
placebo group. The adjusted mean difference between the groups in favour of Ofev was -6.09 (95%
CI: -9.65, -2.53; nominal p=0.0008).
22
Systemic sclerosis associated interstitial lung disease (SSc-ILD)
The clinical efficacy of Ofev has been studied in in patients with SSc-ILD in a double-blind,
randomised, placebo-controlled phase III trial (SENSCIS). Patients were diagnosed with SSc-ILD
based upon the 2013 American College of Rheumatology / European League Against Rheumatism
classification criteria for SSc and a chest high resolution computed tomography (HRCT) scan
conducted within the previous 12 months. A total of 580 patients were randomised in a 1:1 ratio to
receive either Ofev 150 mg bid or matching placebo for at least 52 weeks, of which 576 patients were
treated. Randomisation was stratified by antitopoisomerase antibody status (ATA). Individual patients
stayed on blinded trial treatment for up to 100 weeks (median Ofev exposure 15.4 months; mean Ofev
exposure 14.5 months).
The primary endpoint was the annual rate of decline in FVC over 52 weeks. Key secondary endpoints
were absolute change from baseline in the modified Rodnan Skin Score (mRSS) at week 52 and
absolute change from baseline in the Saint George’s Respiratory Questionnaire (SGRQ) total score at
week 52.
In the overall population, 75.2% of the patients were female. The mean (standard deviation [SD, Min-
Max]) age was 54.0 (12.2, 20-79) years. Overall, 51.9% of patients had diffuse cutaneous systemic
sclerosis (SSc) and 48.1% had limited cutaneous SSc. The mean (SD) time since first onset of a non-
Raynaud symptom was 3.49 (1.7) years. 49.0% of patients were on stable therapy with mycophenolate
at baseline. The safety profile in patients with or without mycophenolate at baseline was comparable.
Annual rate of decline in FVC
The annual rate of decline of FVC (mL) over 52 weeks was significantly reduced by 41.0 mL in
patients receiving Ofev compared to patients receiving placebo (Table 10) corresponding to a relative
treatment effect of 43.8%.
Table 10: Annual rate of decline in FVC (mL) over 52 weeks
Placebo Ofev
150 mg twice daily
Number of analysed patients 288 287
Rate1 (SE) of decline over
52 weeks
-93.3 (13.5) -52.4 (13.8)
Comparison vs placebo
Difference1 41.0
95% CI (2.9, 79.0)
p-value <0.05
1Based on a random coefficient regression with fixed categorical effects of treatment, ATA status, gender, fixed
continuous effects of time, baseline FVC [mL], age, height, and including treatment-by-time and baseline-bytime
interactions. Random effect was included for patient specific intercept and time. Within-patient errors were
modelled by an unstructured variance-covariance matrix. Inter-individual variability was modelled by a
variance-components variance-covariance matrix.
The effect of Ofev in reducing the annual rate of decline in FVC was similar across pre-specified
sensitivity analyses and no heterogeneity was detected in pre-specified subgroups (e.g. by age, gender,
and mycophenolate use).
In addition, similar effects were observed on other lung function endpoints, e.g absolute change from
baseline in FVC in mL at week 52 (Figure 5 and Table 11) and rate of decline in FVC in % predicted
over 52 weeks (Table 12) providing further substantiation of the effects of Ofev on slowing
progression of SSc-ILD. Furthermore, fewer patients in the Ofev group had an absolute FVC decline
> 5% predicted (20.6% in the Ofev group vs. 28.5% in the placebo group, OR=0.65, p=0.0287). The
relative FVC decline in mL > 10% was comparable between both groups (16.7% in the Ofev group vs.
23
18.1% in the placebo group, OR=0.91, p=0.6842). In these analyses, missing FVC values at week 52
were imputed with the patient’s worst value on treatment.
An exploratory analysis of data up to 100 weeks (maximum treatment duration in SENSCIS)
suggested that the on treatment effect of Ofev on slowing progression of SSc-ILD persisted beyond
52 weeks.
Figure 5: Mean (SEM) observed FVC change from baseline (mL) over 52 weeks
bid = twice daily
Table 11: Absolute change from baseline in FVC (mL) at week 52
Placebo Ofev
150 mg twice daily
Number of analysed patients 288 288
Mean (SD) at Baseline 2541.0 (815.5) 2458.5 (735.9)
Mean1 (SE) change from
baseline at week 52
-101.0 (13.6) -54.6 (13.9)
Comparison vs placebo
Mean1 46.4
95% CI (8.1, 84.7)
p-value <0.05
1Based on Mixed Model for Repeated Measures (MMRM), with fixed categorical effects of ATA status, visit,
treatment-by-visit interaction, baseline-by-visit interaction age, gender and height. Visit was the repeated
measure. Within-patient errors were modelled by unstructured variance-covariance structure. Adjusted mean was
based on all analysed patients in the model (not only patients with a baseline and measurement at week 52).
24
Table 12: Annual rate of decline in FVC (% predicted) over 52 weeks
Placebo Ofev
150 mg twice daily
Number of analysed patients 288 287
Rate1 (SE) of decline over
52 weeks
-2.6 (0.4) -1.4 (0.4)
Comparison vs placebo
Difference1 1.15
95% CI (0.09, 2.21)
p-value <0.05
1Based on a random coefficient regression with fixed categorical effects of treatment, ATA status, fixed
continuous effects of time, baseline FVC [% pred], and including treatment-by-time and baseline-by-time
interactions. Random effect was included for patient specific intercept and time. Within-patient errors were
modelled by an unstructured variance-covariance matrix. Inter-individual variability was modelled by a
variance-components variance-covariance matrix
Change from baseline in Modified Rodnan Skin Score (mRSS) at week 52
The adjusted mean absolute change from baseline in mRSS at week 52 was comparable between the
Ofev group (-2.17 (95% CI -2.69, -1.65)) and the placebo group (-1.96 (95% CI -2.48, -1.45)). The
adjusted mean difference between the treatment groups was -0.21 (95% CI -0.94, 0.53; p = 0.5785).
Change from baseline in St. George’s Respiratory Questionnaire (SGRQ) total score at week 52
The adjusted mean absolute change from baseline in SGRQ total score at week 52 was comparable
between the Ofev group (0.81 (95% CI -0.92, 2.55)) and the placebo group (-0.88 (95% CI -2.58,
0.82)). The adjusted mean difference between the treatment groups was 1.69 (95% CI -0.73, 4.12;
p = 0.1711).
Survival analysis
Mortality over the whole trial was comparable between the Ofev group (N = 10; 3.5%) and the
placebo group (N = 9; 3.1%). The analysis of time to death over the whole trial resulted in a HR of
1.16 (95% CI 0.47, 2.84; p = 0.7535).
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).

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).
25
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'-diphosphoglucuronosyltransferase
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. singledose
data can be extrapolated to multiple-dose data). Accumulation upon multiple administrations was
1.04-fold for Cmax and 1.38-fold for AUCτ. 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, patients with
other chronic fibrosing ILDs with a progressive phenotype, patients with SSc-ILD, 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).
26
Age
Exposure to nintedanib increased linearly with age. AUCτ,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. AUCτ,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 population mean exposure to nintedanib was 33 - 50% higher in Chinese, Taiwanese, and Indian
patients and 16% higher in Japanese patients while it was 16 - 22% lower in Koreans compared to
Caucasians (body weight corrected). Data from Black individuals were 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 dedicated pharmacokinetic study, concomitant treatment of nintedanib with pirfenidone was
investigated in patients with IPF. Group 1 received a single dose of 150 mg nintedanib before and after
uptitration to 801 mg pirfenidone three times a day at steady state (N=20 patients treated). Group 2
received steady state treatment of 801 mg pirfenidone three times a day and had a PK profiling before
and after at least 7 days of co-treatment with 150 mg nintedanib twice daily (N=17 patients treated). In
group 1, the adjusted geometric mean ratios (90% confidence interval (CI)) were 93% (57% - 151%)
and 96% (70% - 131%) for Cmax and AUC0-tz of nintedanib, respectively (n=12 for intraindividual
comparison). In group 2, the adjusted geometric mean ratios (90% CI)) were 97% (86% - 110%) and
95% (86% - 106%) for Cmax,ss and AUCτ,ss of pirfenidone, respectively (n=12 for intraindividual
comparison).
Based on these results, there is no evidence of a relevant pharmacokinetic drug-drug interaction
between nintedanib and pirfenidone when administered in combination (see section 4.4).
Concomitant treatment with bosentan
In a dedicated pharmacokinetic study, concomitant treatment of Ofev with bosentan was investigated
in healthy volunteers. Subjects received a single dose of 150 mg Ofev before and after multiple dosing
of 125 mg bosentan twice daily at steady state. The adjusted geometric mean ratios (90% confidence
interval (CI)) were 103% (86% - 124%) and 99% (91% - 107%) for Cmax and AUC0-tz of nintedanib,
respectively (n=13), indicating that co-administration of nintedanib with bosentan did not alter the
pharmacokinetics of nintedanib.
Concomitant treatment with oral hormonal contraceptives
In a dedicated pharmacokinetic study, female patients with SSc-ILD received a single dose of a
combination of 30 μg ethinylestradiol and 150 μg levonorgestrel before and after twice daily dosing of
150 mg nintedanib for at least 10 days. The adjusted geometric mean ratios (90% confidence interval
(CI)) were 117% (108% - 127%; Cmax) and 101% (93% - 111%; AUC0–tz) for ethinylestradiol and
101% (90% - 113%; Cmax) and 96% (91% - 102%; AUC0–tz) for levonorgestrel, respectively (n=15),
27
indicating that co-administration of nintedanib has no relevant effect on the plasma exposure of
ethinylestradiol and levonorgestrel.
Exposure-response relationship
Exposure-response analyses of patients with IPF and other chronic fibrosing ILDs with a progressive
phenotype, indicated a weak relationship between nintedanib plasma exposure and ALT and/or AST
elevations. Actual administered dose might be the better predictor for the risk of developing diarrhoea
of any intensity, even if plasma exposure as risk determining factor could not be ruled out (see section
4.4).

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.

Capsule content
triglycerides, medium-chain
hard fat
28
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)

Not applicable.

Store in a refrigerator (2 - 8°C)
Store in the original package in order to protect from moisture.

Ofev 100 mg soft capsules
Ofev 100 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
Ofev 150 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.

In the event of coming in contact with the content of the capsule, hands should be washed off
immediately with plenty of water (see section 4.2).
Any unused medicinal product or waste material should be disposed of in accordance with local
requirements.