(1156) Cough and Caution: Thalidomide Use for Chronic Cough in a Patient With Idiopathic Pulmonary Fibrosis

Introduction: Idiopathic pulmonary fibrosis (IPF) is a progressive interstitial lung disease characterized by chronic scarring of the lung tissue; one of its most common and challenging symptoms is persistent cough. Thalidomide, a drug with immunomodulatory and anti-inflammatory properties, can be successful in managing chronic cough. Previously associated with severe teratogenic effects, thalidomide also increases the risk of deep vein thrombosis (DVT) and neurotoxicity. We describe a patient with IPF who developed both of these adverse effects while on thalidomide, underscoring the importance of cautious use and vigilant monitoring of this medication in patients with low respiratory reserve.

Description: A 67-year-old woman with a history of obstructive sleep apnea, uterine cancer, hysterectomy, and bilateral salpingo-oophorectomy, presented for follow-up of IPF diagnosed in 2014 via VATS biopsy. Despite pirfenidone and nightly CPAP, her oxygen needs increased over the past decade to 6L at home. Her chronic cough significantly impacted her quality of life. After a trial of first-line medications, only thalidomide provided significant relief. She eventually developed paresthesia and peripheral neuropathy of her lower extremities attributed to chronic thalidomide use and then presented with new onset left lower extremity pain, which ultrasound revealed to be DVT, leading to initiation of apixaban. Of note, the patient had no other clot-provoking factors. Despite discussion of the risks, the patient chose to continue thalidomide with lifelong anticoagulation due to the immense improvement of her symptoms.

Discussion: Thalidomide exerts anti-inflammatory effects through the inhibition of TNF-alpha production. Despite its past controversies, it remains a relevant treatment option. Most studies have linked venous thromboembolism and pulmonary embolism with thalidomide treatment of malignancies, particularly renal cancer and myelomas. Central neurotoxicity in the form of somnolence, sedation, and peripheral neuropathy occur in 10% of patients. Our case demonstrates thalidomide’s effectiveness in managing persistent cough as well as the need to be vigilant for potential adverse effects. Careful consideration and, if indicated, anticoagulation therapy are crucial when using thalidomide in these scenarios.