Metastatic EGFR-positive lung adenocarcinoma: osimertinib cardiomyopathy managed with SGLT2 inhibitor support

What happened, in summary

This 85-year-old man had recently been diagnosed with metastatic EGFR-positive non-small cell lung adenocarcinoma and was treated with osimertinib 80 mg by mouth. Within 1 month, he was hospitalized with progressive respiratory distress, volume overload, atrial fibrillation with rapid ventricular response, prolonged QTc, acute kidney injury, and decompensated heart failure. Osimertinib was held. He was volume-optimized with diuretics, and his atrial fibrillation was managed with metoprolol succinate, dronedarone, and apixaban. His rhythm returned to normal sinus rhythm, and echocardiography later showed left ventricular ejection fraction recovered to 60%. Because osimertinib was important for cancer control, it was restarted after shared decision-making between oncology and cardiology. Within 3 months, however, LVEF fell to 46%, so osimertinib was held again. After 3 subsequent echocardiograms showed normalized LVEF, osimertinib was restarted with losartan for cardioprotection. LVEF stabilized at 60%, but 11 months later it again dropped asymptomatically to 45%, leading to another hold. His team considered switching EGFR therapy but favored osimertinib because of its central nervous system penetration. For a final rechallenge, he restarted osimertinib with empagliflozin 10 mg, losartan 12.5 mg, and metoprolol succinate 50 mg, with close ECG and echocardiography monitoring. At 3 months, he had no LVEF reduction, QTc prolongation, or heart-failure signs. As of December 2024, 12-month follow-up showed he remained clinically stable and asymptomatic, with stable electrocardiographic and echocardiographic examinations. The case illustrates a cardio-oncology strategy that preserved access to an effective EGFR-targeted therapy while actively monitoring and treating cardiac risk over time through continued care.