Severe Erosive Esophagitis Induced by Crizotinib Therapy: A Case Report and Review of the Literature

Crizotinib is an oral tyrosine kinase inhibitor used in the treatment of anaplastic lymphoma kinase (ALK)-positive non-small cell lung cancer (NSCLC). The phase III trial completed prior to approval noted visual disturbances and gastrointestinal symptoms (e.g. nausea, vomiting, and diarrhea) as common adverse events, but no cases of esophagitis were reported. Since then a few case reports have described esophagitis secondary to crizotinib therapy. In all previous reports, esophagitis appears to have developed quite soon (i.e. within 90 days) after initiating or re-initiating crizotinib therapy (see Table 1). We present a woman who developed acute odynophagia and severe erosive esophagitis ten months after beginning crizotinib (see Figure 1). We suspect the provoking factor was a change in her medication administration routine, done to accommodate religious practices during the period of Ramadan. Careful history taking revealed that she had altered her medication schedule as she reported taking her crizotinib earlier in the morning and later in the evening after which she would immediately lay supine, which was much different than her usual routine. Within 2 weeks of this schedule change she began experiencing significant odynophagia. She was on no other medications and biopsies from her endoscopy revealed no signs of candida infection. This unique case suggests that esophagitis related to crizotinib therapy may be directly related to medication administration practices, which can be preventable. Our patient was found to have tumor progression despite therapy so she was started on second line treatment and the crizotinib was not restarted. Her symptoms disappeared within days of stopping the crizotinib and starting twice daily PPI therapy. Our case highlights the importance of patient education surrounding medication administration, which is of utmost importance for cancer patients who require a specific treatment and have few alternative options. Medication administration and any recent changes should always be considered in the differential diagnosis for those presenting with pill esophagitis.Figure 1Table 1: Timing of onset and resolution of symptoms after initiating and discontinuing crizotinib therapy in five previous case reports.

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