recce101 Posted May 23, 2007 Share Posted May 23, 2007 A couple of messages back I said I'd check with my onc about the Avastin + ibuprofen question, so I did, just before going into the chemo room for today's 3-week refresher. His answer: in my case, no problem. Standard label dose is fine. NSAIDs could be an issue if membranes are already damaged (from surgery, etc.) since healing is being retarded by the Avastin to begin with, a situation more likely to occur in colon cancer than in lung cancer. There's probably not any clear right-or-wrong here. Some docs may be recommending the no-ibuprofen restriction from an abundance of caution growing out of a bad outcome earlier in their career. Anyway, that's my input on the question. I wonder if a new thread is in order... Aloha, Ned Quote Link to comment Share on other sites More sharing options...
DrWest Posted May 23, 2007 Share Posted May 23, 2007 I've been trying for a week to get a substantive answer from Genentech about this, but unfortunately everyone's so busy because it's the week before ASCO, the most important oncology meeting of the year, and everyone is working their tails off getting set for it. I have seen references to decreased absortion at least of Iressa at higher pH levels (when the stomach acid is blocked), and it's apparently the same situation with Tarceva. However, for some reason this issue isn't highlighted at all in any of the teaching materials for patients, nor is it included as a specific instruction for oncologists. If it's clinically significant, it's an issue that should be addressed much more clearly by the company, because it could lead to greater numbers of people responding and showing a survival benefit with tarceva than would be seen if people are taking drugs that can diminish absorption. What I'd really like to find out is whether there is evidence, from the records of patients on some of the larger trials with tarceva that included the lists of concurrent medications patients were taking, that people on proton pump inhibitors (PPIs) like protonix or prevacid or nexium, or antacids like TUMS, had a lower response rate and/or shorter survival benefit than patients who weren't on these medicines. It will be worth us knowing this whether there is a difference or not. For avastin, it's an IV drug, so it's getting delivered no matter what, unlike an oral drug, where what goes in is less directly related to what the body actually takes up. Avastin sticks around in the bloodstream for weeks. The only interaction I know of is a concern about bleeding risk being exacerbated by patients with lung cancer being on therapeutic levels of blood thinners, and that is not based on experiences of bleeding as much as fear of it. Patients with other types of cancer, such as colon cancer, don't have that restriction, but the risk of fatal bleeding has been a greater concern in lung cancer than in colon cancer, so I believe that's why the development of the drug in lung cancer has been very conservative. I hope and expect to get a real answer from Genentech on a real "policy statement" about PPIs and antacids while taking Tarceva. In the meantime, I'd definitely recommend against taking PPIs or antacids along with Tarceva if there isn't a major need for it. -Dr. West Quote Link to comment Share on other sites More sharing options...
yirol Posted May 23, 2007 Author Share Posted May 23, 2007 We haven't gotten a straight answer from Dad's oncologist yet either, just a status quo shrug. Will have to keep pushing.... The only consolation (and it's a teeeeeeny one) is that my Dad is on 150mg rather than 100mg, and though it's my understanding that 150mg is the recommended dose, maybe his doctor factored in the acid medications somewhere? Still, my Dad is Stage IV, and Stage IV doesn't do status quo!!! "DrWest"] What I'd really like to find out is whether there is evidence, from the records of patients on some of the larger trials with tarceva that included the lists of concurrent medications patients were taking, that people on proton pump inhibitors (PPIs) like protonix or prevacid or nexium, or antacids like TUMS, had a lower response rate and/or shorter survival benefit than patients who weren't on these medicines. It will be worth us knowing this whether there is a difference or not. -- I hope and expect to get a real answer from Genentech on a real "policy statement" about PPIs and antacids while taking Tarceva. In the meantime, I'd definitely recommend against taking PPIs or antacids along with Tarceva if there isn't a major need for it. -Dr. West Dr. West, though you didn't get an answer from Genetech yet, your follow-through has been very important and reassuring. How does one go about gathering info. from patient records you mentioned above? Are any oncologists looking at that now? My Dad's stomach acid problems are real and need to be handled, but I just can't see squandering any possible benefits of Tarceva. Anyone out there know of good ways to combat over-acidity without medication? Quote Link to comment Share on other sites More sharing options...
recce101 Posted May 23, 2007 Share Posted May 23, 2007 [ yirol ] ...Anyone out there know of good ways to combat over-acidity without medication? Does your dad feel the acidity in any position, or just when lying down? I can't explain the mechanism, but I've found that when I lie flat on my back (as in parts of my exercise routine) I'll often notice acidity that wasn't there before. If I pay attention, I can detect the point (almost horizontal) where it starts, as if a little acid is spilling out of the top of the stomach into the esophagus. Weird! Anyway, I have some old blankets stuffed under the head end of my mattress to keep that end elevated slightly. Of course a more intense bout of acidity will make its presence known in any position, but that's quite rare for me and is handled with a couple of fruit-flavored Tums. Aloha, Ned Quote Link to comment Share on other sites More sharing options...
john Posted May 24, 2007 Share Posted May 24, 2007 Some of the information says that the PH has to be lower than 5? Dr West, how high (basic) does the stomach get after taking a PPI or TUMS? How fast is Tarceva absorbed into the bloodstream. Yirol, It seems like if he needs antacids then there might be a better time to take them. It seems best to not take them around the same time as the Tarceva. Dr West could you provide more input. thanks From one of the tarceva clinical trials: Study Specific: Patients on enzyme-inducing anticonvulsants will be changed to non-enzyme inducing anticonvulsants or will not be allowed on this study. Patients receiving proton pump inhibitor or H2 blockers will not be allowed on study. Patients taking antacids will be allowed on study although they should not take the antacid for two hours before or two hours after taking erlotinib. Quote Link to comment Share on other sites More sharing options...
yirol Posted May 24, 2007 Author Share Posted May 24, 2007 Great research! Keep it coming. Seems those studies have securities built-in to them...wish the doctors here would be as specific. Quote Link to comment Share on other sites More sharing options...
yirol Posted May 24, 2007 Author Share Posted May 24, 2007 Also, Dr. West, how do physicians adjust the dose of Tarceva? How did "they" settle on 150mg/day? I know people reduce the dose to 100mg/day when their side effects become too much. Do physicians ever increase the dose? I know more is not always more, especially in the medical profession, but I'm curious about the rationale of 150mg "recommended" dosage specific to Tarceva. My Dad is on day +/-18 with Tarceva, and he's yet to have the expected diarreha or rash (yet his symptoms --SOB, appetite, coughing-- seem to be improving really well). Could all the PPI's be playing a role in his lack of symptoms? I know I'm rambling and repeating and grasping ignorantly, but if nothing else comes of it, it's very good therapy. Please bear with me. Quote Link to comment Share on other sites More sharing options...
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