Topic: adenocarcinoma stage 1V AND Tarceva

Tagged: omeprazole, pericardial effusion, PPI, Tarceva interaction

This topic has 5 voices, contains 9 replies, and was last updated by certain spring 90 days ago.

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February 19, 2012 at 6:32 pm #6423
tilly15	this is a post for doctor west i asked in a prior post re tarceva and mentioned my husband was having an echogram for pericardal effusion cardiolgist not intervening as says effusion is only 1cm but my husband has pleural effusion left lung also again they say to small ammount to intervene but im worrying that they are not doing anything because the cancer is too advanced although they have not said this , also my husband is due to start tarceva on this week i asked if any current medication my husband was on would contra indicate with tarceva and oncologist said no yet when i read the list of contraindications there are omerprazole , blood pressure meducation , clarithromycin antibiotic etc to name a few that my husband is taking im finding so very difficult to trust what im being told by anyone my husband is in hospital for the second time the first time was chest infection , they gave him oral antibotics kept him in for 2 days then sent him home but he remained unwell was breathless and had chest pain , now he is back in and they say he has pnuemonia and gave him the same antibiotic intravenously , nothing is being done about the effusions round heart they say heart pumping fine no cardiac problems but is this fluid just going to be left there , my husband has had 4 sessions pemetrexed/cisplatin chemo and 10 sessions pallitaive radio therapy and up to now he has done really well and even now despite being in hospital he feels good he says from diagnosis his performance status has been good no wieght loss and very active but i have an overwhelming feeling of mistrust of the management of his treatment when i discover things ie the contraindications re tarceva and other medications and the fact that if the prognosis is poor the cardioligist would not intervene with the pericardal effusion yes my husbands cancer is inoperable and not curable but he is so strong and positive and cheerful i can by no means accept that he is anywhere near end of life stage and yet im so confused by all the conflicting infromation from the treatment side of things my aim is to try and keep my husband as stable and as well as he has been now im araid the tarceva may make him worse because of the medications he takes and the effusions he has when they seem quite willing to put him on tarceva without taking all these factors into account and because of this i feel i have good reason to be worrying
February 19, 2012 at 7:42 pm #6425
Dr West	It sounds to me like a second opinion could be very helpful for you. The issue with many of these additional medications is not actually incredibly critical — certainly, with omeprazole (Prilosec), there is no evidence that taking both together is associated with a worse outcome, and there is even some evidence looking back at people who did take the two drugs together that they did just as well as the people who didn’t take it or another “proton pump inhibitor” to block stomach acid. It is actually true that for a small to moderate amount of fluid around the heart that isn’t affecting the function of the heart, you don’t rush in to drain it — the procedure is not without some risk, especially if there isn’t a lot of fluid to serve as a significant cushion around the heart. I’m not hearing anything that suggests that the doctors are saying things that sound unreasonable, but I think it would potentially be reasonable for you to seek a second opinion from someone who can actually directly review his case to clarify whether what the current docs are saying is appropriate. -Dr. West +++++++++++++++++++++++++ Howard (Jack) West, MD Medical Oncologist Views expressed here represent my opinion, not those of GRACE or Swedish Cancer Institute. This information does not constitute medical advice and is intended to supplement and not replace medical information provided by your doctor.
February 20, 2012 at 1:11 am #6431
certain spring	Hi Tilly15 – I know what you mean about mistrusting everything you are told, not least because I’ve become like that after eighteen months with lung cancer. However every drug comes with a massive list of contra-indications: that is completely normal. I am stage IV and have been taking Tarceva for a year. Antibiotics have not been a problem at all. (I’ve just finished 7 days of amoxycillin, for eg). There are lots of posts on the old GRACE about people who took omeprazole or similar with Tarceva – usually they dealt with it by taking it at a different time of day. Some doctors can be a bit casual about this stuff (apologies to all here, but that is my experience) but pharmacists are not, so you have a second line of defence and information if you are worried. I hope the pneumonia clears up quickly – having had it myself, that is what I would want to focus on if I were you. I really do understand your wariness (my own experiences after pneumonia in hospital left me close to paranoid) but – although I’m not a doctor – it doesn’t sound to me as if your husband is getting substandard treatment. There are stories on here that would make your blood run cold, but I’m glad to say his isn’t one of them. Just on GRACE and its conventions, all the doctors see all the posts. And you can stick with your old thread if you want. Best of luck. 48-year-old non-smoker, dx stage IV NSCLC May 2010 (squamous tumour of the left lung with multiple brain metastases). Radiotherapy to chest and brain; progressed through two cycles carbo/gemcitabine. Repeated lung collapses; pneumonia in collapsed lung, Nov 2010; bronchial stent placed, Dec 2010. Declined second-line Taxotere. Mutation testing Feb 2011, surprise EGFR exon deletion 19, ALK negative. Started Tarceva (150mg), Feb 2011.
February 20, 2012 at 1:34 pm #6446
Dr Walko	Tilly, I just wanted to expand on the interaction between Tarceva and other drugs. Tarceva is broken down by a very common enzyme in the liver that is used to break down many other drugs (including the clarithromycin/Biaxin you mentioned). When more than one drug that uses the same pathway are given together, you can get somewhat of a traffic jam (think about what happens during rush hour). In the case of Tarceva, this would actually increase the amount the of drug in the drug body. The amount of increase depends on several factors including the dose of Tarceva and the specific drug being used. Generally it is recommended to avoid drugs that use this common pathway when possible, since the risk is increased toxicity from the Tarceva. However, the risk and benefit of each should be weighed by you and your doctor. As a note, there are more than one enzyme that breaks down Tarceva so interactions can come from a variety of pathways. Smoking is a common one that has been shown to decrease the levels of Tarceva in the body which can decrease the effects of the drug. In terms of the Prilosec (omeprazole), this is a VERY common interaction concern with Tarceva. Tarceva also needs an acid environment to be absorbed, which is unfortunate since this is the same acid that causes stomach problems including reflux. The package insert does state that giving proton pump inhibitors (like Prilosec, Protonix. and others) can decrease the amount of the Tarceva that gets absorbed in the body, lowering the amount that gets into the body. This was seen when the 2 were given at the same time and levels of the Tarceva were measured. Based on this, the recommendation became to avoid these drugs (like Prilosec) if possible, change to Zantac or Pepcid (which may not work as well), or at least separate the Tarceva from the Prilosec by at least 10 hours (i.e. taking one in the AM and one in the PM). However, since then, a trial looking at patients who took drugs like Prilosec AND Tarceva did not show a decrease in efficacy of the Tarceva: http://www.asco.org/ASCOv2/Meetings/Abstracts?&vmview=abst_detail_view&confID=102&abstractID=78829. I know this is a detailed explanation, but hopefully may help explain why interactions are such a concern and how clinically important (or not) they may be. Here is another forum discussion from Grace that discusses this topic more: http://cancergrace.org/forums/index.php?topic=9784.5;wap2 Best wishes, Dr. Walko +++++++++++++++++++++++++++++++ Christine Walko, Pharm. D University of North Carolina-Chapel Hill Views expressed here represent my opinion, not those of GRACE or University of North Carolina-Chapel Hill. This information does not constitute medical advice and is intended to supplement and not replace medical information provided by your doctor.
February 20, 2012 at 4:09 pm #6460
tilly15	thankyou doctor west , dr walko , and certain spring for your advice its reassuring to know that I can ask questions about my concerns and have them answered in view of dr wests reply we do intend getting a second opinion we have a cancer specialist centre an hours distance from us , this we want to do despite being offered tarceva , and whether my husband is taking it or not whilst he is in hospital the tarceva treatment has been deferred but he will go on it as soon as he is discharged and i will take dr walkos advice re the omerprazole I feel more reassured by dr wests reply re the fluid round the heart and i do trust that intervention would not be appropriate for the reasons mentioned thank goodness for a site like this where you can air concerns and that they are replied to its very reassuring to know that you all care enough to do that and its very much appreciated we have had a lot of conflicting information from the oncologists registra and its diffucult to place faith in them when this happens there does seem to be a reluctance re the referral elsewhere but i feel its my husbands right to have that , we have never undermined any treatment that has been given so far but they are not consistant with what they say for example 3 weeks ago my husband was told he was in remission as he had good response to the chemo yet 3 weeks later he was told the cancer is back its very frightening the speed at which it has progressed so obviously we want to do all we can my husband is very strong , maintained weight and up to the current problem he has been doing really well and despite having pnuemonia he says he feels much better no breathing problems no chest pain and he is the life and soul on the ward with his joke telling so we as his family want nothing but the best treatment as you all do fighting this awful disease and sometimes its very daunting because there is so much out there and time isnt something we can afford to play with and if we know and can be confident we are doing all we can and that the treatment is the right one even though we know nothing is guaranteed we at least know all options have been tried thankyou so much again for your replies to my post xxxxx
February 20, 2012 at 7:37 pm #6471
laya d.	Hi Tilly. . . I have nothing of substance to add here. . .but just wanted to wish your husband and the rest of you all the best. Pleasedo keep us posted on how he is doing. . . Laya 1/10 – My Mom (58) dx w/ NSCLC-Adeno 3a; 1 cycle of neoadjuvent Carbo/Alimta before finding out EGFR+ (Ex. 19), then switched to 7 wks of neoadjuvent Tarceva/150 mg (major shrinkage); 4/10 – right pneumonectomy; 6/10 started 3 rounds of adjuvent Cis/Alimta w/ concurrent chest radiation (7 wks); 8/10 – NED; 11/10 – small nodule in left lung; 1/11 – 3 small nodules in left lung, start Tarceva/100 mg; 4/11 – suspected sclerotic met to hip, continue w/ Tarceva, add XGEVA, brain MRI clear; 9/11 – solitary 3 cm met (adeno w/ T790m mutation) to cerebellum, surgery and gamma knife, up Tarceva to 150 mg; 11/11 – 2 left lung nodules growing, biopsy on 1 shows mutation from adeno to squamous (shocker!), brain MRI clear, continue Tarceva & Xgeva; 2/12 – brain MRI clear, CT scan, remaining nodule slightly bigger – – monitor for now, Tarceva (reduced to 100 mg) & Xgeva continued; 4/12 progression and rebiopsy (confirmed adeno), stop Tarceva, switch to Carbo/Alimta.
February 21, 2012 at 12:57 am #6480
tilly15	Hello laya thankyou for your reply I wish your mum well xxxxxxxx hugs it is very hard to take one day at a time I know i find it hard to do that too , you cant make plans and its so scary , we booked a holiday in april and my husband said he is going if he has to go in a wheelchair bless him , theres so much of the mundane stuff to do in everyday life as well and all you want to do is have normality but its so very hard hugs xxxxxxxxxxxxx
February 21, 2012 at 1:04 am #6481
tilly15	hello certain spring thankyou for your reply im glad the tarceva is working for you hugs xxxxxx and i wish you well and all the very best for positivity with your treatment xxx my husband is a lot better but we dont know when he is home yet and as soon as he is discharged he will go on the tarceva all the treatment options are confusing some work for others some dont , we all feel a bit in shock at the moment it was only 3 weeks ago they told my husband the cancer was in remiission its just so scary take care hugs xxxxx t
February 21, 2012 at 7:15 am #6495
laya d.	Hi tilly: Thanks so much for the cyber-hugs and well-wishes for my Mom. . . I know what you mean about not being able to plan ahead for everyday stuff, including vacations. Just the other day, a friend invited my family to travel with them to Hawaii in July. I couldn’t commit and explained that we are living scan to scan at the moment – - and that my Mom has a few scans coming up between now and July. Bummer! We’ve had a few trips cancelled because of cancer. . .and have learned to buy good travel insurance to cover last minute cancellations. It’s panned out twice now for us in this regard. So, look into insurance. Continued best of luck. . . Laya 1/10 – My Mom (58) dx w/ NSCLC-Adeno 3a; 1 cycle of neoadjuvent Carbo/Alimta before finding out EGFR+ (Ex. 19), then switched to 7 wks of neoadjuvent Tarceva/150 mg (major shrinkage); 4/10 – right pneumonectomy; 6/10 started 3 rounds of adjuvent Cis/Alimta w/ concurrent chest radiation (7 wks); 8/10 – NED; 11/10 – small nodule in left lung; 1/11 – 3 small nodules in left lung, start Tarceva/100 mg; 4/11 – suspected sclerotic met to hip, continue w/ Tarceva, add XGEVA, brain MRI clear; 9/11 – solitary 3 cm met (adeno w/ T790m mutation) to cerebellum, surgery and gamma knife, up Tarceva to 150 mg; 11/11 – 2 left lung nodules growing, biopsy on 1 shows mutation from adeno to squamous (shocker!), brain MRI clear, continue Tarceva & Xgeva; 2/12 – brain MRI clear, CT scan, remaining nodule slightly bigger – – monitor for now, Tarceva (reduced to 100 mg) & Xgeva continued; 4/12 progression and rebiopsy (confirmed adeno), stop Tarceva, switch to Carbo/Alimta.
February 22, 2012 at 10:30 am #6545
certain spring	Tilly15, there’s a very useful post by Dr Weiss which you might like to look at, discussing when it’s reasonable to get a second opinion and how to approach the consultation. I really recommend it: http://cancergrace.org/cancer-101/2011/11/13/an-insider%E2%80%99s-guide-to-the-second-opinion/ Re holidays, my advice is to go for it regardless, while being aware you may have to cancel. Laya, I think you should say yes to Hawaii in July! If they are good friends they will understand and be flexible. 48-year-old non-smoker, dx stage IV NSCLC May 2010 (squamous tumour of the left lung with multiple brain metastases). Radiotherapy to chest and brain; progressed through two cycles carbo/gemcitabine. Repeated lung collapses; pneumonia in collapsed lung, Nov 2010; bronchial stent placed, Dec 2010. Declined second-line Taxotere. Mutation testing Feb 2011, surprise EGFR exon deletion 19, ALK negative. Started Tarceva (150mg), Feb 2011.