Seeking clarification about Tarceva and aspirin interaction - 1253468

Excellent question, wcw2012. Dr Quesnelle wrote a great post about aspirin last year, but I don't think she addressed the Tarceva interaction point:
http://cancergrace.org/cancer-treatments/2012/04/18/the-biology-of-aspi…
I wonder if she or Dr Walko might be interested in this? I have often wondered about it. I have occasionally taken aspirin and naproxen (Aleve) while on Tarceva, but I have steered clear of the one-a-day option for fear of the bleeding risk as you describe.
Hope you are doing well.

We can seek Dr. Walko's input, but I'll offer my response in the meantime. The company information is designed to be unfathomably conservative and isn't as much mean to actually be informative as to be a shield for legal action in case anyone ever decided that aspirin could have been the reason they didn't respond to Tarceva or had a side effect -- even though it's exceptionally likely that the aspirin was just a bystander and that the same thing would have happened anyway. If corporate lawyers for pharma companies could say that animal and plant nutrition and oxygen might have a negative interaction and should be avoided, they might have a long discussion about whether to add that to the package insert as one more barrier to legal action against them.

There is no question that aspirin can increase the risk of bleeding -- it is given for its anti-inflammatory and anti-platelet effects, which in many settings are significantly beneficial. There is also evidence that aspirin can have anti-cancer properties, which is reviewed in a post or two over the past few years and has been the subject of growing research. The 81 mg dose is very small and quite low risk overall.

It's probably fairer to say that anything you ingest can potentially interact with Tarceva or any other drug. Aspirin is not an agent for which there is any remotely compelling evidence that we should tell patients to avoid while on Tarceva.

-Dr. West

I completely agree with Dr. West. Some of the generic drug information handouts can be more confusing than helpful. That being said, when it comes to Tarceva, it is always goodt to ask!

Best wishes,
Dr. Walko

I am a person with NSCLC on Tarceva. I am not a physician, but here is my experience.

I had a very serious stomach bleed that sent me to our local hospital ICU for a few days. I was scoped and an AVM and possibly other sources of bleeding were cauterized.

For a few days before the bleed I had taken two Ibuprofen tablets before bed. I noticed that I had small blood leakages from my nose and also from my rectum, the latter probably hemorrhoids. I also have somewhat "thin" blood anyway.

I was told by a doctor at my institution that somebody else on Tarceva had a similar serious stomach bleed.

My dosage of Ibuprofen was a lot bigger than the baby aspirin mentioned by WCW2012. I am sure that the baby aspirin is important to this person for maintenance of cardiac health. (I do not take baby aspirin.)

Since I have just used Ibuprofen for analgesic purposes, I have decided to stop using them except for possible emergency. Tylenol is contraindicated for use with Tarceva, so mostly I will do without either. However, if I have a high fever, I will use one or both if necessary.

My message here is, please take seriously the possibility of stomach bleeding caused or aided by Tarceva, and take it into account when balancing the benefit of aspirin or other NSAIDs.

Thanks Bill for your input. I'm sure your experience is exactly why that info shows up on the paperwork.

I hope you are otherwise doing well on tarceva and stay on it for a long time.

Janine

That's a good cautionary tale, Bill -- very much appreciated. The challenge we face is that all of these decisions are a calculation of risk/benefit for one situation vs. another, with none completely risk-free (i.e., stopping a drug may be associated with a greater risk than continuing it). I personally have seen and treated 150-200 patients over the past several years with Tarceva and haven't seen someone experience a significant bleeding ulcer, but seeing one would perhaps change my perspective, and seeing two would make me quite cautious for the future. I suspect that the ibuprofen was a contributor as well, as was random bad luck, but I very much appreciate your experience and justifiable concern for others.

It's always hard when the risks are 1 in 100 or 1 in 1000 -- do we want to create a general rule to prevent something that is still a rare occurrence? Perhaps, if the aspirin is given just for a reflexive reason (and plenty of people are on medicines more as a ritual than for a true, compelling reason), but not in someone who would have far greater risk were they to forgo the aspirin (or whatever the potentially interacting drug in question happens to be).

-Dr. West

Bill, I wanted to add my thanks for sharing your experience, and to hope you are doing well on the Tarceva despite this frightening episode with the internal bleeding.

Dear Dr. West,

I do not have stomach ulcers and have never had them, so my stomach bleed was not related to ulcers.

As I mentioned, I have "thin" blood, although I clot OK when necessary, so this might have been a contributing factor. As you indicate, the human body is complicated, and individuals vary considerably, so it is hard to make general rules. I agree that risk-benefit must be considered. I don't really need Ibuprofen, so I am going to give it up for now.

I will give you one more example of how I managed risk benefit in the face of contradictory advice. I had a CT that a radiologist said showed a possible pulmonary embolism, and another doctor told me I should start a blood thinner. I was skeptical because of my thin blood. Yet another doctor (not a radiologist) said he didn't think it was significant, so I didn't take any blood thinner.

Some time later a different doctor (on a subsequent hospital visit) started nagging me about blood thinners, based on the initial CT report. However, she then showed me the report, which said the PE might be an image artifact! (Nobody had said that before.) Then I really refused. Sure enough, in a subsequent CT, the alleged PE disappeared.

Blood clots are not one of my medical problems, although I have plenty of others. In general, I think a blood thinner would be dangerous for me, and I am not going to take one without a *very* good reason.

Regards,
Bill

Dear WCW,

I don't believe I have low platelets.

I have personally seen over many years that I bleed a bit longer or more than other people, and had examples of more than average bleeding (according to doctors) after a few procedures/operations (before the cancer diagnosis).

This has not been fully explained, but I always let doctors who are going to do some procedure on me know of this propensity. I intend to avoid blood thinners, which I think could be dangerous for me. My GI doctor and oncologist agreed with avoiding Ibuprofen from now on.

This is just a decision I have made for myself only.

Thanks and regards,
Bill