Tarceva and Proton Pump Inhibitors - 1249940

Hi Apra I hope your husband is doing better otherwise. Below is a quote from Dr. West that states the latest on the thoughts and practices of tarceva and ppi. I think i recall at the very beginning your husband had a clinical response to tarceva while still taking ppi. If so that's a good sign of the suggestion in Dr. West's last sentence in the quote below.

"3) Probably not. Proton pump inhibitors (PPIs) can decrease the uptake of oral EGFR inhibitors, but the limited evidence that exists actually shows that people who were on a PPI while they took Tarceva didn’t do any worse than the people who weren’t. Moreover, many of the people who have an EGFR mutation are extremely sensitive to EGFR inhibitors, so even getting a reduced dose often leads to a great response."
http://cancergrace.org/topic/egfr-positive-but-tarceva-doesn´t-work-lung-cancer-spread-to-liver-what-nowI

The recommendation is still to avoid concurrent PPI use with oral EGFR inhibitors, and that's what I try to do, if feasible. The data out there on clinical outcomes suggest that patients on a PPI while on Tarceva do comparably well as those not on a PPI, so I don't mind too much having someone on both if it's needed, but my preference is still to avoid it. There's no formal change in world thinking -- the recommendation according to the package insert for Tarceva favors avoiding a PPI with it.

-Dr. West

from www.nlm.nih.gov
Furosemide, a 'water pill,' is used to reduce the swelling and fluid retention caused by various medical problems, including heart or liver disease. It is also used to treat high blood pressure. It causes the kidneys to get rid of unneeded water and salt from the body into the urine.

That medicine specialist may or may not know more than your husband's medical oncologist about what's best for your husband but it isn't normal for that to be the case. His oncologist is trained and practices everyday to know what works best for patients with cancer.

I hope your husband is still feeling better than before.

Janine

I'm afraid I am not directly involved and therefore can't speak to whether chemo would be advisable right now. Lasix (furosemide) can be somewhat helpful for ascites, which is a fluid collection in the belly, but it tends to be only minimally to moderately helpful, at most, for patients with significant fluid developing from cancer. Sometimes it is necessary to drain fluid with a needle, like a thoracentesis that we commonly do for lung cancer, except it's called a paracentesis when removing fluid from the abdomen.

Good luck.

-Dr. West

I will once again ask the faculty to correct me on anything I have wrong here. Before I got diagnosed with lung cancer I was being evaluated for liver transplant. I'm at risk of developing ascites, and I have seen patients at the clinic with very large bellies. It just looks awfully miserable, so I am sorry your husband is having to deal with this.

My understanding of Lasix is that it induces diarrhea. In patients with liver disease it is given for encephalopathy, which is a brain disorder that occurs when the liver fails to filter out toxins (mostly ammonia) Encephalopathy causes mental confusion and can lead to coma. My hepatology nurse practitioner says "nothing like 2 or 3 bowel movements a day to keep your head clear" but it sounds very unpleasant to me. My primary gave me some samples once for constipation, but I never used it. I guess that's one way of getting rid of the fluid but it seems that would put him at risk for dehydration and electrolyte imbalances (?)

I took furosemide for a time but experienced leg cramps due to lowered potassium levels. I was put on spironolactone instead (a potassium sparing diuretic) and have had no problems.

I think I have brought this up in a post to you once before that I have to restrict my intake of salt. When I fall off that wagon I feel miserable. I think it is very important in preventing ascites.

I don't know if these things get recommended once a patient has ascites. It was my understanding that it would have to be drained, as Dr. West says, by paracentesis. Then perhaps measure to avoid a recurrance would include a diuretic (?) and salt restricted diet.

I'm fortunate that my cancer team and my liver team are both in the same center, and that they communicate with one another. I really think being able to defer questions about liver function to a liver specialist is very helpful.

I hope he gets some relief soon. All that fluid has got to be very uncomfortable. My heart goes out to you both. Good luck.
Debra

I'd be surprised if the diarrhea inducing medication is Lasix...what you're describing in the beginning of your comment above sounds like a great description of Lactulose, which can be used for constipation but is also typically used as a treatment for hepatic encephalopathy and high blood ammonia levels. Both it and lasix can cause low potassium levels, and the rest of what you discuss after that sounds very much like Lasix...but I'd expect Lasix to lead to lots of urination, and Lactulose to lead to diarrhea.

-Dr. West

oops, my bad. I did get them mixed up, Dr. West, thank you. So, Lasix is furosemide... I knew I had had it in the house at some time. Sorry if I added any confusion to the pot. Sometimes I think I'm a lot smarter than I really am :roll:

Debra

Apra-

I don't have anything to add here, but just wanted to pop in to say hello and wish your husband continued luck with his treatment. I hope the docs figure out a way to make him more comfortable with his fluid retention issues. It's interesting that my Mom's effusion issues (in her right lung cavity) also started while she was on Alimta.

All my best,
Laya

I just wanted to add that there is some concern that Alimta (pemetrexed) can be "sequestered" in the fluid cavities like ascites and pleural effusions, then taking a long time to be metabolized. In theory, this can lead to greater side effects because it's effectively like giving an excessively high dose of the drug.

In practice, that has rarely emerged as an issue, and most oncologists are not very concerned with giving Alimta to someone who has anything less than a rather large pleural effusion. However, the fluid collections from ascites can be very large, sometimes as much as 5-10 liters, and one of the only cases I've heard of where the oncologist thought that the fluid collection may have messed up the metabolism of Alimta was in someone with a large amount of ascites fluid.

I just mention this because having a large amount of ascites could appropriately lead to concern about giving Alimta in that setting and the potential for excessive side effects.

-Dr. West

To my knowledge, there is no association of Tarceva with developing ascites, nor is the presence of ascites in itself an issue with receiving Tarceva. And if the ascites is mild enough that his belly doesn't appear obviously distended, it's not likely to be very clinically significant.

-Dr. West

It's possible to take supplemental potassium, though bananas are probably the most palatable way to get lots of potassium. And taking a good amount of protein in the diet can help make up for albumin lost when fluid is drained, but yes, that's a real concern.

-Dr. West