The following article is from U.S.-China Jiahe Cancer Prevention and Treatment by Concord Medical
- Pabolizumab
- Navuliyuzumab
- Tripril monoclonal antibody
- Sindilliumab
- Carellizulizumab
- Terelizumab
- Devaluzumab
- Atenizolizumab
The above are PD-1 inhibitors and PD-L1 inhibitor immunotherapy drugs that have been listed in China. Patients taking either of these must keep the following in mind, because it's about the effectiveness of the treatment and the money you spend on the medicine.
After the birth of immune drugs, many tumor patients benefit from them, prolong survival, and some patients even reach the goal of a high-quality long-term life. With the continuous approval of immune drugs and indications and the expansion of medical insurance coverage, more and more cancer patients will be exposed to immunotherapy. More patients can benefit from immunotherapy, but it also exposes a question: each patient's situation is different, there are more or less underlying diseases and other medications, so does taking these drugs simultaneously during immunotherapy affect the effectiveness of treatment?
The answer is yes. Next, we will unveil this blind spot of medication for everyone.
In immunotherapy,
Caution should be exercised while taking the following medications:
1. Antibiotics
The use of antibiotics destroys the diversity of the intestinal flora, significantly affects the efficacy of PD-1/PD-L1 inhibitors, and greatly reduces the effectiveness of immunotherapy, whether antibiotics are used before or in treatment.
Use before treatment:
A prospective, multicenter, cohort study published in JAMA Oncology showed that patients with different cancers, including non-small cell lung cancer and melanoma, had an overall survival of only 2 months before receiving immune point inhibitors, compared with 26 months after treatment for patients who had not been treated with antibiotics before immunotherapy.
Use in treatment:
The researchers fed four groups of colorectal tumor mice treated with PD-1 inhibitors different antibiotics, including a mixture of ATB (ampicillin, streptomycin, E. coli), vancomycin, colistin, and sterile drinking water. The results showed that the tumor volume of mice without antibiotics was significantly reduced, while the tumors of mice with antibiotics were not significantly reduced.
There are many broad-spectrum antibiotics in life, such as a few common: various cephalosporins, penicillin, erythromycin, gentamicin, azithromycin, ofloxacin and so on.
2. Hormonal drugs
After receiving immunotherapy, patients will have some toxic side effects, and the drugs commonly used in managing these side effects may have an impact on the effectiveness of treatment.
Evidence 1:
In a study of advanced melanoma, for example, patients who experienced severe toxic side effects after treatment with the immune point inhibitor PD-1 inhibitor:
- Some received steroid therapy only and had an overall survival of 27 months;
- The other part received anti-TNF (anti-tumor necrosis factor) steroids and had an overall survival of only 17 months, a shortened period of 10 months.
Evidence 2:
Another recent study showed that the overall survival of patients who did not use corticosteroids during immunotherapy was 13.5 months, and the overall survival of corticosteroids used by another group to alleviate the side effects caused by radiotherapy was only 4.9 months.
In summary, the use of steroids during immunotherapy can affect efficacy and shorten overall survival. However, patients need to discuss with their doctors how to deal with the side effects of cancer treatment whether to stop the drug or change the treatment plan.
3. Acid suppressants
A recent multicenter, observational, retrospective study looked at stage IV cancer patients using standard doses of PD-1/PD-L1 inhibitor drugs, taking different concomitant drugs at the beginning of immunotherapy and assessing the effect of these drugs on clinical outcomes. Studies have found that the use of gastric acid inhibitors (including H2 antagonists and proton pump inhibitors) during treatment significantly affects the effect of immunotherapy.
Among all patients included in the study:
- The overall survival of the group without gastric acid inhibitors was 29.4 months;
- The overall survival of the group treated with concomitant use of H2 antagonists was 21.1 months;
- The overall survival of the group treated with concomitant proton-pump inhibitors was 15.4 months.
It can be seen that taking PD-1/PD-L1 inhibitors at the same time as gastric acid inhibitors will affect the effect of immunotherapy, especially proton pump inhibitors.
Common proton pump inhibitor drugs are omeprazole, lansoprazole, pantoprazole, rabeprazole, and esomeprazole.
Common H2 receptor antagonists include cimetidine, ranitidine, famotidine, rosatidine, and ebromotidine.
4. Anticoagulants
The above studies also found that the synergistic use of anticoagulants also affects the effect of immunotherapy.
In the treatment of PD-1/PD-L1 inhibitors,
- The overall survival of patients in the group without anticoagulants was 10.9 months,
- The overall survival of patients in the group who also took anticoagulants was 6.3 months, a decrease of 42.2%.
The anticoagulants used here include oral anticoagulants (but not aspirin), low molecular weight heparin, and bean flavor anticoagulants.
5. Opioids
Similar to anticoagulants, opioids can also affect immunotherapy effects. During cancer treatment, doctors recommend opioids for severe pain in some patients, and this retrospective study showed:
- The overall survival of patients in the non-opioid group was 11 months;
- The overall survival of the group with coordinated use of opioids in immunotherapy was 3.8 months.
6. Traditional Chinese medicine
Whether or not chinese medicine can be taken at the same time during immunotherapy is a topic of concern for many patients. It is controversial because of the complexity of the composition of Chinese medicines and the fact that "side effects are not clear" in the instructions of most Chinese medicines. In addition, the efficacy and side effects of traditional Chinese medicines have not been verified and tested by clinical trials, and it is not clear whether the compound components in them conflict with immunotherapy drugs.
Therefore, in the course of immunotherapy, it is not recommended to take traditional Chinese medicine at the same time. As for when it can be taken, it is recommended to follow the professional guidance of a doctor.
Write at the end
To sum up, antibiotics, steroid drugs, gastric acid inhibitors (especially proton pump inhibitors), anticoagulants, opioids and traditional Chinese medicines should be used with caution during immunotherapy so as not to affect the effect of cancer treatment.
If you face serious treatment side effects, do not use your own medication, you should seek medical treatment in time and standardize treatment under the guidance of a doctor.
bibliography
Zhou Bin, Shang Fumei, Fan Qilin, etc. Research Progress on the Role of Intestinal Flora in Tumor Immunotherapy[J]. Chinese Journal of Oncology, 2020, v.47(22):48-51.
[2] Pinato DJ, Howlett S, Ottaviani D, et al. Association of Prior Antibiotic Treatment With Survival and Response to Immune Checkpoint Inhibitor Therapy in Patients With Cancer. JAMA Oncol. 2019 Dec 1;5(12):1774-1778.
[3] Xu X, Lv J, Guo F, et al. Gut microbiome influences the efficacy of PD-1 antibody immunotherapy on MSS- type colorectal cancer via metabolic pathway[J]. Front Microbiol, 2020, 11:814.
[4] Verheijden RJ, May AM, Blank CU, et al. Association of Anti-TNF with Decreased Survival in Steroid Refractory Ipilimumab and Anti-PD1-Treated Patients in the Dutch Melanoma Treatment Registry. Clin Cancer Res. 2020 May 1;26(9):2268-2274.
[5] Cortellini A, Tucci M, Adamo V, et al. Integrated analysis of concomitant medications and oncological outcomes from PD-1/PD-L1 checkpoint inhibitors in clinical practice. J Immunother Cancer. 2020 Nov;8( 2):e001361.
*This article aims to popularize the science behind cancer, not drug promotional materials, and it is not a treatment recommendation. For guidance on treatment options, visit a regular hospital.
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