Nilotnib and PPI

I would question your doctors judgement on this point. 

After oral administration, the onset of the effect of omeprazole occurs within one hour. The maximum effect occurring within two hours. It’s about 50% of maximum at 24 hours and the duration of inhibition lasts up to 72 hours. Esomeprazole is pretty similar.

So just running the maths, you can see that the PPI is active a long time and not a short-acting drug. And typically it’s toppled up every 12 or 24 hours. Novartis will tell you that you should not take a PPI with nilotinib and they are right. In fact, imatinib is the only TKI that’s OK to take with PPIs.

This is a little pet topic of mine. I see people taking PPIs with TKIs all the time and the bioavailability of the TKI will be reduced. Taking PPIs effectively reduces your TKI dose (bar imatinib). You can do a few things:

• Take more TKI - but this is not a good route as it’s guesswork 
• Take short-acting antacids (gastrocote / Gaviscon) 
• Fix the underlying problem

Fixing the underlying problem can be easy - usually it’s lose weight, or cut out certain foods - or can be surgical. In my case I didn’t need to lose weight and diet wasn’t the issue. I opted for a Nissan fundoplication to fix a loose lower oesophageal sphincter... a surgical procedure not to be taken lightly.

If I were you, I’d look at short acting antacids. Don’t take them 2 hours either side of your TKI schedule.

David.

It's not a good idea as a long-term solution. The esomeprazole will reduce that 800mg of nilotinib to what is effectively a lower dose. I can't say to exactly what, but it's not insignificant. 

Have you tried an algenate antacid out something similar that is short acting? You can take gavisgon several times a day and just avoid it a couple of hours before pill time. 

Lastly, have you looked into other reasons for the reflux? Any significant weight gain or changes to your diet?

David

Ranitadine is a H2 agonist, and is a long-acting drug like omeprazole or esomeprazole (which are PPIs). So that's out, too, unfortunately.

Gaviscon is short acting - only a few hours. If you must take something to help your reflux / indigestion then Gaviscon is the best of a bad bunch. You need to avoid taking it 2 hours before or after your medication though. 

If this turns out to be a long-term problem you might want to see a gastroenterologist. They have lots of tools at heir disposal that a primary care doctor does not. In my case they repaired a hiatus hernia and performed a surgical procedure on the bottom of my oesophagus to eliminate the reflux. My PCR went down quickly once I was able to stop taking the PPIs. 

David.

In that case you'd want to avoid taking Gaviscon between 04:30 and 08:30 and 16:30 and 20:30. 2 hours either side of your TKI. 

Make sure you discuss with your doctor because things like Gaviscon aren't as effective as a PPI against an ulcer. You might need to balance the risks of mixing the  medications to get things right on both fronts. 

Ulcers can often be caused by h.pylori bacteria, and this is treatable with the right antibiotics. 

This is an interesting read: http://discovermagazine.com/2010/mar/07-dr-drank-broth-gave-ulcer-solved...

David

In general, yes antibiotics are usually absolutely fine. But there are a small set of them that are not - e.g. erythromycin and clarithromycin. These are called macrolides and you generally identify them by the "mycin" ending of their name. 

However it's always worth checking interactions between any drugs you are taking.

https://www.drugs.com/drug-interactions/nilotinib.html