Drug Interactions between Cyramza and diclofenac / misoprostol

MONITOR CLOSELY: Theoretical concerns exist that nonsteroid anti-inflammatory drugs (NSAIDs) and salicylates may potentiate the risk of bleeding and gastrointestinal perforation associated with ramucirumab therapy. Ramucirumab can cause bleeding, including severe and sometimes fatal hemorrhagic complications. In one clinical study, the incidence of severe bleeding was 3.4% for ramucirumab versus 2.6% for placebo. Ramucirumab can also increase the risk of gastrointestinal perforation. Four of 570 patients (0.7%) who received ramucirumab monotherapy in clinical trials experienced gastrointestinal perforation, which can be fatal. However, the risk of gastric hemorrhage and perforation during concomitant use of ramucirumab and NSAIDs is unknown, since patients with gastric cancer receiving NSAIDs (except low dose aspirin up to 325 mg/day) were generally excluded from clinical trials.

MANAGEMENT: Caution is advised if ramucirumab must be used with chronic NSAID or salicylate therapy. Close clinical and laboratory observation for bleeding complications is recommended. Patients should be advised to promptly report any signs of bleeding to their physician, including pain, swelling, headache, dizziness, weakness, prolonged bleeding from cuts, increased menstrual flow, vaginal bleeding, nosebleeds, bleeding of gums from brushing, unusual bleeding or bruising, red or brown urine, or red or black stools. Ramucirumab should be permanently discontinued in patients who experience severe bleeding or gastrointestinal perforation.

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