Classification: Monoclonal Antibody
About: Ramucirumab (Cyramza®)
Ramucirumab is a monoclonal antibody. Monoclonal antibodies are created in a lab to attach to the targets found on specific types of cancer cells. The antibody “calls” the immune system to attack the cell it is attached to, resulting in the immune system killing the cell. These antibodies can work in different ways, including stimulating the immune system to kill the cell, blocking cell growth or other functions necessary for cell growth. Ramucirumab inhibits the activity of vascular endothelial growth factor (VEGF). VEGF is responsible for angiogenesis, or the development of new blood vessels by and for the tumor (or any tissue), so blocking VEGF’s activity prevents the growth of new blood vessels, essentially cutting off the tumor's source of nutrients.
How to Take Ramucirumab
Ramucirumab is given by intravenous (IV, into a vein) infusion. The actual dosage depends on the patient’s weight. It may be given in combination with other chemotherapy medications. Prior to each dose, you may be given medications, including acetaminophen and an antihistamine (such as diphenhydramine), to decrease the risk of an infusion reaction.
Possible Side Effects of Ramucirumab
There are a number of things you can do to manage the side effects of ramucirumab. Talk to your care team about these recommendations. They can help you decide what will work best for you. These are some of the most common or important side effects:
The infusion can cause a reaction that may lead to chills, fever, low blood pressure, nausea and vomiting. You will receive Tylenol and diphenhydramine prior to the infusion to help prevent these reactions. Reactions are most common during the first week of therapy, including the evening after the infusion. Your oncology care team will tell you what to do if this happens.
Serious bleeding has also occurred in patients treated with this medication. People who have a history of serious bleeding should not take this medication. If you take aspirin, non-steroidal anti-inflammatory medications (i.e. Motrin, ibuprofen, naproxen) or other medication that interferes with blood clotting, let your healthcare provider know. Signs of bleeding can include: nose bleeds, blood in the stool or dark, tarry stools, coughing up or vomiting blood or vomit that looks like coffee grounds. While some bleeding, such as a nosebleed, may not seem like much of a concern, you should notify your healthcare team right away if you develop bleeding of any sort.
High Blood Pressure
This medication can cause high blood pressure (hypertension). Patients should have their blood pressure checked regularly during therapy. Any hypertension should be treated appropriately. If hypertension cannot be controlled, the medication may be stopped. Report any headaches, vision changes or dizziness to your oncology care team.
Your oncology care team can recommend medications to relieve diarrhea. Also, try eating low-fiber, bland foods, such as white rice and boiled or baked chicken. Avoid raw fruits, vegetables, whole grain breads, cereals and seeds. Soluble fiber is found in some foods and absorbs fluid, which can help relieve diarrhea. Foods high in soluble fiber include: applesauce, bananas (ripe), canned fruit, orange sections, boiled potatoes, white rice, products made with white flour, oatmeal, cream of rice, cream of wheat, and farina. Drink 8-10 glasses on non-alcoholic, un-caffeinated fluid a day to prevent dehydration.
Mouth Ulcers (Mucositis)
Certain cancer treatments can cause sores or soreness in your mouth and/or throat. Notify your oncology care team if your mouth, tongue, inside of your cheek or throat becomes white, ulcerated or painful. Performing regular mouth care can help prevent or manage mouth sores. If mouth sores become painful, your doctor or nurse can recommend a pain reliever.
- Brush with a soft-bristle toothbrush or cotton swab twice a day.
- Avoid mouthwashes that contain alcohol. A baking soda and/or salt with warm water mouth rinse (2 level teaspoons of baking soda or 1 level teaspoon of salt in an eight ounce glass of warm water) is recommended 4 times daily.
- If your mouth becomes dry, eat moist foods, drink plenty of fluids (6-8 glasses), and suck on sugarless hard candy.
- Avoid smoking and chewing tobacco, drinking alcoholic beverages and citrus juices.
This medication can lead to slower or incomplete wound healing, such as a surgical wound not healing or staying closed. Be sure to inform the team performing the surgical procedure that you are taking ramucirumab. You should also inform your oncology team that a surgical procedure is planned It is recommended that this medication be discontinued prior to any surgery. In addition, any surgical incision should be fully healed prior to starting or restarting the medication. If you have a surgical wound that has not healed or begins to have signs of infection (redness, swelling, warmth), report this to your healthcare team.
Peripheral edema is swelling of the extremities caused by retention of fluid. It can cause swelling of the hands, arms, legs, ankles and feet. The swelling can become uncomfortable. Notify your oncology care team if you are experiencing any new or worsening swelling.
Decrease in Appetite or Taste Changes
Nutrition is an important part of your care. Cancer treatment can affect your appetite and, in some cases, the side effects of treatment can make eating difficult. Ask your oncology care team about nutritional counseling services at your treatment center to help with food choices.
- Try to eat five or six small meals or snacks throughout the day, instead of 3 larger meals.
- If you are not eating enough, nutritional supplements may help.
- You may experience a metallic taste or find that food has no taste at all. You may dislike foods or beverages that you liked before receiving cancer treatment. These symptoms can last for several months or longer after treatment ends.
- Avoid any food that you think smells or tastes bad. If red meat is a problem, eat chicken, turkey, eggs, dairy products and fish without a strong smell. Sometimes cold food has less of an odor.
- Add extra flavor to meat or fish by marinating it in sweet juices, sweet and sour sauce or dressings. Use seasonings like basil, oregano or rosemary to add flavor. Bacon, ham and onion can add flavor to vegetables.
Less common, but important side effects can include:
- GI Tear: This medication can cause a tear in the intestinal wall. Symptoms include: unexpected bleeding, blood in the stool or black stools, coughing up blood, vomiting blood, vomit that looks like coffee grounds, fever, severe pain in the abdomen or new abdominal swelling. If you experience any of these, contact your oncology care team immediately or go to the emergency room.
- Posterior Reversible Encephalopathy Syndrome (PRES): In rare cases this medication has caused a neurological disorder called posterior reversible encephalopathy syndrome (PRES), also called reversible posterior leukoencephalopathy (RPLS). Symptoms of PRES/RPLS include headache, seizure, lethargy, confusion, blindness and other visual and neurological disturbances. Report any of these symptoms to your healthcare team immediately.
- Blood Clots, Heart Attack and Stroke: This medication can increase the risk of blood clots, stroke and heart attack. Symptoms can include: swelling, redness or pain in an extremity, chest pain or pressure, pain in your arm, back, neck or jaw, shortness of breath, numbness or weakness on one side of the body, trouble talking, confusion or mental status changes. If you experience any of these symptoms, you should contact your oncology care team immediately or go to an emergency room.
- Thyroid Problems: This medication can cause hypothyroidism (under active thyroid) and hyperthyroidism (over active thyroid). Your healthcare provider will perform blood tests to check the function of your thyroid and treat this side effect if it develops. Symptoms of thyroid problems include: tiredness, feeling hot or cold, change in your voice, weight gain or loss, hair loss and muscle cramps. Report any of these symptoms to your oncology care team.
- Proteinuria: This medication can cause an increase in the amounts of protein in your urine. Your healthcare team will monitor your kidney function and protein in your urine throughout treatment with this medication.
Exposure of an unborn child to this medication could cause birth defects, so you should not become pregnant or father a child while on this medication. Effective birth control is necessary during treatment and for at least 3 months after treatment. Even if your menstrual cycle stops or you believe you are not producing sperm, you could still be fertile and conceive. You should consult with your healthcare team before breastfeeding while receiving this medication.