Controlling Nausea and
Vomiting (antiemetics)
Patients should not suffer this side effect of chemotherapy
Definitions
-
acute - in the first 24 hours after chemotherapy
-
delayed - 24 to 120 hours after chemotherapy
-
anticipatory - occurs when a prior bad experience with treatment is
triggered by certain aspects of the clinical visit and treatment.
-
CINV - chemotherapy induced nausea and vomiting
emetogenicity - how likely a chemotherapy
is to cause nausea and vomiting.
HEC - highly emetogenic
chemotherapy.
Cisplatin and Adriamycin
(doxorubicin) are two chemotherapy drugs associated with nausea and
vomiting.
Introduction
Nausea and vomiting are considered side effects of chemotherapy. The
technical name for the class of drugs that treat this side effect are
antiemetics. These drugs can help reduce or prevent nausea and vomiting.
Chemotherapy can trigger nausea and vomiting due to their effect on
the cells lining the stomach. You might receive these drugs as a
pre-medication IV drug just prior to chemotherapy or possibly in pill form
with the intent of preventing nausea and vomiting. Or they might be given
once you experience this side effect. Trying different antiemetics might be
necessary to find one that works for you.
There is room for improvement
as up to 70% of patients receiving chemotherapy report nausea and vomiting.
Risk factors for CINV include patient
gender and age, past history of CINV, plus the emetogenicity and
administration schedule of chemotherapy.
The National Cancer Institute has more about chemotherapy side effects.
http://www.cancer.gov/cancertopics/chemo-side-effects
The
Cancer Nausea website provides comprehensive coverage of this subject.
Treatment Options
| |
Trade Name |
Generic name |
Primary Use |
| 5-HT3 Inhibitors (seratonin antagonists) |
Sancuso® |
granisetron |
A patch version of Kytril®.
Provides up to 5 days of relief. |
|
Aloxi® |
palonosetron |
May provide extended relief. Used for prevention of acute and
delayed nausea and vomiting. |
|
Kytril® |
granisetron |
antiemetic |
|
Anzamet® |
dolasetron |
antiemetic |
|
Zofran® |
ondansetron |
antiemetic |
| NK1-receptor
Antagonists |
Emend® |
aprepitant |
Usually combined with one of the 5-HT3 inhibitors, e.g., Aloxi®
Prevents and reduces delayed nausea and
vomiting for patients on a chemotherapy drug with a moderate to
strong risk of causing nausea and vomiting. |
|
synthetic cannabinoids |
Marinol |
dronabinol |
2nd line. |
|
Cesamet |
nabilone |
2nd line. |
Recent
Clinical Trial Results
Casopitant
Mesylate (CM) to Dexamethasone and Ondansetron (phase III). (2).
11 May, 2009.
This combination was found to greatly reduce chemotherapy-induced nausea and
vomiting (CINV) in patients receiving highly emetogenic chemotherapy(HEC).
810 Patients.
Dexamethasone
and Ondansetron - Effective 1st 24 hours after HEC; Moderate relief during
delayed phase (24-120 hours after HEC).
810 Patients received dexamethasone and onansetron after HEC. Then 269
received a placebo; 271 patients received 150mg oral CM or 3 day IV plus
oral CM(90mg IV on first day plus 50mg oral on the 2nd and 3rd days.
Complete
response (CR) for the first 120 hours after receiving 1st cycle of HEC
treatment (CR defined as
no vomiting, retching or use of rescue medications:
Aloxi vs
Kytril
A recent study published online and slated
to appear in the February 2009 issue of The Lancet Oncology found
that Aloxi was as effective as Kytril for nausea and vomiting in the
first 24 hours after chemotherapy, but was more effective than
Kytril for preventing this side effect in the first 5 days following
chemotherapy.
The phase III trial with 1143 patients from around
Japan, found that about 75% of the patients given Aloxi and Dexamethasone or
Kytril and dexamethasone did not experience nausea and vomiting in the 24
hours after receiving cisplatin or combined anthracycline and
cyclophosphamide. In the first 5 days after treatment, 57% on Aloxi
avoided this side effect versus about 44% given the standard Kytril.
See a
summary of the trial The Lancet Oncology On-Line. The trial has been
completed, but information on it is still available
NCT00359567 .
Casopitant.
This drug is not yet available. It may be marketed
as Rezonic in the U.S. and Zunrisa in the EU. It is an NK-1 inhibitor
(neurokinin-1) receptor antagnonist. See the abstracts presented at ASCO
2008.
Strautz
J et al, abstract no. 20585.
Grunberg SM et al, abstract no. 9540.
Ginger (3)
(Zingiber Officinale).
Ginger is not, strictly speaking, a drug but could
be considered an alternative or complementary treatment.
A phase II/III randomized, placebo-controlled, double-blind clinical trial
to assess the efficacy of ginger for chemotherapy-related nausea in cancer
patients that ginger plus anti-emetic drugs can reduce
chemotherapy-associated nausea. The study was placebo-controlled and
there were 644 patients total.
Patients were randomized into four arms: 1) placebo,
2) 0.5g ginger, 3) 1.0g ginger, or 4) 1.5g ginger.
| |
All groups:
5-HT3 receptor antagonist antiemetics (ondansetron (Zofran)
or granisetron (Kytril)) - on day 1 of each chemotherapy cycle plus three
250mg capsules of ginger or placebo twice daily for six days
starting three days before the first day of the next two cycles. |
| Treatment Arm |
Placebo |
0.5mg ginger |
1.0 g ginger |
1.5g ginger |
| % Reduction in Severity of Nausea. |
N/A |
40% |
40% |
not available |
-
All doses of ginger significantly reduced nausea
compared to a placebo, but largest reductions were the .5mg and 1g
groups.
-
Most patients reported the most severe nausea on
day 1 of chemotherapy.
-
There was a statistically significant linear
decrease in nausea over 24 hours.
-
1g ginger approx. equals 1/2 teaspoon of ground
ginger.
-
Gingersnaps or ginger ale? Unknown.
-
Mechanism? Might be an anti-inflammatory agent
in the gut.
Other
Information.
Lohr L (1)
lists the appropriate drugs to use after different categories of
chemotherapy drugs for their likelihood of causing nausea and vomiting.
Highly
likely to cause CINV and moderately likely for high risk of delayed CINV.
Other
moderately risk level for CINV
Breakthrough
symptoms of CINV
-
Dopamine antagonists, lorazepam,
metoclopramide, haloperidol, droperidol and other agents.
Refractory
CINV Options
Lastly, L
Lohr says that there is new evidence from non-controlled studies to support
the use of olanzapine, casopitant and gabapentin for controlling the
symptoms of CINV.
Non-drug
help for Nausea and Vomiting
The website,
www.caring4cancer.com has an
entire set of pages devoted to side effects among them being Nausea and
Vomiting. They offer the following suggestions:
-
Eat
small, frequent meals slowly. Chew food well, and eat food either cold
or at room temperature. Do not get hungry. Carry a snack with you.
-
Avoid
doing your own cooking when possible as the smell of cooking may bring
on nausea and vomiting (eat out, have food prepared elsewhere and
brought to your house.)
-
Eat a
snack. No very
spicy or acidic foods on an empty stomach. Eat a light meal (not heavy
or greasy) prior to your chemotherapy. Eat crackers, toast and drink
flat ginger ale. Eat small, frequent meals served at room temperature.
-
Drink at
a lot -- at least six to eight 8-ounce glasses of water-based liquid the
day before, the day of, and the day after chemotherapy. Talk to your
doctor or nurse if you are unable to keep fluids down.
-
Rest after eating to help your
digestion, but be careful not to lie flat for a couple of hours after
eating.
-
If you do feel nauseous, practice
relaxation techniques and other types of soothing distractions.
-
For anticipatory nausea and vomiting, perhaps an anti-anxiety drug might
help or relaxation and distraction to decrease anxiety. Acupressure,
acupuncture and guided imagery in conjunction with medication might also
help. Experiment.
Anecdotal Report A patient suggests
Zofran and a change of diet, "Try to get a Rx of Zofran. We have found it
to be the best Rx to counteract nausea. Also, when dealing with nausea, I
seem to best tolerate really bland white types of food, i.e., scrambled
eggs, white bread, puddings, mashed potatoes, bananas, rice, applesauce,
chicken noodle soup, jello, saltines, dry cheerios, etc.
Author: Howard Hansen, 17 January 2009, 5 July 2009
Note: The author is not a medical doctor and cannot render medical
advice. As a prostate cancer patient, this was written in an attempt to
understand these treatments and how it affects me. I make no claims that
this review is definitive, complete or authoritative and I request any
contributions to, or clarification of the subject which might contribute to
the issue or inquiry. In conjunction with a medical team, every cancer
patient must make their own decisions regarding treatment options. Your own
medical team's directions should be carefully followed.
1. Lohr L.,
Chemotherapy-induced nausea and vomiting,
Cancer J. 2008 Mar-Apr;14(2):85-93.
2.
Steven M Grunberg MD, Janusz Rolski MD, Janos Strausz MD, Prof Zeba Aziz MD,
Stephen Lane MSc, Mark W Russo MD, Paul Wissel MD, Mary Guckert RN MSN,
Oliver Wright MD f, Prof Jørn Herrstedt MD, Efficacy and safety of
casopitant mesylate, a neurokinin 1 (NK1)-receptor antagonist, in prevention
of chemotherapy-induced nausea and vomiting in patients receiving cisplatin-based
highly emetogenic chemotherapy: a randomised, double-blind,
placebo-controlled trial, The Lancet Oncology, Volume 10, Issue 6,
Pages 549 - 558, June 2009 doi:10.1016/S1470-2045(09)70109-3Cite or Link
Using DOI.
3. J. L. Ryan, C. Heckler, S. R. Dakhil, J. Kirshner, P. J. Flynn, J. T.
Hickok, G. R. Morrow; University of Rochester Medical Center, Rochester, NY;
Wichita CCOP, Witchita, KS; HOACNY CCOP, Syracuse, NY; Metro-MN CCOP, St.
Louis Park, MN,
Ginger for chemotherapy-related nausea in cancer patients: A URCC CCOP
randomized, double-blind, placebo-controlled clinical trial of 644 cancer
patients,
2009 ASCO Annual Meeting, J Clin Oncol 27:15s, 2009 (suppl; abstr 9511).
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