AINV

Question 1

AINV whats the big deal

Answer 1

short term impact: stress/anxiety, poor QoL during tx
long term: loss of adherence to tx - cancer progression
anorexia, dehydration fatigue

Question 2

define nausea, vomiting, AINV

Answer 2

inclination to vomit or feeling in the throat or epigastric area that vomiting is imminent

vomiting: ejection or expulsion of gastric contents thru month w involuntary muscle contractions
emesis occues when VC in brain is triggered

AINV: previously chemo induced NV (CINV)
classified as acute, delayed, anticipatory, breakthru, refractory

Question 3

why does it happen?

Answer 3

emesis occurs when vomiting center is actived by affferent impulses
the VC sends effect impulses to salivation centra, abdominal muscles, stomach, esophagus

Question 4

what are 2 ways chemo can cause vomiting

Answer 4

peripheral visceral vagal afferednt impulsesL iritated GIT send msg along vagal afferents, activating VC

chemo trigger zone (CTZ): lies outside of BBB in area postrema of 4th ventricle, exposed to circulating noxious drugs

nausea: may have diff mechanism

prinicpal Neuroectptors: serotonin, dopamine
others: acetylcholem corticosteroid, histamine, etc/

Question 5

define acute, delayed, anticipatory, breakthru, refractory AINV

Answer 5

see slide 5

Question 6

emetic risk of tx

Answer 6

determined by drug wth highest risk in combo

most imp factor in pt assessment

Question 7

diff bw 4 classes of emetic risk?

Answer 7

slide 8
minimal <10%
low 10-30
moderate 30-90
high >90

Question 8

pt specific risk factors

Answer 8

women >men
NV w/ previous chemo
history of motion sickness
morning sickness with pregnancy
high alcohol consumption lower risk
ager older than 50 lower risk (peds higher risk)

Question 9

goals of tx and approach

Answer 9

goal is no NV, focus is prevention
prevent and provide strategy for breakthru

much easier to preven AINV than treat
easier to prevent vomiting than nausea

all pt need evidence based prevention regimen appropriate for their risk AND a breakthru agent

Question 10

prophylaxis
5HT3 receptor antagonist

Answer 10

3 on market
ondansetron, granisetron, 2nd gen palonosetron

role is prevention of acute AINV. evidence lacking for delayed AINV for 1st gen

AE: constipation (1in 10 pt), QT prolongation

Question 11

dexamethosone

Answer 11

unclear mech
goodfor prevnetion of acute and delayed

AE: short term high dose steroid AE (sleep distrubance, mood change, dyspepsia, hyperglycemia)

Question 12

NK1 receptor antagonist

Answer 12

combin with 5HT3 +/- dex, improved efficacy for acute AND delayed

AE: well tolerated, headache (9%)

DI: CYP3A4, 2C9, dex, warfarin,OCs (contracep)

Question 13

olanzapine

Answer 13

off label

good efficacy for preventing and also breakthrough

max daily dose is 10mg/day for AINV (higher for mental)

AE: sedation, EPS, orthostatic hypotension

Question 14

prophyl of acute and delayed with parenteral HEC

Answer 14

HEC = highly emetic chemo

see sldie 14
pt should get 3-4 drugs
always 5HT3
usually NK1 and dex
sometimes olan

5ht3 Given on day 1, 30-60min before chemo

Question 15

prophyl of acute and delayed with parenteral MEC

Answer 15

usually recieve 2 drugs or 3 (if oxaliplatin or carboplatin)

NK1 is common when oxaliplatin or carboplatin is present
If not it is not given

Olanzapine is rarely used

Question 16

prophyl of acute and delayed with parenteral LEC

Answer 16

usually recieve 1 drugs or 2

usually 5HT3 and sometimes dex
1 dose of each 60 mins before chemo

Question 17

prophyl of acute and delayed with oral HEC/MEC

Answer 17

5HT3 always given
dex occasionally

daily before tx

Question 18

prophyl of acute and delayed with oral LEC

Answer 18

might only use a 5HT3

ily before tx
but after they may take it away if pt feelign good

Question 19

breaktrhoguh pharm

Answer 19

just in case med

metoclopramde, procholrperazine
olanzapine

slide 20

Might see olanzapine better, found superior to metoclopramide

Question 20

non-pharm measures

Answer 20

smaller meals more frequently
easy fods on stomach
rm temp food
avoid foods with strong smell
drink fluids 30 mins before food
in extreme case, implement liquid diet

Question 21

anticipatory AINV

Answer 21

best way is to prevent NV so they never have this repsonse

lorazepma most common to help them relax

Question 22

refractory AINV

very diffuclt to treat

Answer 22

escalate: add NK!, onlanz, dex

cannabinoids have a role
2nd 3rd line agents

Question 23

cannabis

Answer 23

n orole for prophyl
small role for breakthru
mod role for refractory

hesistant for elderly
spurce of infection when smoking