Chemo Induced N/V

Question 1

High CINV Risk

Answer 1

• Anthracycline/Cyclophosphamide combination
• Carmustine
• Cisplatin
• Cyclophosphamide >= 1500 mg/m^2
• Dacarbazine
• Mechlorethamine
• Streptozocin

Question 2

Antiemetics for Acute CINV

Answer 2

5HT3 Antagonists

• Zofran
• Granisetron
• Dolasetron - IV is CI for CINV
• Palonosetron

Dosing varies based on age, type of chemo, IV/PO

NOT used for Delayed CINV

Question 3

Corticosteroids for Acute CINV

Answer 3

• Dexamethasone is the top choice - dosing varies by chemo agent and if peds patient
• Infuse over at least 20 minutes to reduce perianal irritation risk
• Reduce dose if combined with aprepitant or other NK-1 antagonists
• NK-1 antagonists used for acute and delayed N/V

Question 4

Antiemetics for Delayed CINV

Answer 4

• Most often occurs with Cisplatin or Cyclophosphamide + Doxorubicin
• Dexamethasone + NK-1 Antagonist in combination
• NK-1 antagonist increases dexamethasone’s AUC by ~50%
• Choose NK-1 antagonist based on price and convenience (efficacy is similar)

Question 5

NK-1 Antagonists

Answer 5

• Aprepitant - peds dosing available
• Fosaprepitant - peds dosing available
• Rolapitant
• Akynzeo PO/IV

Question 6

New Evidence for CINV Prevention

Answer 6

• Olanzapine with Dexamethasone, 5HT3 and NK-1 antagonist shown to be superior to standard therapy
• Better N/V control over 0-120 hours following chemo
• Tolerability has caused it to be unclear if Olanzapine should be added

Question 7

Cannabis for CINV

Answer 7

• Limited evidence
• Not shown much difference in acute CINV
• However, there is a possible effect on delayed CINV

Question 8

Antiemetic AEs

Answer 8

• Extrapyramidal symptoms are feared of metoclopramide and phenothiazines (use anticholinergic to prevent)
• Sedation with benzos, phenothiazines, olanzapine
• Diarrhea (high dose metoclopramide)
• Hypotension - rapidly administered phenothiazines
• Acute perianal irritation - secondary to rapid IV administration of corticosteroids
• Headache - 5HT3 antagonists
• QT prolongation - 5HT3 antagonists

Question 9

Radiation Induced NV

Answer 9

• Incidence, severity, and onset of RINV are related to field size, site, and dose
• Can occur within 2-3 weeks after radiation to upper abdomen received
• Can occur acutely in most who have TBI for bone marrow transplantation
• Can also occur w/in 30-60 minutes in most patients after single-dose large field hemibody radiation

Question 10

RINV Prevention

Answer 10

• 5HT3 is the treatment choice for adults and peds
• Recommended in combination with a corticosteroid if TBI was received
• Given orally on the day of radiotherapy
• Adults/pediatric dosing differs