Chemotherapy-induced nausea vomiting

Question 1

Three Elements of Emesis

Answer 1

• Nausea –the sensation of the need to vomit. Subjective.
• Retching –the synchronized spasmodic motion of the respiratory and abdominal muscles before or during vomiting.
• Vomiting –the expulsion of gastric contents through the mouth

Question 2

Clinical presentation of N/V

Answer 2

Clinical Presentation

• Increase saliva production
• Increased skin temperature
• Tachycardia
• Unpleasant feeling, sick –stomach
• “Queasy, butterflies

Question 3

Negative Impact of CINV

Answer 3

Negative Impact of CINV

• Dehydration
• Malnutrition
• Metabolic disturbances
• Aspiration pneumonia
• Esophageal rupture
• Reduced functional capacity and quality of life

Question 4

Causes of N/V

Answer 4

Drugs

1) Potassium
2) Anesthetics
3) NSAIDs and Opioids
4) Iron
5) Cytotoxic agents

Medical Conditions

1) Malignancies (CNS, GI)
2) Radiation
3) Hepatitis
4) Migraine
5) Pain
6) Hypercalcemia
7) Motility disorders
8) Morning sickness
9) Surgery
10) Anxiety

Question 5

Pathophysiology of CI-emesis

Answer 5

1) Chemotherapy acts on enterochromaffin cells of GI tract
2) causing them to secrete 5-HT and subsequent activation of 5-HT3 receptors on vagal afferents. This excitatory signal is then relayed to the NTS
3) The CTZ along with the nucleus of the solitary tract (NTS) and the dorsal motor nucleus of the vagus makes up the so-called dorsal vagal complex, which is the major termination site of vagal afferent nerve fibers.
4) The dominant receptors in this area are serotonin type 3 (5-HT3), dopamine type 2 (D2) and NK1.

5) CTZ then stimulates Vomiting center.
which has 5-HT3, Dopamine and NK1 receptors.

6) The “vomiting center” within the hindbrain, then precisely co-ordinate multiple autonomic reflexes that including
- excessive salivation,
- Increase respiratory rate
- inhibition of normal gastric motility, retroperistaltic activity in the duodenum and stomach,
- relaxation of the lower esophageal sphincter,
- tachycardia,
- sweating,
- breath holding
- contraction of abdominal and thoracic muscles

Question 6

Risk for CINV

Answer 6

• History of motion sickness
• Anxiety
• Low alcohol use Age: Younger than 30 (or 50) years old
• Type, dose, and schedule of chemotherapy treatment

•History of pregnancy-associated emesis

• History of poorly controlled emesis in a prior chemotherapy treatment
• Age: Younger than 30 (or 50) years old
• Gender: Females

Question 7

Anticipatory CNIV

Answer 7

The day before Chemo

- can give BZD to tranquilize the pt

Question 8

Acute CNIV

Answer 8

1st 24 hour

Question 9

Delayed CNIV

Answer 9

24 - 120hr

2nd day to 5th day

Question 10

Breakthrough

Answer 10

CINV that happens after using all possible means to prevent acute and delayed CINV

Question 11

Selecting Anti-emetic Regimens for Chemotherapy Induced Emesis

Answer 11

1. Chemotherapy agents are classified by their ability to cause nausea and vomiting.
2. The emetogenicity of a chemotherapy regimen is based on the most emetogenicity drug within a regimen.
3. Timing is the key (acute vs. delayed antiemetics)
4. Account for patient specific risk factors. (clinical pearl)

Question 12

_____________, when combined with _________________ (for __________ cancer only), are designated as high emetic risk

when administered ___________

Answer 12

Anthracyclines, when combined with cyclophosphamide (for breast cancer only), are designated as high emetic risk

when administered IV

Question 13

Anthracyclines example

Answer 13

Daunorubicin
Doxorubicin
Epirubicin
Idarubicin
Valrubicin
Mitoxantrone
\_\_\_\_\_\_rubicin

Question 14

ANTIEMETICS use in ACUTE Nausea and Vomiting:

Answer 14

AC = Anthracycline + cyclophosphamide

RISK Grp = Antiemetics required

• HIGH non AC = 5-HT3 + DEX + NK1
• HIGH AC = 5-HT3 + DEX + NK1
• Carboplatin = 5-HT3 + DEX + NK1
  (HIGH RISK GRP)
• Moderate (other than carboplatin) = 5-HT3 + DEX
• Low = 5-HT3 OR DEX OR DOP
• Minimal = NO PROPHYLAXIS

5-HT3 = serotonin 3 receptor antagonist 
DEX = Dexamethasone 

NK1 = neurokinin1 receptor antagonist such as APREPITANT or FOSAPREPITANT or ROLAPITANT or NEPA (combination of netupitant and palonosetron)

DOP = dopamine receptor antagonist

If the NK1receptor antagonist is not available for AC chemotherapy, palonosetron is the preferred 5-HT3receptor antagonist

Question 15

In ___________ prophalaxis

If the NK1receptor antagonist is not available for AC chemotherapy, ____________ is the ______________antagonist

Answer 15

In acute CINV prophalaxis

If the NK1receptor antagonist is not available for AC chemotherapy, PALONOSETRON is the preferred 5-HT3receptor antagonist

Question 16

Antiemetic use in DELAYEDNausea and Vomiting:

Answer 16

High Non-AC = DEX or (if APR 125mg for acute: (MCP + DEX) or (APR + DEX))

High AC = NONE or (if APR 125mg for acute: DEX or APR)

Carboplatin = NONE or (if APR 125mg for acute: APR)

Oxaliplatin or anthracycline or cyclophosphamide = DEX can be considered

moderate (other) / low/ minimal = NO routine prophylaxis

DEX = DEXAMETHASONE
MCP = METOCLOPRAMIDE
APR = APREPITANT

Question 17

___PITANT

Answer 17

NK1 receptor antagonist

eg aprePITANT or fosaprePITANT or rolaPITANT

Question 18

_____SETRON

Answer 18

5HT3 receptor antgonist

eg
ondanSETRON
graniSETRON
DolaSETRON

Question 19

Refractory Emesis

Answer 19

RefractoryEmesis

• Need to re-evaluate risk, chemotherapy, tumor and concurrent disease
• Try other unconventional agents: haloperidol, olanzapine

Question 20

Patient Education (Nutritional Tips)

• •Diet Related:

Answer 20

•Diet Related:
–Eat small, frequent meals vs large meals
–Eat the largest meal when least nauseated
–Avoid your favorite foods (?) –> metallic taste
–Eat room temperature foods (less aroma)
–Avoid sweet, salty, spicy, fatty, or aromatic food,
–Avoid raw food, fruits with skin
–Do not eat for 1 to 2 hours before treatments if nausea occurs during treatments or within a few hours of treatment

Question 21

Patient Education (Nutritional Tips)

If experience CINV..

Answer 21

If experience CINV..

–Use shakes, or nutritional supplements
–Keep crackers or bread within reach
–Increase fluid intake
–Drink clear fluids, fruit juices: sip slowly
–Popsicles, jello, frozen fruit juices, ice chips are sources of fluid