Chemotherapy-induced nausea vomiting Flashcards
Three Elements of Emesis
- 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
Clinical presentation of N/V
Clinical Presentation
- Increase saliva production
- Increased skin temperature
- Tachycardia
- Unpleasant feeling, sick –stomach
- “Queasy, butterflies
Negative Impact of CINV
Negative Impact of CINV
- Dehydration
- Malnutrition
- Metabolic disturbances
- Aspiration pneumonia
- Esophageal rupture
- Reduced functional capacity and quality of life
Causes of N/V
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
Pathophysiology of CI-emesis
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
Risk for CINV
- 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
Anticipatory CNIV
The day before Chemo
- can give BZD to tranquilize the pt
Acute CNIV
1st 24 hour
Delayed CNIV
24 - 120hr
2nd day to 5th day
Breakthrough
CINV that happens after using all possible means to prevent acute and delayed CINV
Selecting Anti-emetic Regimens for Chemotherapy Induced Emesis
- Chemotherapy agents are classified by their ability to cause nausea and vomiting.
- The emetogenicity of a chemotherapy regimen is based on the most emetogenicity drug within a regimen.
- Timing is the key (acute vs. delayed antiemetics)
- Account for patient specific risk factors. (clinical pearl)
_____________, when combined with _________________ (for __________ cancer only), are designated as high emetic risk
when administered ___________
Anthracyclines, when combined with cyclophosphamide (for breast cancer only), are designated as high emetic risk
when administered IV
Anthracyclines example
Daunorubicin Doxorubicin Epirubicin Idarubicin Valrubicin Mitoxantrone \_\_\_\_\_\_rubicin
ANTIEMETICS use in ACUTE Nausea and Vomiting:
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
In ___________ prophalaxis
If the NK1receptor antagonist is not available for AC chemotherapy, ____________ is the ______________antagonist
In acute CINV prophalaxis
If the NK1receptor antagonist is not available for AC chemotherapy, PALONOSETRON is the preferred 5-HT3receptor antagonist
Antiemetic use in DELAYEDNausea and Vomiting:
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
___PITANT
NK1 receptor antagonist
eg aprePITANT or fosaprePITANT or rolaPITANT
_____SETRON
5HT3 receptor antgonist
eg
ondanSETRON
graniSETRON
DolaSETRON
Refractory Emesis
RefractoryEmesis
- Need to re-evaluate risk, chemotherapy, tumor and concurrent disease
- Try other unconventional agents: haloperidol, olanzapine
Patient Education (Nutritional Tips)
- •Diet Related:
•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
Patient Education (Nutritional Tips)
If experience CINV..
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
