CINV

Question 1

Which chemo agents have high emetic risk?

Answer 1

Cisplatin
Carmustine
Dacarbazine
Cyclophosphamide (over 1500 mg/m2)
Streptozocin
Dactinomycin
Mechlorethamine

Question 2

Which agents cause delayed emesis?

Answer 2

Cisplatin (onset 1-6 hours, duration 24-120)
Carboplastin (onset 2-6, duration 1-48)
Cyclophosphamide (onset 6-12, duration 6-36)
Doxorubicin (2-6, 6-24)
Ifosfamide (3-6, 24-72)
Mitomycin (2-6, 18-24)

Question 3

What are the serotonin antagonists? When do we use them? Adverse effects?

Answer 3

All the setrons (set = serotonin)
Ondansetron
Granisetron
Dolasetron
Palonosetron (long acting)

Used for ACUTE n/v in moderate/high emetic risk

Worry about QT prolongation (don’t use in arrhythmia pts)

Question 4

Which 5ht antagonist is good for delayed CINV?

Answer 4

Palonosetron ONLY

Question 5

Which 5ht antagonist is bad for RINV?

Answer 5

Dolasetron

Palonosetron

Question 6

Which 5ht antagonist is good for PONV?

Answer 6

All of them!!!

Question 7

What are the corticosteroids? When are they used? Adverse effects?

Answer 7

Dexamethasone, prednisone, methylprednisolone

Used as monotherapy for low risk, or with 5HT antagonists in high risk

Effective for acute and delayed (she italicized delayed). Also useful for PONV and RINV.

Worry about mood changes, hyperglycemia, weight gain, insomnia

Question 8

What are the NK1 antagonists? When are they used? Adverse effects?

Answer 8

Aprepitant, fosaprepitant, netupitant, rolapitant (Pitant = Petite, NK sounds like MK like Marykate who is petite)

They’re used in combination with dexamethasone and a 5ht antagonist to prevent HIGH risk N/V for acute and delayed (italicized delay)

Worry about fatigue, hiccups, anorexia, dyspepsia

Question 9

Drug interactions with the NK1 antagonists?

Answer 9

Fosaprepitant/aprepitant:
CYP3A4 substrate (inhib and induc) and 2c9 inducer
Doses of steroid need to be reduced if used for antiemetic
Avoid with ifosfamide

Netupitant
CYP3a4 substrate and inhibitor
Reduce doses of steroids

Rolapitant
CYP3a4 substrate, cyp2d6/p-gp inhibitor, do not have to reduce dexamethasone!!

Question 10

What are the dopamine antagonists? Use? Adverse effects?

Answer 10

Phenothiazines (promethazine, prochlorperazine), metoclopramide, butyrophenones (droperidol, haloperidol)

Metoclopramide increases GI motility to decrease food in stomach!!

Used in low-risk or moderate/high if other agents intolerable; used for PRN/rescue as well!

Worry about EPS, sedation
Metoclopramide - abdominal pain (increases GI motility)
Phenothiazines - anticholinergic (sleepy), confusion, ECG changes

Butyrophenones - black box for QT prolongation, hyppotension, arrhythmias

Question 11

What are the antihistamines? Place in therapy? Adverse effects?

Answer 11

Diphenhydramine, meclizine, scopolamine patch

Adjunctive for motion sickness (not alone) or used as a rescue

Adverse effects: drowsiness, confusion, blurred vision, dry mouth

Question 12

What are the anxiolytics? Place in therapy? Adverse effects?

Answer 12

Benzodiazepines (lorazepam, alprazolam)

Used for anticipatory n/v, breakthrough, and adjunctive

Safety: Sedation, disorientation, hypotension, respiratory depression

Question 13

What are the cannabinoids? Place in therapy? Adverse effects?

Answer 13

Dronabinol, nabilone

Refractory CINV and appetite stimulant

Side effects - drowsiness, confusion, hallucinations, mood changes, memory loss

Question 14

What is olanzepine? Place in therapy? Adverse effects?

Answer 14

2nd gen antipsychotic

Prevents delayed and breakthrough CINV

Side effects: sedation, dry mouth, weight gain

Question 15

When you have high emetic risk, what do you use?

Answer 15

Day one:
5HT antagonist and Dexamethasone

Day 2-3
Dexamethasone and aprepitant

Day 4
Dexamethasone

Question 16

When you have moderate emetic risk, what do you use?

Answer 16

Day one:
5HT antagonist
Dexamethasone

Days 2-3
Aprepitant (NCCN)
Dexamethasone

Question 17

When you have low emetic risk, what do you use?

Answer 17

Dexamethasone on day one, only

Or prochloreprazine or metoclopramide or 5HT antaogonist

Question 18

Recommendations for multiday chemotherapy?

Answer 18

Continue for each day of chemo and 2 days after

NCCN: If high risk, continue for 3 days after at least

Question 19

What is anticipatory n/v?

Answer 19

Seeing/smelling something chemotherapy related and suddenly feeling sick

Give lorazepam (0.5-2 mg)

Question 20

Should antiemetics for breakthrough tx be given prn or at specific times?

Answer 20

At specific times!

Question 21

Radiation induced N/V - high risk?

Answer 21

High risk is total body irradiation

5HT antagonist before each fraction until 24 hours after (steroid daily for fractions 1-5 with or without dexamethasone)

Question 22

Radiation induced N/V - moderate risk?

Answer 22

Upper abdomen, craniospinal

5HT antagonist before each fraction with or without steroid daily for fractions 1-5

Question 23

Radiation induced N/V - low risk?

Answer 23

5HT antagonist before each fraction or as needed

Sccheduled prior to each fraction if N/V occurs

Question 24

Radiation induced N/V - minimal risk?

Answer 24

Breast, head and neck, extremities

As needed dopamine or 5HT antagonist, schedule if N/V occurs

Question 25

Prophylaxis for postoperative N/V? treatment?

Answer 25

2 agents if high risk
Moderate risk: 1-2 agents
More droperidol than other agents, administer them at the end of surgery

Treatment: additional agent with different mechanism than the prophylaxis