Exam 2 CINV Flashcards
Risk factors for N/V
- female
- previous N/V
- having motion sickness
- young
- non-smoker
- having previous chemo
- non-drinker
- have anxiety
Agents with High Emetogenic Potential
- Cisplatin
- Carboplatin ≥ AUC 4
- Doxorubicin ≥ 60 mg/m2
- Anthracylines + cyclophosphamide
Agents with Moderate Emetogenic Potential
- Carboplatin AUC < 4
- Oxaliplatin
pathophysiology of N/V
- Serotonin released from enterochromaffin cells in GIT ; activates 5-HT3 receptors that stimulate the CTZ
- Dopamine stimulates CTZ
- Substance P stimulate GIT and vomiting center
Which drugs are more likely to cause delayed N/V?
- platinum drugs
- anthracyclines
- cyclophosphamide / ifosphamide
prevention of N/V
- 5HT3 antagonist
- NK-1 antagonist
- steroid
5-HT3 Receptor Antagonists MOA
Selectively block 5-HT3 receptors peripherally on vagal nerve terminals (i.e., in GI mucosa) and centrally in the CTZ
Ondansetron dosing
- IV: 8mg
- PO: 16mg
Granisetron dosing
- IV: 1mg
- PO: 2mg
adverse effects of Ondansetron and Granisetron
- headache
- constipation
Palonosetron dosing
0.25 mg IV x 1 dose over 30 min. prior to chemotherapy
Palonosetron uses
- moderately delayed emetogenic chemotherapy
- moderately and highly acute emetogenic chemotherapy
What is the Gold standard for prevention of acute CINV from moderate to highly emetogenic chemotherapy?
5-HT3 Antagonists
Emend® (Aprepitant) dosing
- oral: 125 on day 1, 80 mg on days 2 and 3
- IV: 150 on day 1
NKI1 MOA
selectively blocks the binding of substance P at the NK1 receptor in the central nervous system
Rolapitant (Varubi®) dosing
180 mg PO 1 hour before chemotherapy
Rolapitant uses
select moderate emetogenic regimens especially in those who have failed standard CINV treatment regimens
Netupitant + Palonosetron NEPA (Akynzeo®) dosing
Fixed dose combination of netupitant 300 mg plus palonosetron 0.5 mg PO only
Netupitant + Palonosetron NEPA (Akynzeo®) uses
highly emetogenic chemotherapy
metoclopramide uses
- Low emetogenic chemo
- Moderate-highly emetogenic chemotherapy if cannot tolerate 5HT3 ant.
- Breakthrough CINV
Phenothiazines (prochlorperazine & promethazine) uses
- low emetogenic chemotherapy
- Breakthrough CINV
Butyrophenones: Olanzapine (Zyprexa®) uses
- May be as effective as NK-1 antagonist for
prevention of CINV - Can be used in combination with 5HT3 antagnoists and dexamethasone for prevention of CINV
- Alternative agent for refractory CINV (treatment)
Olanzapine (Zyprexa®) MOA
Block DA2 (dopamine) receptors
Olanzapine (Zyprexa®) ADE
- Sedation
- hypotension
- EPS (less than phenothiazines)
Corticosteroids uses
- Used in combination with 5HT3 antagonist in moderately to highly emetogenic chemotherapy
- Can be used as single agent in low emetogenic chemotherapy
Cannabinoids uses
Used as 2nd/3rd line breakthrough CINV in younger patients
Benzodiazepines uses
- Prevention of anticipatory N/V
- Adjuvant treatment in highly emetogenic chemotherapy
Acute CINV High
Emetogenicity treatment
- Aprepitant / Fosaprepitant*
- 5HT3 antagonist
- Dexamethasone
Acute CINV Moderate
Emetogenicity treatment
- Aprepitant / Fosaprepitant*
- 5HT3 antagonist
- Dexamethasone
Acute CINV Low
Emetogenicity treatment
Dexamethasone single agent
Delayed CINV High
Emetogenicity treatment
Aprepitant (80mg dose)@ days 2 & 3 + Dexamethasone days 2, 3 & 4
Delayed CINV Moderate
Emetogenicity treatment
Aprepitant (80mg dose)@ days 2 & 3 +/- Dex days 2 & 3 OR dexamethasone* alone days 2 & 3
OR 5HT3 antagonist alone days 2 & 3 (if NK-1 antagonist not used)
