Lec 2: Chemo-Induced Nausea/ Vomiting (CINV)

Question 1

Neurological pathways associated with nausea and
vomiting… know the general receptors that come into play

Answer 1

Question 2

Mechanisms for CINV

Answer 2

Question 3

Types of Nausea and our goals

Answer 3

Question 4

Prophylaxis of acute and delayed nausea and vomiting

Answer 4

• Acute: occurs shortly after chemo administration and continues for 24 hours
• Delayed: occurs 24 hours after the start of chemo and can last for 6-7 days (more common with highly emetogenic chemotherapy)
• Prophylaxis regimen determined based on emetogenicity of the chemotherapy regimen
• Can be adjusted for subsequent cycles based on patient’s response

Question 5

Emetogenicity of select chemotherapy agents

Answer 5

Question 6

Prophylactic antiemetic regimens based on emetogenicity

Answer 6

Question 7

Prophylactic antiemetic regimens: 5HT3 RAs and SE!!

Answer 7

Question 8

Prophylactic antiemetic regimens: NK1 RAs and SE/ Consideration

Answer 8

Question 9

Prophylactic antiemetic regimens: Dexamethasone

Answer 9

• High: 12 mg PO/IV day 1, then 8 mg PO daily days 2-4 (dose adjusted for DDI with fosaprepitant/aprepitant)
• Moderate: 12 mg PO/IV day 1, then 8 mg PO daily days 2-3
• Low: 8-12 mg PO/IV on chemo days
• Side effects: hyperglycemia, insomnia, emotional instability
  -NOTE: Prefer to give IV dose via IVPB over at least 10 minutes (over IV push) to prevent perianal skin irritation

Question 10

Prophylactic antiemetic regimens: Olanzapine

Answer 10

• 5-10 mg PO daily
• For high emetogenic regimen can be given on days 1-4
• Side effects: sedation

Question 11

Anticipatory Nausea/Vomiting… what is it? Management?

Answer 11

Anticipatory Nausea/Vomiting: Can be triggered by memories, anticipation, or fear in the cerebral cortex
.
Management:
- Optimizing prophylaxis regimen to help prevent any nausea
- Can be anxiety related, so can consider lorazepam
- Nonpharmacological interventions: behavior therapy

Question 12

Breakthrough nausea/vomiting…What is it? Management?

Answer 12

Question 13

Refractory nausea/vomiting….What is it? Management?

Answer 13

• Occurs when nausea/vomiting occurs during subsequent cycles when antiemetic
  prophylaxis and/or rescue have failed in previous cycles
• Dronabinol and nabilone are FDA approved for treatment of refractory nausea/vomiting

Question 14

What emetogenicity would you classify this chemotherapy regimen:
A. High
B. Moderate
C. Low
D. Minimal

Answer 14

B

Question 15

What emetogenicity would you classify this chemotherapy regimen:
A. High
B. Moderate
C. Low
D. Minimal

Answer 15

A

Question 16

A. High
B. Moderate
C. Low
D. Minimal

Answer 16

C. Low

Question 17

H.R. is a 55 YOF currently C1D5 of dose-dense AC (ddAC). Reviewing her history, you see she got an antiemetic three-drug regimen including a 5HT3 RA, NK1 RA, and
dexamethasone. Today she has had 2 episodes of breakthrough vomiting overnight.
Which agent would you recommend be added at this time?
1 Cycle of ddAC (every 14 days):
Doxorubicin 60 mg/m2 on day 1
Cyclophosphamide 600 mg/m2 on day 1
.
A. Olanzapine 5 mg IV
B. Olanzapine 5 mg PO
C. Prochlorperazine 10 mg IV
D. Dronabinol 2.5 mg PO

Answer 17

C. Prochlorperazine 10 mg IV