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nausea/vomiting - chemotherapy induced

Epidemiology: - nausea/vomiting occurs in 40-70% of patients with advanced cancer Pathology: - stimulation of intestinal lining - stimulation of the chemoreceptor trigger zone (CTZ) - perturbation of the vestibular apparatus - effects on cerebral cortex Management: 1) hydration is probably the most effective antiemetic [1] 2) ondansetron probably single drug of choice (also see vomiting) 3) high-emetic-risk chemotherapy - cisplatin or anthracycline combined with cyclophosphamide - 4 drug combination of: - substance P receptor antagonist; neurokinin-1 receptor antagonist (aprepitant or fosaprepitant) - 5-HT3 receptor anagonist (ondansetron)* - dexamethasone - olanzapine - continue dexamethasone & olanzapine on days 2-4 [2] * continue ondansetron even if refractory to ondansetron [NEJM Knowledge+,3] 4) moderate-emetic-risk chemotherapy - carboplatin, oxaliplatin - 3 drug combination of - substance P receptor antagonist (aprepitant or fosaprepitant) - 5-HT3 receptor anagonist (ondansetron)* - dexamethasone [2] * continue ondansetron even if refractory to ondansetron [NEJM Knowledge+,3] 5) breakthrough nausea/vomiting (not reponsive to prophylactic prochlorperazine) - intravenous palonsetron + dexamethasone [NEJM Knowledge+,3,4] - olanzapine [2] 6) aprepitant, lorazepam, a dopamine receptor antagonist, dronabinol, or nabilone in patients with continued nausea/vomiting despite adequate hydration & olanzapine [2] - fosaprepitant (precursor of aprepitant) 150 mg weekly IV infusion [5] 7) high-emetic risk radiation therapy - 2 drug combination before each fraction & on the day after each fraction - 5-HT3 receptor anagonist (ondansetron) - dexamethasone [2] 8) concurrent radiation & chemotherapy - treat for highest emetic risk [2] 9) children: - 3 drug combination of - substance P receptor antagonist (aprepitant) - 5-HT3 receptor anagonist (ondansetron) - dexamethasone [2] - ondansetron + dexamethasone if aprepitant contraindicated - palonosetron + aprepitant if dexamethasone contraindicated 10) prophylaxis: prochlorperazine

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chemotherapy

General

nausea vomiting

References

  1. Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016
  2. Anello J, Feinberg B, Heinegg J et al Antiemetics in Adults and Children Guidelines on antiemetics by the American Society of Clinical Oncology. Medscape: New Guidelines and Recommendations, August 2017. http://reference.medscape.com/viewarticle/884517
  3. Navari RM, Aapro M Antiemetic Prophylaxis for Chemotherapy-Induced Nausea and Vomiting. N Engl J Med 2016;374:1356-67 PMID: 27050207 https://www.nejm.org/doi/pdf/10.1056/NEJMra1515442
  4. Hesketh PJ, Kris MG, Basch E et al Antiemetics: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol. 2017 Oct 1;35(28):3240-3261. PMID: 28759346 Review.
  5. Yang Q, Zou X, Xie YL et al Fosaprepitant Weekly vs Every 3 Weeks for the Prevention of Concurrent Chemoradiotherapy-Induced Nausea and Vomiting. A Pilot Randomized Clinical Trial. JAMA Netw Open. 2023;6(7):e2326127. July 27 PMID: 37498596 https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2807658