CHEMOTHERAPY-INDUCED NAUSEA AND VOMITING

Transcription

1 CHEMOTHERAPY-INDUCED NAUSEA AND VOMITING Jennifer Shamai MS, RN, AOCNS, BMTCN Professional Practice Leader Department of Clinical Practice And Professional Education Click How to the edit Experts Master Treat Presentation Hematologic Date Malignancies Las Vegas, NV March 11, 2016

2 DISCLOSURES No Disclosures

3 Objectives Provide an overview of chemotherapy-induced nausea and vomiting (CINV) Review published guidelines Discuss CINV in the Hem/HSCT setting

4 Definition Nausea: unpleasant, subjective sensation felt with the urge to vomit Vomiting: contractions of the GI and thoracic muscles that result in oral discharge of gastric content Retching (dry heaves): muscular activity of the abdomen and thorax attempting to expel gastric contents, without actually expelling them

5 CINV Categories Acute Occurs within first 24 hours after administration of chemotherapy Delayed Begins after first 24 hours May last for 120 hours Anticipatory Learned or conditioned response from poorly controlled nausea and vomiting associated with previous chemotherapy Breakthrough CINV that occurs despite prophylaxis and requires rescue treatment Refractory Occurs during subsequent treatment cycles when prophylaxis and/or rescue has failed in previous cycles

6 Significance Most feared and unpleasant side effect of chemotherapy Common side effect of chemotherapy May delay treatment and interfere with compliance Physiologic complications Electrolyte imbalances Dehydration Malnutrition Negatively affects quality of life (QOL) Impacts healthcare costs

7 Risk Factors for CINV Age < 50 years Women > men History of light alcohol use History of nausea/vomiting with prior exposure to chemotherapeutic agents Other risks History of motion sickness History of nausea or vomiting during pregnancy History of anxiety

8 CINV Pathway Janelsins, 2013

9 Principles of Treatment Prevention is the goal Based on emetogenicity of agents Highly emetogenic (HEC) Moderately emetogenic (MEC) Low emetogenic (LEC) For multi-drug regimens, base therapy on drug with highest emetic risk Patients should be protected during the entire period of risk Start before administration of chemotherapy

10 CINV Management Antiemetics Corticosteroids: dexamethasone Serotonin receptor antagonists (5-HT3): ondansetron, granisetron, palonosetron NK-1 receptor antagonists: aprepitant, fosapretitant, netupitant Dopamine antagonists: prochlorperazine, metoclopramide, olanzapine Cannabinoids: dronabinol, nabilone Benzodiazepines for treatment of anticipatory CINV H2 blocker or proton pump therapy (PPI) therapy for dyspepsia

11 Nonpharmacologic Management Diet restrictions Eat small, frequent meals Eat foods at room temperature Avoid fatty, spicy, or highly salty foods Behavioral approaches Distraction, relaxation, hypnosis, guided imagery, music therapy Acupuncture/acupressure Effective for anticipatory nausea and CIN

12 Nursing Management Assessment Standardized tools Communication to healthcare team Patient education Advocate for guideline adherence Management strategies Administer antiemetics prior to meal times Encourage proper dietary practices Small, frequent meals with bland flavors Assess effectiveness of interventions Promote nonpharmacologic measures

13 Guidelines National Comprehensive Cancer Network (NCCN) Multinational Association of Supportive Care in Cancer/European Society for Medical Oncology (MASCC/ESMO) American Society of Clinical Oncology (ASCO) Oncology Nursing Society (ONS) Putting Evidence into Practice (PEP)

14 Recent Updates to Guidelines Newer agents Palonosetron (Aloxi ) second generation 5-HT3 antagonist Superior to early 5-HT3 antagonists: longer half-life, high binding affinity, exceptional safety profile Aprepitant (Emend ) NK-1 antagonist Netupitant/Palonosetron (Akynzeo ) Long-lasting combination antiemetic activity with one dose Rolapitant (Varubi ) NK-1 antagonist Delayed CINV

15 CINV in the Hem/HSCT Population CINV management in Hem/HSCT is complex High prevalence of risk factors Young age High-dose regimens Previous exposure to highly-emetogenic agents and repeated cycles Total body irradiation (TBI) in conditioning regimens High psychological burden of treatment

16 Common Chemotherapy Agents Hem/HSCT High-dose Melphalan (200 mg/m 2 ) Cytarabine (1,000-3,000 mg/m 2 ) ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) Bendamustine (high-dose) Combinations of moderately emetogenic single agents Cytarabine Anthracyclines Cyclophosphamide Fludarabine Clofarabine

17 Hem/HCT Treatment Challenges Currently no formal recommendations or guidelines for treatment of CINV in the Hem/HSCT setting Limited research on the unique characteristics Multiple days and daily doses regimens Cryopreserved (DMSO) stem cell infusion Concomitant administration of supportive therapy such as IV antimicrobial prophylaxis Fragmentation and limited number of studies in HSCTrelated CINV

18 Summary Treatment guidelines have been updated Lack of guidance for treatment in the Hem/HSCT setting Further research is needed in the Hem/HSCT setting Despite advances, control of CINV remains an unmet need among cancer patients Next steps: Improve adherence to clinical guidelines Further development of regimens to treat delayed CINV and nausea

19 References Bechtel, T., McBride, A., Crawford, B., Bullington, S., Hofmeister, C.C., Benson, D.M.,... Devine, S.M. (2014). Aprepitant for the control of delayed nausea and vomiting associated with the use of high-dose melphalan for autologous peripheral blood stem cell transplants in patients with multiple myeloma: a phase II study. Supportive Care in Cancer, 22, Coyle N., Adelhardt, J., Foley, K.M., & Portenoy, R.K. (1990). Character of terminal illness in the advanced cancer patient: Pain and other symptoms during the last 4 weeks of life. Journal of Pain and Symptom Management, 5(2), Einhorn, L.H., Grunberg, S.M., Rapoport, B., Rittenberg, C., & Feyer, P. (2011). Supportive Care in Cancer, 19(Suppl. 1), S1-S4. Glare, P., Pereira, G., Kristjanson, L.J., Stockler, M., & Tattersall, M. (2004). Systematic Review of the efficacy of antiemetics in the treatment of nausea in patients with far-advanced cancer. Supportive Care in Cancer,12(6), Gonella, S. & Di Giulio, P. (2015). Delayed chemotherapy-induced nausea and vomiting in the hematology population: A Review of the literature. Clinical Journal of Oncology Nursing, 19(4), Gralla, R.J., Roila, F., Tonato, M., & Herrstedt, J. MASCC/ESMO antiemetic guideline 2013, Janelsins, M.C., Tejani, M., Kamen, C., Peoples, A., Mustian, K.M., & Morrow, G.R. (2013). Current pharmacotherapy for chemotherapy-induced nausea and vomiting in cancer patients. Expert Opinion on Pharmacotherapy, 14(6), Jordan K., Sippel, C., & Schmoll, H.J. (2007) Guidelines for antiemetic treatment of chemotherapy-induced nausea and vomiting, past, present and future recommendations. The Oncologist, 12(9), Krishnasamy, M., So, W.K., Yates, P., Ayala de Calvo, L.E., Annab, R., Wisniewski, T., & Aranda, S. (2014). The Nurse s role in managing chemotherapy-induced nausea and vomiting. Cancer Nursing, 37(4), E27-E35. Lopez-Jimenez, J., Martin-Ballesteros, E., Sureda, A., Uralburu, C., Lorenzo, I., Campo, R.,... Fernandez, G. (2006). Chemotherapy-induced nausea and vomiting in acute leukemia and stem cell transplant patients: Results of a multicenter, observational study. The Hematology Journal, 91(1), Mattiuzzi, G. N., Cortes, J.E., Blamble, D.A., Bekele, B.N., Ziao, L., Cabanillas, M.,... Kantarjian, H. (2010). Daily palonosetron is superior to ondansetron in the prevention of delayed chemotherapy-induced nausea and vomiting in patients with acute myelogenous leukemia. Cancer,116(24), National Comprehensive Cancer Network. (2015). NCCN guidelines version antiemesis, Rice, M.M. (2011, July 16). Management of chemotherapy-induced nausea and vomiting. OncoLink. Retrieved from