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
DISCLOSURES No Disclosures
Objectives Provide an overview of chemotherapy-induced nausea and vomiting (CINV) Review published guidelines Discuss CINV in the Hem/HSCT setting
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
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
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
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
CINV Pathway Janelsins, 2013
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
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
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
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
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)
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
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
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
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
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
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