3. Introduction
Patients with cancer may experience many
side effects while receiving chemotherapy
but few side effects are more feared than
nausea and vomiting
In the past, nausea and vomiting were
inevitable side effects of chemotherapy and
forced up to 20% of patients to postpone or
refuse potentially curative treatment.
4. Cont..
Nausea and vomiting are usually self-
limiting .
Sometime they can have the
deleterious effects on nutritional status
and quality of life .
5. Cont..
• Many recently introduced therapeutic
antibodies and oral agents have less
potential to produce nausea and
vomiting.
• However, combination chemotherapy
continues to be the cornerstone of
treatment for many types of cancer.
6. Types of emesis
• Three distinct types of CINV :
acute emesis
delayed emesis
anticipatory emesis
7. Cont..
Acute emesis :
Occurs during the first 24 hours after
chemotherapy.
In the absence of effective
prophylaxis, it most commonly begins
within 1-2 hours of CT and usually
peaks in the first 4-6 hours.
8. Cont..
Delayed emesis
occurs more than 24 hours after
chemotherapy is classified as delayed
It is best characterized following
treatment with high-dose cisplatin .
9. Cont..
In the absence of antiemetic
prophylaxis, delayed emesis after
cisplatin peaks at approximately 48 to
72 hours after therapy, then gradually
subsides over the next 2-3 days.
10. Cont..
Anticipatory emesis
Anticipatory emesis is a conditioned
response in patients who have
developed significant nausea and
vomiting during previous cycles of CT.
11. PATHOPHYSIOLOGY
The pathophysiology of CINV is not
entirely understood; however, it is
thought to have many contributing
pathways.
The central nervous system plays a
critical role in the physiology of
nausea and vomiting.
12. Cont..
The existence of two distinct sites in
the brainstem believed to be critical for
the control of emesis:
vomiting center.
chemoreceptor trigger zone (CTZ)
13. Vomiting center
• It was also thought to be located
adjacent to the other structures
involved in the coordination of the
respiratory, vasomotor, and salivary
centers, and cranial nerves VIII and X
14. Cont..
More recent studies have suggested
that it is actually not anatomically
discrete but the initiation of the
vomiting reflex is controlled by a
complex system of networks located in
the brainstem.
15. Area postrema (AP)
Called a "chemoreceptor trigger zone“.
• It is located outside the blood-brain
barrier, is exposed to various noxious
agents borne in the blood or
cerebrospinal fluid.
Located circumventricularly (at the caudal
end of the 4th ventricle)
19. Neurotransmitters
Although over 30 neurotransmitters
have been associated with the
peripheral and central nervous system
sites involved in CINV, three
neurotransmitters have the most
clinical relevance
21. Predictive factors
There are multiple clinical factors that
are important in determining the
incidence and severity of
chemotherapy-induced nausea and
vomiting .
These factors include the type of
chemotherapy administered, certain
patient characteristics, and the
antiemetic regimen used.
22. Cont..
DETERMINANTS OF CHEMOTHERAPY-INDUCED
NAUSEA AND VOMITING
•Chemotherapy
• Emetic potential of drug(s) used
• Dose
• Schedule of administration
• Route of administration
•Patient Characteristics
•.Age
• Gender
• Alcohol use
• Emesis control during prior chemotherapy
•History of motion sickness
23. Cont..
The most important is:
the intrinsic emetogenicity of the
chemotherapy agent
mode of administration of CT
CT agents were placed into four risk
categories in the absence of effective
antiemetic prophylaxis.
24. Cont..
High — >90 percent risk of emesis
Moderate — >30 to 90 percent risk of
emesis
Low — 10 to 30 percent risk of emesis
Minimal — <10 percent risk of emesis
28. Prevention and treatment
The four categories of drugs with the
highest therapeutic index for the
management CINV include:
type three 5-hydroxytryptamine (5-
HT3) receptor antagonists
the neurokinin-1 (NK1) receptor
antagonists aprepitant and fosaprepita
nt
Glucocorticoids
Dopamine receptor antagonist
29. All first-generation 5-HT3
receptor antagonists
They have proven to be most effective
in the prevention of acute CINV
They are considered therapeutically
equivalent and are used
interchangeably
They have similar toxicity profiles
Oral formulations have similar
efficacy to intravenous formulations.
30. Palonosetron is a second-
generation 5-HT3 antagonist
Has a longer half-life of 40 hours
Has a higher binding affinity to the 5-
HT3 receptor.
31. Cont…
Adverse effects are qualitatively
similar among agents and include:
headache
constipation
diarrhea
transiently increased hepatic
transaminase concentrations
transient electrocardiogram (ECG)
changes decreased cardiac rate
32. Glucocorticoids
Mechanism of action is unknown
probably
It may have multiple site of action
In the acute and delayed phase, it
increase the chance of complete
prevention of vomiting by 25% to 30%
versus placebo
With moderate to highly emetogenic
chemotherapy regimens,
corticosteroids are typically not used
alone
33. Cont…
Although no obvious differences in
efficacy have been demonstrated
among the corticosteroids,
dexamethasone is almost universally
used.
They consistently add to the effect of
other antiemetic agents when used in
combination presumably because of
their different mechanism of action
34. Dopamine-2 Receptor
Antagonists
Metoclopramide is a D2 receptor
antagonist, and is a weak competitive
5-HT3 receptor antagonist at high
doses.
Its activity against delayed-phase
symptoms is equivalent to that of
ondansetron.
35. Cont..
The profile of adverse effects of potent
D2 receptor antagonists:
Dose-related sedation
Extrapyramidal reactions (EPRs).
Anticholinergic effects
Gastrointestinal prokinetic effects may
be useful for patients who have
concomitant motility disorders or
gastroesophageal reflux disease.
36. Cont..
Incidence of adverse effects also
correlates directly with the magnitude
of the dose and the frequency of
administration:
Sedation
EPRs
Anticholinergic effects
37. Other agents
Other agents that have been used in
the treatment or prevention of CINV
include;
phenothiazines, butyrophenones, and
cannabinoids.
These agents have a lower
therapeutic index than the 5-HT3
receptor antagonists, aprepitant , and
glucocorticoids for highly or
moderately emetogenic chemotherapy
regimens
38. Cont..
Their use should be restricted to
patients who are intolerant of or
refractory to these first line agents.
Phenothiazines could be used as an
alternative to single
agent dexamethasone for those
receiving chemotherapy with a low risk
of emesis, if a glucocorticoid is
contraindicated.
39.
40.
41.
42.
43. Olanzapine for the Prevention of
Chemotherapy-Induced Nausea and Vomiting
July 14, 2016