Chemotherapy Induced nausea and vomiting

1. Chemotherapy induced
Nausea and vomiting
CINV
Dr. SHEKH ABDULLAH AL MUKIT
Resident
MD(Oncology), BSMMU

2. Key Ideas:
• Most common side effect
• Most feared side-effect
• May be more distressing than future concerns of life expectancy
• Medical complications: dehydration, electrolyte imbalance, risk of
aspiration pneumonia.
• So Effective management of Nausea and Vomiting is essential

3. Definitions
Nausea is an unpleasant, diffuse sensation of unease and
discomfort, often perceived as an urge to vomit.
Vomiting is the involuntary, forceful expulsion of the contents of
one's stomach through the mouth and sometimes the nose.

4. Risk factors
• Female
• Younger age (less than 50 years)
• Genetic variation in metabolism of 5 HT3
• History of
o Motion sickness
o Nausea and vomiting associated with pregnancy
o CINV in prior CT
• Alcohol use
• Emesis prior to chemotherapy
• Emetogenic potential of drug

5. Centers involved in CINV
• Vomiting center in reticular formation of medulla activated by
stimuli from:
Chemoreceptor Trigger Zone (CTZ) in area postrema, floor of
the fourth ventricle which is outside blood-brain barrier
(fenestrated venules)
• Upper GI tract & pharynx
I. Vestibular apparatus
II. Higher cortical centers

6. Centers involved in CINV

7. Pathophysiology of vomiting

8. Mechanisms of Chemotherapy-Induced
Nausea and Vomiting (CINV)
Central mechanism:
• Chemotherapeutic agent activates the chemoreceptor trigger
zone (CTZ)
• Activated CTZ invokes release of various neurotransmitters,
which stimulate vomiting center
Peripheral mechanism:
• Chemotherapeutic agent causes irritation and damage to
gastrointestinal (GI) mucosa, resulting in the release of
neurotransmitters
• Activated receptors send signals to vomiting center via vagal
afferents

9. Types of Chemotherapy Induced Nausea
&Vomiting

10. Categories of CINV
Acute: Here patient will experience nausea and vomiting within 24 hours of chemotherapy
Delayed: Here patient will experience nausea and vomiting after 24 hours of
chemotherapy
Anticipated: Here patient will experience nausea and vomiting before starting of
chemotherapy
Break through: Even after giving prophylactic drugs to prevent nausea and
vomiting patients will have episodes of nausea and vomiting, which requires rescue
antiemetics
Refractory: Nausea and vomiting occurs when there is a poor response to multiple
antiemetic regimens

11. CINV: Classification
Anticipatory Acute Delayed
Chemo 16 - 24 hours

12. Post Chemotherapy Nausea and Vomiting

13. Definition of Risk for CINV
Minimal: <10%
Low:10-30%
Moderate 30-90%
High >90%

14. Emetic risk Agent
High (>90%) Cisplatin
Cyclophosphamide ≥1500mg/m2 Carmustine
Dacarbazine
Dactinomycin
Moderate (30–90%) Oxaliplatin
Cytarabine >1000mg/m2 Carboplatin
Ifosfamide
Cyclophosphamide Doxorubicin
Daunorubicin Epirubicin
Low (10–30%) Paclitaxel
Docetaxel
Mitoxantrone Topotecan Etoposide
Pemetrexed Methotrexate
Gemcitabine
Cytarabine ≤1000mg/m2 Fluorouracil
Trastuzumab
Minimal (<10%) Bevacizumab
Bleomycin
Busulfan Fludarabine Rituximab
Vincristine

15. WHY CINV is important?

16. How to manage children with CINV
• Pharmacological
• Non pharmacological

17. Principles of Management
Exclude the non chemotherapeutic causes
• bowel obstruction or dysmotility
• concomitant medications
• metabolic disturbances
• occult CNS metastasis
Patient counselling and education should be done promptly.
Selection of anti-emetics according to chemotherapy regimen

18. Non pharmacological
1. Counsil about:
• Eating frequent small foods served at room temperature.
• Drinking the liquid one hour before or after meals.
• Walking short distance outdoors and inhale air slowly.
• Keeping away from odor of foods, perfume and fume.
• Putting on comfortable clothes.
• Do not sleep immediately after dinner.
• Eating light foods (soup, yoghurt) after control of nausea &
vomiting.

19. Non pharmacological
• Acupuncture
• Acupressure
• Music therapy
• Progressive muscle relaxation
• Massage therapy
• Hypnosis
• Exercise
• Food habit change

20. Pharmacological Anti emetic classes:
• cyclazine
• Diphenhydramine
Antihistaminic
• Phenothiazine(chloropromazine)
• Butyrophenone(haloperidol)
• Benzamides(metaclopromide , domperdione )
antidopaminergic
• ondansetron
• Granisetron
• Palonosetron
Serotonin
antagonists
Neurokinin 1
antagonist
•Aprepitant
•Fosaprepitant

21. Pharmacological Anti emetic classes:
• Dexamethasone
Corticosteroides
• Aloprozolam
• Lorazepam
Benzodiazipens
• nabilone
• Dronabinol
Cannabinoids

22. Management Guidelines

23. Management of CINV with Highly Emetogenic
Agents

24. Management of CINV with Moderately
Emetogenic Agents

25. Management of CINV with Low Risk
Emetogenic Agents

26. Management of CINV with Minimal Risk
Emetogenic Agents

27. Complications
• Dehydration
• Electrolyte imbalance
• Metabolic alkalosis
• Oesophageal tear
• Under nutrition
• Weight loss
• Aspiration pneumonitis

28. THANK YOU