Chemotherapy induced nausea and vomiting

1. Chemotherapy induced Nausea and Vomiting

2. Definition
• It is the one of the most common side
effect of chemotherapy drugs which is
used in treatment of cancer.
• 80% of the patients with cancer will
experience chemotherapy induced nausea
and vomiting

3. Types
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
chemotherapy induced nausea and vomiting,
drugs to prevent
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

4. Risk factors
• Less than 50 years
• Females
• History of motion sickness
• History of pregnancy related nausea and vomiting
• Alcohol use
• Emesis prior to chemotherapy
• Failure to adhere treatment guidelines
• Type of antineoplastic regimen
(Drug, Dose, Route, Schedule, Combination drug)

5. Etiology
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

6. Pathogenesis of Vomiting

7. Pathogenesis

8. Pathogenesis

9. Pathogenesis

10. Clinical Presentation
• Nausea
• Vomiting
• Sweating
• Paleness of skin
• Palpitations

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

12. Diagnosis
• Patient history
• Clinical presentation

13. Non Pharmacological Treatment
• Hypnosis
• Relaxation techniques
• Acupuncture
• Music therapy
• Systemic desensitization
• Guided imagery
• Biofeedback

14. Treatment options for Chemotherapy
induced Nausea and Vomiting
For high risk of Emesis
Acute CINV Delayed CINV
DAY 1 DAY 2 DAY 3 DAY 4
Aprepitant
125mg-PO-1
Aprepitant
80mg-PO-1
Aprepitant
80mg-PO-1
-
Dolasetron
100mg-PO-1/
Granisetron
2mg-PO-1
- - -
Dexamethasone
12mg-PO/IV-1
Dexamethasone
8mg-PO/IV-1
Dexamethasone
8mg-PO/IV-1
Dexamethasone
8mg-PO/IV-1

15. Treatment options for Chemotherapy
induced Nausea and Vomiting
For high risk of Emesis
Acute CINV Delayed CINV
DAY 1 DAY 2 DAY 3 DAY 4
Fosaprepitant
150mg-IV-1
- - -
Dolasetron
100mg-PO-1/
Granisetron
2mg-PO-1
- - -
- Dexamethasone
8mg-PO/IV-1
Dexamethasone
8mg-PO/IV-1
Dexamethasone
8mg-PO/IV-1

16. Treatment options for Chemotherapy
induced Nausea and Vomiting
For high risk of Emesis
Acute CINV Delayed CINV
DAY 1 DAY 2 DAY 3 DAY 4
Rolapitant
180mg-PO-1
- - -
Ondansetron
16-24mg-PO-1
- - -
Dexamethasone
20mg-PO/IV-1
Dexamethasone
8mg-PO/IV-1
Dexamethasone
8mg-PO/IV-1
Dexamethasone
8mg-PO/IV-1

17. Treatment options for Chemotherapy
induced Nausea and Vomiting
Acute CINV Delayed CINV
DAY 1 DAY 2 DAY 3 DAY 4
Netupitant
300mg-PO-1
- - -
Palasetron
0.5mg-PO-1
- - -
Dexamethasone
8mg-PO/IV-1
Dexamethasone
8mg-PO/IV-1
Dexamethasone
8mg-PO/IV-1
Dexamethasone
8mg-PO/IV-1
For high risk of Emesis

18. Treatment options for Chemotherapy
induced Nausea and Vomiting
Acute CINV Delayed CINV
DAY 1 DAY 2 DAY 3
Netupitant
300mg-PO-1
-
-
Palasetron
0.5mg-PO-1
Dolasetron-100mg-PO/
Granisetron 1-2mg-PO/
Ondansetron-16mg-PO
Dolasetron-100mg-PO/
Granisetron 1-2mg-PO/
Ondansetron-16mg-PO
Dexamethasone
8mg-PO/IV-1
- -
For moderate risk of Emesis

19. Treatment options for Chemotherapy
induced Nausea and Vomiting
Acute CINV
DAY 1
Dexamethasone 12mg-IV/PO-1/
Dolasetron-100mg-PO-1/
Granisetron-1-2mg-PO-1/
Ondansetron-8-16mg-PO-1
For low risk of Emesis

20. Treatment options for Chemotherapy
induced Nausea and Vomiting
For minimal risk of Emesis-
No treatment required
Anticipatory CINV
• Non pharmacological treatment
• Alprazolam or Lorazepam
Refractory CINV
• Use different combinations of anti emetics
• Add rescue anti emetics

21. Treatment options for Chemotherapy
induced Nausea and Vomiting
Breakthrough CINV
Adults
– Prochlorperazine
– Promethazine
– Lorazepam
– Metaclopromide
– Haloperidol
– Dexamethasone
One dose in the evening of day before chemotherapy
Next dose 1-2 hours prior to chemotherapy
Children
– Chlorpromazine
– Lorazepam
– Dexamethasone

22. Drugs used in treatment of Chemotherapy
induced Nausea and Vomiting (CINV)
Drug Category Mode of action Adverse effects
Aprepitant NK 1 receptor antagonist Antagonises the actions of
substance P/ Neurokinin 1
receptors
 Head ache
 Asthenia
 Anorexia
 GI disturbances
 Alopecia
Fosaprepitant NK 1 receptor antagonist Antagonises the actions of
substance P/ Neurokinin 1
receptors
 Head ache
 Asthenia
 Anorexia
 GI disturbances
 Alopecia
Rotapitant NK 1 receptor antagonist Antagonises the actions of
substance P/ Neurokinin 1
receptors
 Neutropenia
 Loss of appetite
 Dizziness
 Dyspepsia
 Urinary tract
infection

23. Drugs used in treatment of Chemotherapy
induced Nausea and Vomiting (CINV)
Netupitant NK 1 receptor
antagonist
Antagonises the actions of
substance P/ Neurokinin 1
receptors
 Head ache
 Asthenia
 Dyspepsia
 Hepatotoxicity
 Erythema
Palanosetron 5 HT3 receptor
antagonist
Antagonises the actions of
serotonin
 QT prolongation
 Anxiety
 GI disturbances
 Hyperkaelemia
 Hepatotoxicity
Granisetron 5 HT3 receptor
antagonist
Antagonises the actions of
serotonin
 Head ache
 GI disturbances
 Asthenia
 Somnolenance
 Sedation

24. Drugs used in treatment of Chemotherapy
induced Nausea and Vomiting (CINV)
Ondansetron 5 HT3 receptor antagonist Antagonises the actions of
serotonin
 Head ache
 Malaise
 Hypoxia
 Anxiety
 Urinary retention
Dolasetron 5 HT3 receptor antagonist Antagonises the actions of
serotonin
 Head ache
 Diarrhea
 Hypertension
 Arrhythmia
 GI disturbances
Alprazolam Benzodiazepine Decreased anxiety related to
chemotherapy
 Drowsiness
 Depression
 Head ache
 GI disturbances
 Dry mouth
Lorazepam Benzodiazepine Decreased anxiety related to
chemotherapy
 Sedation
 Amnesia
 Vertigo
 Asthenia
 Tremor

25. Resources
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC39
38333/pdf/nihms454621.pdf
• http://www.ijmpo.org/article.asp?issn=0971-
5851;year=2017;volume=38;issue=3;spage=334;
epage=339;aulast=Baburaj
• https://www.frontiersin.org/articles/10.3389/fphar.
2017.00019/full
• https://www.ons.org/sites/default/files/hawkins.pdf
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC31
88425/pdf/nihms-261834.pdf