Chemotherapy Induced Nausea/Vomiting (3) Flashcards
(65 cards)
Impact of CINV
Decrease in…
-nutrition and weight
-physical and mental health
-desire to continue chemotherapy
-quality of life
Increase in…
-medical complications
-dehydration
-electrolyte imbalances
-cost of medical care
Acute vs delayed CINV
Acute = n/v that occurs within the first 24 hours after chemotherapy
Delayed = n/v that occurs after the first 24 hours after chemotherapy
-can last up to 7 days after chemo
Anticipatory CINV
N/v that is a learned reflex or psychological response that occurs before chemotherapy
-can be triggered by sights/sounds/smells/tastes/thoughts
-often occurs due to poor n/v control in previous chemo cycles (so patients get anxious that it will happen again - because they are anticipating that it will happen)
Breakthrough CINV
This is n/v that occurs AFTER chemotherapy despite proper prophylaxis
Because of this patients may require “rescue medications” (that they can use prn)
Refractory CINV
This is n/v that occurs during subsequent cycles despite optimized antiemetic prophylaxis
-we continue to add on agents (use multiple agents with multiple MOAs)
-important to tell patients that medications will probably not eliminate n/v but just limit it
Which pathways/centers lead to n/v when stimulated
High Centers
(5HT3, NK1, D2, GABA)
-from memory, fear, dread, anticipation
Cerebellum
(M, H1)
-inner ear
Chemoreceptor trigger zone
(5HT3, D2, M, CB, opioid)
-blood bone emetics
Solitary Tract Nucleus
(5HT3, NK1, D2, M, H, CB)
When all these are triggered - leads to vomiting center stimulation in the medulla (NK1)
What factors contribute to the overall emetic risk? (2)
Regimen risk factors (how severely emetogenic the specific medications are)
Patient Risk Factors
(Regimen Risk + Patient Risk = Overall Emetic Risk)
What are patient specific factors that increase emetic risk? (5)
- Anxiety/anticipation of nausea (leads to anticipatory n/v)
- Female gender
- YOUNGER age (<50 yo)
- History of motion sickness
- History of pregnancy induced n/v
Which patient specific factor DECREASES emetic risk?
History of alcohol use (> 5 drinks per day) - this decreases risk of developing CINV
Which regimen factors increase emetic risk? (6)
- High emetic risk agent
- Moderate/high dose
- More frequent
- Longer duration
- Short infusion rate
- Radiation - higher amounts of irradiated tissue
IV chemo agents emetic risk categories (4)
Minimal emetic risk
- < 10% frequency of emesis (meaning they have n/v for less than 10% of the time)
Low emetic risk
-10-30% frequency of emesis
Moderate emetic risk
-30-90% frequency of emesis
High emetic risk
- > 90% frequency of emesis
Which IV chemo agents are considered to have minimal emetic risk? (2)
Monoclonal antibodies
Vinca alkaloids (vincristine, vinblastine, vinorelbine)
Which IV chemo agents are considered to have low emetic risk? (2)
Taxanes (paclitaxel and docetaxel)
5-Fluorourical
Which IV chemo agents are considered to have moderate emetic risk? (3)
Carboplatin
Oxaliplatin
Anthracyclines (doxorubicin)
Which IV chemo agents are considered to have high emetic risk? (2)
Cisplatin
Anthracyclines (doxorubicin) - when used in combination with cyclophosphamide
Oral chemotherapy emetic risk categories
Unlike the IV agents (which are broken up into minimal, low, moderate, or high emetic risk) - the oral agents are only broken up into 2 categories …
- Minimal to low emetic risk
- < 30% frequency of emesis - Moderate to high emetic risk
- 30% frequency of emesis or greater
Which oral chemo agents are considered minimal/low risk? (3)
Prophylaxis consideration for these
Capecitabine
Tyrosine kinase inhibitors
Methotrexate
PRN drug therapy (no prophylaxis recommended)
Which oral chemo agents are considered moderate/high risk? (2)
Prophylaxis consideration for these
Etoposide
Lomustine
Prophylaxis IS recommended
Emetic risk categories of radiation
The larger the surface area exposed to radiation –> the higher the emetic potential
- Mild Emetogenic
-radiation to head and neck or extremities (smaller area) - Moderately Emetogenic
-radiation to upper abdomen or pelvis or craniospinal - Highly Emetogenic
-total body irradiation, total nodal irradiation, upper half of body radiation (lots of receptors are in the upper half of the body from the gut to the brain)
How many days should prophylaxis be given for IV chemotherapy?
It depends on the emetic risk of the therapy…
High risk (> 90%) = 4 days
Moderate risk (30-90%) = 3 days
Low risk (10-30%) = 1 day
Minimal risk (< 10%) = no prophylaxis (just prn medications)
Barriers to CINV treatment
Patients may think n/v is just part of their treatment that they have to deal with or they may not want to seem weak so they don’t bring it up - so it’s important to ask patients about this
Patients may fear additional medications (side effects, costs)
Patients may fear that if they bring up these symptoms their provider will stop/lessen their chemotherapy
Non-pharmacologic approaches
Relaxation
Biofeedback therapy
Self-hypnosis
Dietary changes (avoid spicy or high fat foods)
Acupuncture
What are the classes of medications that can be used for CINV? (8)
- Neurokinin-1 Receptor Antagonists (NK1 RAs)
- 5-Seretonin Receptor Antagonists (5HT3 RAs)
- Corticosteroids
- Dopamine antagonists
- Atypical antipsychotics
- Benzodiazepines
- Cannabinoid receptor agonists
- Acid suppressing agents
5HT3 RA mechanism
Inhibits central and peripheral 5HT3 (serotonin) receptors
