Supportive Care In Oncology: CINV

Question 1

Two pathways of CINV

Answer 1

Peripheral and central

Question 2

Peripheral pathway of CINV properties (what it’s mediated by, where it originates, how soon after chemo is it activated, what type of emesis is it associated with)

Answer 2

mediated by serotonin
originates in GI tract
activated in the first 24hrs after chemo
associated with acute emesis

Question 3

Central pathway of CINV properties (what it’s mediated by, where it originates, what type of emesis is it associated with)

Answer 3

mediated by NK-1
occurs primarily in the brain
predominantly involved in delayed CINV

Question 4

Classes of CINV: acute

Answer 4

occurs within first 24 hours after chemo

Question 5

CINV classes: delayed

Answer 5

occurs 24hrs-several days after chemo (days 2-5)

Question 6

CINV classes: breakthrough

Answer 6

occurs despite prophylaxis

Question 7

CINV classes: anticipatory

Answer 7

occurs before a treatment as a conditioned response to the occurrence of CINV in a previous cycle

Question 8

CINV classes: refractory

Answer 8

recurring in subsequent cycles of therapy, excluding anticipatory CINV

Question 9

Risk factors for CINV

Answer 9

age <50, female, emetic potential of chemo (high >90%, moderate >30-90% for IV, ≥30% moderate for PO), little or no previous alcohol use, history of CINV/prone to motion sickness, emesis during pregnancy

Question 10

Emesis prevention for acute/delayed CINV with parenteral agents: high risk, preferred regimen

Answer 10

Day 1: Olanzapine, dexamethasone, NK1RA, 5-HT3 RA
Days 2-4: Olanzapine, dexa, aprepitant (if PO formulation given on day 1)

Question 11

Exception with IV formulation of aprepitant

Answer 11

If the IV formulation is used, DO NOT ADMINISTER AFTER DAY 1!

Question 12

Emesis prevention for acute/delayed CINV with parenteral agents: moderate risk

Answer 12

Day 1: dexamethasone, 5-HT3 RA
Days 2-3: dexa or 5-HT3 RA

Question 13

Emesis prevention for acute/delayed CINV with parenteral agents: low risk

Answer 13

Dexamethasone
Metoclopramide
Prochlorperazine
5-HT3 RA

Question 14

Emesis prevention for acute/delayed CINV with parenteral agents: minimal risk

Answer 14

No prophy

Question 15

Emesis prevention for acute/delayed CINV with oral agents: high-moderate risk

Answer 15

5-HT3 RA

Question 16

Emesis prevention for acute/delayed CINV with oral agents: low-minimal risk

Answer 16

PRN antiemetics

Question 17

Breakthrough emesis treatment

Answer 17

Add one agent from a different drug class to regimen with ATC dosing
Consider antacid therapy if patient has dyspepsia

Question 18

Breakthrough emesis treatment options

Answer 18

Olanzapine, lorazepam, dronabinol, 5-HT3 RA, prochlorperazine, dexamethasone, metoclopramide, scopolamine

Question 19

What med should you NOT use for breakthrough emesis and why?

Answer 19

Palonosetron, because it has a long half-life (40 hours!)

Question 20

Anticipatory emesis treatment

Answer 20

Prevention is key!
Avoid strong smells that trigger symptoms
Lorazepam
Behavioral therapy

Question 21

Dexamethasone place in therapy

Answer 21

Part of the backbone in parenteral CINV regimens

Question 22

Dexamethasone AEs

Answer 22

Insomnia
Dyspepsia
Hyperglycemia
HTN

Question 23

5-HT3 RAs used in CINV

Answer 23

Ondansetron, palonosetron, granisetron

Question 24

5-HT3 RAs place in therapy for CINV

Answer 24

Ondansetron and granisetron are used in acute
Palonosetron used in acute and delayed

Question 25

5-HT3 RA AEs

Answer 25

HA, constipation, QTc prolongation

Question 26

NK1 RAs used in CINV

Answer 26

Aprepitant Fosaprepitant Rolapitant Fosnetupitant Netupitant

Question 27

NK1 RAs role in CINV treatment

Answer 27

Prevention, not treatment

Question 28

NK1 RAs DDI

Answer 28

Inhibition of 3A4 and 2C9; decrease dexa dose to 8mg QD on days 2-4 (exception is rolapitant)

Question 29

Rolapitant dosing schedule exception

Answer 29

Don't administer rolapitant <2 week intervals due to extended half-life (1 week)

Question 30

NK1 RAs AEs

Answer 30

Fatigue, GI upset, HA, hiccups

Question 31

Olanzapine place in CINV treatment

Answer 31

Prevention and breakthrough

Question 32

Olanzapine AEs

Answer 32

Sedation: administer at HS and consider lower dose in elderly Hyperglycemia Fatigue QTc prolongation Weight gain/metabolic AEs

Question 33

Prochlorperazine, metoclopramide, promethazine place in CINV therapy

Answer 33

Breakthrough

Question 34

Prochlorperazine and promethazine AEs

Answer 34

drowsiness, constipation

Question 35

Metoclopramide AEs

Answer 35

drowsiness, diarrhea, QTc prolongation, tardive dyskinesia (don't use >12 weeks)

Question 36

Lorazepam, alprazolam place in CINV treatment

Answer 36

Anticipatory CINV or breakthrough CINV with an anxiety component

Question 37

BZDs AEs

Answer 37

Sedation, dizziness

Question 38

When to give BZDs in CINV

Answer 38

Night before or morning of chemo (or both)

Question 39

Dronabinol place in CINV therapy

Answer 39

Refractory disease

Question 40

Dronabinol AEs

Answer 40

Sedation Euphoria/hallucinations Palpitations Flushing Cough

Question 41

Scopolamine place in CINV therapy

Answer 41

Breakthrough