Chemotherapy-induced Nausea & Vomiting: How to Defeat it?

Overview

No one can deny that Chemotherapy-induced Nausea & Vomiting (CINV) is the most common undesired effect of chemotherapy and the most common cause of anxiety and distress in patients with cancer. Untreated CINV could affect 60% to 80% of cancer patients and impact their Quality of Life (QOL) as well as their families, which often leads them to discontinue their chemo-regimen or delay their chemotherapy cycles.

Classification of CINV

We can classify CINV into 4 categories:

• Acute: which occurs within 24 hours of chemotherapy administration.
• Delayed: which occurs after 24 hours of chemotherapy administration.
• Anticipatory: it starts before chemotherapy administration, often in patients who experienced CINV in the past cycle.
• Breakthrough/Refractory: emesis occurs despite the usage of anti-emetic medication.

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Risk factors

Here are some risk factors that contribute to CINV:

• Gender: It is more common for women to develop CINV than for men.
• Age: It is more common for younger patients to experience CINV as compared to other age groups.
• History of motion sickness or pregnancy morning sickness: Those individuals are more susceptible to CINV than others.
• Previous CINV: Patients who experienced CINV during their last chemotherapy cycle are at a higher risk of experiencing CINV during their next cycle.

Pathophysiology of CINV

In order to treat CINV, it is important to understand how it occurs. There are two main pathways that trigger the emetic response. The central pathway, which is responsible for delayed CINV, involves the chemoreceptor trigger zone (CTZ) and is primarily regulated by the substance P pathway. On the other hand, the peripheral pathway, which is responsible for acute CINV, is mainly regulated by the serotonin pathway.

Figure (1)

Pathophysiology of CINV.

Treatment

Antiemetic drugs in CINV treatment include:

• Neurokinin 1 receptor antagonist (NK1 RA) such as: Aprepitant, Fosaprepitant.
• 5-HT3 receptor antagonists (5-HT3 RA) such as: Granisetron, Ondansetron, Palonosetron.
• Dexamethasone (DEX).
• Olanzapine (Off-label use): it prevents CINV in combination with 5-HT3 and DEX.

The table below shows the antiemetic treatment recommendation..

Risk of Emesis	National Comprehensive Cancer Network Recommendations (NCCN)	American Society of Clinical Oncology Recommendations (ASCO)
High	Day 1 (before chemotherapy): NK1 RA + 5-HT3 RA + DEX, or Olanzapine + Palonosetron + DEX, or NK1 RA + 5-HT3 RA + DEX + Olanzapine Days 2-4: Varies according to day 1 regimen.	Day 1 (before chemotherapy): NK1 RA + 5-HT3 RA + DEX + Olanzapine Days 2-4: continue Olanzapine on days 2-4 Add DEX on days 2-4 for high-emetic risk (non-AC)
Moderate	Day 1 (before chemotherapy): 5-HT3 RA + DEX, OR Olanzapine + Palonosetron + DEX, or NK1 RA + 5-HT3 RA + DEX Days 2-3: Varies according to day 1 regimen.	Treated with carboplatin area under the curve (AUC) ≥ 4 mg/mL/min: NK1 RA + 5-HT3 RA + DEX Other moderate-risk regimens: 5-HT3 RA + DEX on day 1 Delayed: DEX on days 2-3
Low	Start before chemotherapy: DEX or Metoclopramide PO/IV, or Prochlorperazine, or Oral 5-HT3 RA	Acute: 5-HT3 RA, or DEX

Prevention

So, how could we avoid CINV? To prevent it, here are some tips for you to minimize and reduce CINV symptoms:

• Eat small meals: it’s better to have small meals throughout the day despite a few large meals.
• Drink lots of fluids: beverages such as water, unsweetened juice, and ginger could be helpful.
• Avoid unpleasant smells.
• Make yourself comfortable: rest after eating and don’t lie down for a couple of hours.

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References

1. Adel N. Overview of chemotherapy-induced nausea and vomiting and evidence-based therapies. Am J Manag Care. 2017;23(14 Suppl):S259-S265.
2. Tilleman JA, Pick A, DeSimone EM. Chemotherapy-Induced Nausea and Vomiting. US Pharm. 2018:43(2)(Specialty&Oncology suppl):2-5.
3. Gupta K, Walton R, Kataria SP. Chemotherapy-Induced Nausea and Vomiting: Pathogenesis, Recommendations, and New Trends. Cancer Treat Res Commun. 2021;26:100278.
4. Chemotherapy nausea and vomiting: Prevention is best defense, available at: https://www.mayoclinic.org/tests-procedures/chemotherapy/in-depth/cancer/art-20047517
5. Guidelines on Radiation- and Chemotherapy-Induced Nausea and Vomiting: Overview, Chemotherapy-Induced Nausea and Vomiting, Radiation-Induced Nausea and Vomiting. (2022). EMedicine. https://emedicine.medscape.com/article/2500044-overview

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