Chemotherapy-induced Nausea and Vomiting

Chemotherapy-induced Nausea and Vomiting

Matulonis Ursula A , Nevadunsky Nicole S
US ONCOLOGY - VOLUME 5 ISSUE 1
Published: July 2009
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Abstract
Nausea and vomiting are commonly observed and feared side effects of chemotherapy. Understanding of the physiological mechanisms of chemotherapy-induced nausea and vomiting (CINV) has led to the development of several classes of anti-emetic, including substance P antagonists, serotonin antagonists, and dopamine antagonists. The newest of these agents include aprepitant and palonosetron, which are very effective in treating emesis in highly emotegenic chemotherapies. Several organizations, including the Multinational Association of Supportive Care in Cancer (MASCC), the National Comprehensive Cancer Network (NCCN), and the American Society of Clinical Oncology (ASCO), have developed guidelines for classification and treatment of CINV. The aim of this article is to summarize current gold standards of anti-emetics and treatment guidelines, as well as introducing innovations such as approaches to breakthrough and refractory nausea and vomiting, alternative therapies, and transdermal delivery systems.

Keywords
Nausea and vomiting, anti-emetics, chemotherapy

Disclosure: The authors have no conflicts of interest to declare.
Received: December 17, 2008 Accepted: May 12, 2009
Correspondence: Nicole S Nevadunsky, MD, Brigham and Women's Hospital, Department of Gynecologic Oncology, 75 Francis Street, Boston, MA 02115. E: nnevadunsky@partners.org

Traditionally, nausea and vomiting are among the most commonly observed, as well as feared, side effects for patients who are receiving chemotherapy.1 Despite modern anti-emetic therapy, in patients taking highly emetogenic chemotherapy the incidence of nausea and vomiting has been reported to be up to 60 and 50%, respectively;2,3 additionally, anticipatory symptoms may occur in up to 40% of patients.4 It is estimated that in 70–80% of patients, pre-medication and symptomatic treatment can avoid or ameliorate chemotherapy-induced nausea and vomiting (CINV).5 Prior to routine use of modern anti-emetics, up to 20% of patients were not able to complete or delayed doses of their chemotherapy program.6 In the 1990s, the introduction of serotonin receptor antagonists (5HT3 antagonists) and corticosteroids further improved control of nausea and emesis.7 Modern classes of anti-emetic include 5HT3 antagonists, substance P neurokinin 1 receptor antagonists, motility agents, phenothiazine, benzodiazepines, and corticosteroids (see Table 1). Control of CINV is important as it allows patients to complete chemotherapy protocols and enhances the quality of life of patients in therapy. Despite modern anti-emetic regimens, a significant number of patients continue to experience symptoms of nausea and vomiting, and healthcare providers have been shown to underestimate the incidence of CINV.3,8 Seventy-five percent of patients with nausea and 50% of those with vomiting reported a negative impact on the performance of activities of daily living when queried with the Functional Living Index–Emesis (FLIE) questionnaire.9

Mechanisms of Chemotherapy-related Nausea and Vomiting
While the precise mechanism of CINV stimulation remains unknown, there are known anatomical zones of the central nervous system, neuronal pathways, and neurochemical mechanisms underlying the process of emesis.7 Mechanisms by which antineoplastic agents may induce emesis include direct actions on medullary centers, cell damage in the gastrointestinal tract, and learned cortical responses.10 The chemotherapy trigger zone (CTZ) and vomiting center (VC) are two wellknown anatomical centers in the central nervous system attributed to nausea and vomiting.11 Signals in blood as well as spinal fluid can interact with the CTZ because it is a circumventricular structure in the fourth ventricle, outside of the blood–brain barrier. The VC is located in the lateral reticular formation of the medulla. Signals from the CTZ act on the VC and induce efferent impulses to the salivation center, abdominal muscles, respiratory tract, and cranial nerves, which induce emesis. The vestibular system, pharynx and gastrointestinal tract, and cortical structures may also activate the VC.7

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Keywords:
Nausea and vomiting, anti-emetics, chemotherapy, chemotherapeutic agents, types of antibiotics, chemotherapy side effects, cancer vomiting, Chemotherapy induced Nausea and Vomiting, nausea vomiting,

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