Chemotherapy-and cancer-related nausea and vomiting.
Approximately one half of cancer patients will experience nausea or vomiting during the course of their disease either because of the cancer itself or because of their treatment. Emesis attributable to cancer warrants a careful investigation to determine whether a treatable underlying cause is responsible. Interventions using dexamethasone and octreotide may reduce vomiting attributable to bowel obstruction. In the absence of a bowel obstruction or a correctable cause, the usual approach is a sequential trial of antiemetics guided by considerations of cost and side effects.Major progress in managing chemotherapy-induced emesis followed from the use of a combination of a corticosteroid and 5-hydroxytryptamine(3) (5-HT(3)) receptor antagonist for moderately to highly emetogenic chemotherapy. Nevertheless, vomiting still occurred in approximately 40% of women receiving chemotherapy containing an anthracycline plus cyclophosphamide and in approximately 50% of patients receiving high-dose cisplatin. The addition of aprepitant, a neurokinin 1 receptor antagonist, improved control of emesis by a further 15%-20%, and that agent is now recommended as part of standard antiemetic therapy for patients at high risk of emesis. Based largely on anecdotal experience, cannabinoids and olanzapine are sometimes also recommended in patients with refractory emesis. Phase III trials are required to confirm their efficacy as add-ons to a corticosteroid, a 5-HT(3) receptor antagonist, and possibly aprepitant.
Warr
D G
DG
Department of Medicine, Princess Margaret Hospital, Toronto, Ontario. david.warr@uhn.on.ca