A Comparative Study of the Use of Navoban (ICS 205-930), a 5-HT3 Antagonist, versus a Standard Antiemetic Regimen of Dexamethasone and Metoclopramide in the Treatment of Cisplatin-Containing Chemotherapy

[Management of chemotherapy-induced emesis: what is the standard after 20 years of clinical research]

BACKGROUND

The knowledge of the importance, the physiopathological mechanisms, and the management of the chemotherapy-induced emesis has increased exponentially during the last 20 years. High-dosage metoclopramide (MCP) therapy has been introduced in the eighties and serotonine type-3 receptor antagonists (5-HT(3) antagonists) have been used since the late eighties and early nineties. Due to both classes of substances the results of the antiemetic therapies have improved drastically. After 20 years of intensive clinical research it seems to be appropriate to come to an intermediate conclusion.

METHOD

With the aid of an overview and a new analysis of the literature published on this topic so far, the current state of research is shown (including the fields in which further improvement will be necessary), and suggestions are made, wherever it seemed possible, to attain the "gold standard" in antiemetic therapy.

RESULTS AND CONCLUSIONS

In connection with all highly or very highly emetogenic chemotherapies, an antiemetic prophylaxis should be initiated on the day of therapy, especially when using platinum or most of the cyclophosphamide-based regimes for cancer treatment. The recommended prophylaxis consists of a combination of 5-HT(3) antagonists with a corticosteroid. To combat the so-called delayed emesis on the days following therapy, all patients should undergo an oral corticoid therapy, possibly in combination with MCP (especially platinum-therapy patients), less frequently with 5-HT(3) antagonists. With these means of prophylaxis emesis can be prevented/avoided completely in most patients, and nausea can at least be reduced. It is sufficient to administer a single dose of 5-HT(3) antagonists prior to chemotherapy. For ondansetron and granisetron, the best documented substances within this class of drugs, 8 mg (ondansteron) and 3 mg (granisetron) are considered standard dosages. Among the corticoids, most data have been accumulated for dexamethasone. A standard dose of 10 to 20 mg can be administered prior to chemotherapy. Right after and especially on the days following chemotherapy higher dosages seem to be indicated.

PROSPECT

Further therapy improvements, especially concerning emesis and nausea on the days following chemotherapy, are necessary and are currently object of clinical research.

Control of delayed nausea and vomiting with granisetron plus dexamethasone or dexamethasone alone in patients receiving highly emetogenic chemotherapy: a double-blind, placebo-controlled, comparative study

BACKGROUND

The efficacies of granisetron plus dexamethasone and dexamethasone alone in controlling delayed nausea and vomiting after cisplatin chemotherapy (> or = 69 mg/m2) were compared in a multicentre, double-blind, placebo-controlled comparative study.

PATIENTS AND METHODS

In all, 654 patients (of whom 619 were evaluable) received prophylactic granisetron plus dexamethasone before chemotherapy on day 0; on day 1 complete responders and non-responders were randomized separately to receive dexamethasone, 8 mg b.d. p.o., with either granisetron, 1 mg b.d. p.o., or matching placebo for six days.

RESULTS

Over days 1-6 the complete response rates were 54.5% (dexamethasone group) and 52.1% (dexamethasone plus granisetron group). Response rates were higher over days 4-6 (71.8% and 70.7%, respectively) than over days 1-3 (60.4% and 57.9%, respectively). Significantly more patients who responded to antiemetic treatment during day 0 were responders over days 1-6 (63% vs. 17%; P < 0.001). No other treatment-related differences were found. Adverse events tended to be minor, with constipation and headache the most common. Overall, there were no significant differences in the safety profiles of the two regimens, but constipation and abdominal pain were significantly more common in the dexamethasone plus granisetron group.

CONCLUSIONS

Granisetron plus dexamethasone did not appear to confer additional benefit over use of dexamethasone alone in controlling delayed nausea and vomiting following cisplatin chemotherapy. Control of acute nausea and vomiting, however, appeared to be an important factor influencing delayed nausea and vomiting.

An open multicentre study of tropisetron for cisplatin-induced nausea and vomiting

OBJECTIVES

(i) To assess the efficacy and tolerability of tropisetron when used for acute and delayed cisplatin-induced emesis. (ii) To investigate whether dexamethasone added to tropisetron improves the control of emesis for patients who do not achieve a complete response to tropisetron alone. (iii) To assess sex of the patient and alcohol intake as prognostic factors for nausea and vomiting.

DESIGN

A prospective open label phase II trial over one or two cycles of chemotherapy. Data collection was based on observed response and patients' self-reporting.

SETTING

Twenty Australian tertiary care hospitals in 1994.

PATIENTS

102 male and female patients from 18 to 75 years with histologically confirmed malignancy receiving their first chemotherapy containing > or = 50 mg/m2 cisplatin.

INTERVENTION

In Cycle 1 tropisetron 5 mg was given intravenously before chemotherapy on Day 1, then 5 mg orally before breakfast on Days 2 to 6. In Cycle 2, dexamethasone 20 mg intravenously on Day 1, then 8 mg orally on Days 2 to 6 could be added to tropisetron if a complete antiemetic response had not been achieved in Cycle 1.

MAIN OUTCOME MEASURES

Number of vomiting episodes and severity of nausea for 6 days after chemotherapy; severity of side effects; patient satisfaction with chemotherapy treatment; oestradiol levels in women; and past alcohol consumption in men and women.

RESULTS

(i) The complete response rate (CR) for acute emesis in Cycle 1 was 64% (95% confidence interval [CI], 54%-72%), with 84% (95% CI, 76%-90%) having < or = 2 vomits. The CR for delayed emesis was 24% (95% CI, 17%-32%). The CR for acute nausea was 56% (95% CI, 47%-66%), with 97% (95% CI, 91%-99%) having < or = 2 nausea episodes. The CR for delayed nausea was 21% (95% CI, 14%-30%). Seventy-one patients received Cycle 2. The main side effects were headache (20 patients) and constipation (16 patients). The control of acute emesis was rated as "good" or "very good" by 68% of investigators; 85% rated the tolerability of treatment as "good" or "very good". Treatment was rated as "very satisfactory" or "satisfactory" by 52% of patients. (ii) The CR for acute emesis with dexamethasone added was 78% (95% CI, 64%-88%). (iii) Women with lower oestradiol levels had better control of emesis, although this difference was not statistically significant. Chronic alcohol intake and binge drinking were strongly associated with a complete acute antiemetic response.

CONCLUSIONS

Tropisetron was effective for acute cisplatin-induced emesis; adding dexamethasone enhanced this response. Both single and combined therapy had less effect on delayed emesis. The impact of alcohol on control of emesis is a chronic rather than acute phenomenon which requires prospective testing.

Tropisetron and metoclopramide in the prevention of postoperative nausea and vomiting. A comparative, placebo controlled study in patients undergoing ophthalmic surgery

One hundred and twenty patients undergoing elective ophthalmic surgery under general anaesthesia were investigated in a randomised, double-blind, parallel group study of postoperative nausea and vomiting. Patients received tropisetron 0.1 mg.kg-1, metoclopramide 0.25 mg.kg-1 or placebo given at the end of anaesthesia. In comparison with placebo, tropisetron significantly reduced the degree of nausea (p < 0.01), whereas metoclopramide reduced both nausea (p < 0.05) and vomiting (p < 0.05). There were no statistically significant differences between the two active agents in their efficacy to postoperative nausea and vomiting. The patients in the placebo group required rescue antiemesis more often in the postanaesthesia care unit. Our results suggest that tropisetron may not be suitable as a routine, primary therapy for the prevention of postoperative nausea and vomiting.