Delayed emesis induced by moderately emetogenic chemotherapy: Do we need to treat all patients?

Effectiveness of Palonosetron, 1-Day Dexamethasone, and Aprepitant in Patients Undergoing Carboplatin-Based Chemotherapy

INTRODUCTION

Dexamethasone (DEX)-sparing strategy with 5-hydroxytryptamine-3 receptor antagonist (5HT3RA) and aprepitant (APR), as triplet antiemetic prophylaxis, is associated with poor control of delayed chemotherapy-induced nausea and vomiting (CINV) in patients receiving carboplatin (CBDCA)-based chemotherapy. This study aimed to evaluate whether using palonosetron (PALO) as a 5HT3RA provides superior control with CINV than first-generation (1st) 5HT3RA in triplet antiemetic prophylaxis with a DEX-sparing strategy.

METHODS

Pooled patient-level data from a nationwide, multicenter, and prospective observational study were analyzed to compare the incidence of CINV between patients administered PALO and 1st 5HT3RA in combination with 1-day DEX and APR.

RESULTS

No significant differences were observed in the incidence of CINV, pattern of CINV, or severity of nausea by type of 5HT3RA in triplet antiemetic prophylaxis with DEX-sparing strategy. In both groups, the incidence of nausea gradually increased from day 3, peaked on day 4 or 5, and then declined slowly. The visual analog scale scores in the delayed phase remained high throughout the 7-day observation period.

CONCLUSION

Careful patient selection and symptom monitoring are needed when implementing the DEX-sparing strategy in triplet antiemetic prophylaxis for patients undergoing CBDCA-based chemotherapy. Furthermore, additional strategies may be needed to achieve better control of delayed CINV.

Chemotherapy-Induced Delayed Emesis: What is the Role of 5-HT3Antagonists?

Objective:

To review the current literature assessing the efficacy of different antiemetics, with a focus on comparison between serotonin (5-HT3) antagonists and other antiemetics, in the treatment of delayed emesis induced by either cisplatin or non-cisplatin cytotoxic agents.

Data Sources:

A MEDLINE search (1966–July 2002) was performed using delayed emesis, vomiting, nausea, chemotherapy, cisplatin, moderately emetogenic, selective serotonin subtype-3 (5-HT3) receptor antagonists, metoclopramide, domperidone, corticosteroids, dexamethasone, prognostic factors, risk factors, and neurokinin-1 (NK1) receptor antagonists as key words or subject headings. Only English-language articles were identified and included. Additional references were retrieved from selected articles.

Data Synthesis:

Various antiemetic consensus guidelines have recommended the use of different pharmacologic treatment, including the use of 5-HT3antagonists, for the prevention of chemotherapy-induced delayed emesis. In some instances, it has been suggested that combinations containing a 5-HT3antagonist may be superior to others. Current data have been synthesized in an attempt to demonstrate the efficacy of 5-HT3antagonists in the treatment of chemotherapy-induced delayed emesis.

Conclusions:

Dexamethasone has consistently shown its antiemetic efficacy for delayed emesis induced by cisplatin and non-cisplatin agents, whereas the role of 5-HT3antagonists alone remains controversial. Metoclopramide has been shown to be as efficacious as 5-HT3antagonists when combined with dexamethasone for the prevention of delayed emesis. As a result, 5-HT3antagonists should be reserved as second-line agents to metoclopramide in addition to dexamethasone. NK1 receptor antagonists have shown some early promising results. However, many questions need to be addressed before their extensive use in clinical practice.

Should clinicians always administer dexamethasone beyond 24 h after chemotherapy to control delayed nausea and vomiting caused by moderately emetogenic regimens? Insight from the re-evaluation of two randomized studies

Purpose

Data from two noninferiority trials of a dexamethasone-sparing regimen were assessed for the impact of acute nausea and vomiting on delayed outcome in patients undergoing moderately emetogenic chemotherapy (MEC) or anthracycline plus cyclophosphamide (AC).

Methods

Chemo-naive patients were randomized to receive palonosetron (0.25 mg IV) plus dexamethasone (8 mg IV) on day 1 of chemotherapy, or the same regimen followed by oral dexamethasone on days 2 and 3 in the MEC (n = 237) and AC (n = 380) cohorts. Patients were divided into two groups according to whether or not they experienced vomiting and/or moderate-to-severe nausea during the acute phase (high- and low-risk groups, respectively). Primary efficacy endpoint was the complete protection (CP) against delayed vomiting and moderate-to-severe nausea. Patient’s satisfaction (0–100 mm visual analog scale) was also analyzed.

Results

Among the 209 low-risk patients undergoing MEC, delayed CP occurred in 82.9 % of those who received single-dose dexamethasone and 89.8 % of those who received 3-day dexamethasone (P = 0.165). Of the 271 low-risk patients undergoing AC, CP was achieved in 71.7 % of those treated with single-dose dexamethasone and 84.2 % treated with 3-day dexamethasone (P = 0.019). In spite of these observations, the patient satisfaction data was not influenced by dexamethasone regimen. In both cohorts, occurrence of acute vomiting or moderate-to-severe nausea was the key independent-predictor for delayed vomiting or nausea, respectively.

Conclusions

The dexamethasone-sparing regimen provides adequate delayed protection in patients undergoing MEC who are at low risk for delayed symptoms, and can still be discussed for low-risk AC patients as the daily difference in control is modest. Additional dexamethasone doses can be customized on the basis of occurrence or absence of acute symptoms in the first cycle of MEC and even AC.

Aprepitant as prophylaxis of chemotherapy-induced nausea and vomiting in anthracyclines and cyclophosphamide-based regimen for adjuvant breast cancer

The aim of our study was to evaluate the efficacy and safety of a three-drug antiemetic prophylaxis in a single-center series treated with anthracyclines and cyclophosphamide-based regimen for BC. We collected data from 92 consecutive patients treated with routine antiemetic prophylaxis consisted of aprepitant (oral 125 mg, on day 1; oral 80 mg, on days 2 and 3), a 5-HT3 receptor antagonist (palonosetron iv 0.25 mg, on day 1), and dexamethasone (iv 12 mg, on day 1). Acute and delayed phases were defined as the first 24 h and days 2-5 after treatment, respectively. Therapy outcomes were defined as complete response (CR), in case of no vomiting, no rescue treatment; complete protection (CP), in case of no vomiting, no rescue treatment, no significant nausea; and total control (TC), in case of no vomiting, no rescue treatment, no nausea. Overall, 89.1 and 81.5% of patients showed CR in acute and delayed phase, respectively; 67.4 and 62% showed CP in acute and delayed phase, respectively; and 52.2 and 48.9% of patients showed TC in acute and delayed phase, respectively. 4.3% complained an episode of emesis during the first 24 h from treatment, while in delayed phase, only 2.2% of patients had vomiting. Our analysis confirmed that a three-drug prophylaxis is safe, effective, and consequently highly recommended in patients who undergo anthracyclines and cyclophosphamide-based regimens, though still not classified as highly emetogenic chemotherapy by all the international guidelines.

A randomized double-blind placebo-controlled cross-over trial of the impact on quality of life of continuing dexamethasone beyond 24 h following adjuvant chemotherapy for breast cancer

Uncertainty remains about the optimal anti-emetic regimen for control of delayed nausea and vomiting after adjuvant chemotherapy for breast cancer. Many patients receive dexamethasone but complain of insomnia, anxiety/agitation, and indigestion. The aim was to determine if patients receiving chemotherapy for breast cancer prefer treatment with dexamethasone or placebo for prophylaxis against delayed nausea and vomiting, and to compare quality of life (QOL) between the two treatments. In this randomized, double-blind, cross-over trial, we compared oral dexamethasone (4 mg twice daily for 2 days) versus placebo for chemotherapy-naïve patients with breast cancer. All patients received intravenous granisetron and dexamethasone pre-chemotherapy and oral granisetron on day 2. Primary endpoints were: (i) patient preference; (ii) difference between cycles in change of QOL from days 1 to 8. Median age of the 94 women was 51 years (range 27-76): 79 received fluorouracil/epirubicin/cyclophosphamide and 15 received doxorubicin/cyclophosphamide. Thirteen withdrew pre-cycle 2 with no differences between arms. Of 80 patients stating a preference, 31 preferred placebo (39 %, 95 % CI: 28-50 %) and 37 (46 %, 95 % CI: 35-58 %) preferred dexamethasone; 12 had no preference. There were no differences in intensity of vomiting, nausea, or time to onset of vomiting. There was greater decrease in global QOL (p = 0.06) when patients received dexamethasone. No other symptom/QOL domains differed significantly. In conclusion, no significant difference was found in patient preference, QOL, or symptoms regardless of whether dexamethasone or placebo was used after adjuvant chemotherapy.

The relationship of chemotherapy-induced nausea to the frequency of pericardium 6 digital acupressure

PURPOSE/OBJECTIVES

To explain the relationship between the intensity of chemotherapy-induced nausea (CIN) and the frequency of pericardium 6 (P6) digital acupressure.

DESIGN

Secondary data analysis of a multicenter, longitudinal, randomized, clinical trial.

SETTING

Nine community clinical oncology programs and six independent sites in the United States.

SAMPLE

53 patients with breast cancer who received moderate to highly emetogenic chemotherapy and applied P6 digital acupressure in addition to antiemetics to control CIN.

METHODS

A daily log measuring nausea intensity and the frequency of acupressure for 11 days after the administration of chemotherapy. Hierarchical generalized linear modeling procedure (multilevel negative binomial regression) was used for analyzing the data.

MAIN RESEARCH VARIABLES

Nausea intensity and acupressure frequency.

FINDINGS

Participants used acupressure an average of two times per day (SD = 1.84, range 0-10). Women who used acupressure more frequently after the peak of nausea (on day 4) were predicted to have a 0.97-point higher nausea intensity in the acute phase than women who used acupressure less frequently, controlling for the effects of other variables in the model (incidence rate ratio = 1.52, p < 0.01).

CONCLUSIONS

Patients with breast cancer whose nausea intensity started higher from the acute phase continued to experience higher symptom intensity during the 11 days after chemotherapy administration and required more frequent acupressure even after the peak of nausea.

IMPLICATIONS FOR NURSING

Careful assessment and management of acute CIN with continuous monitoring and care of CIN in the delayed phase are important nursing issues in caring for patients receiving chemotherapy.

Efficacy and tolerability of aprepitant for the prevention of chemotherapy-induced nausea and vomiting in patients with breast cancer after moderately emetogenic chemotherapy

PURPOSE

This is the first study in which the NK(1)-receptor antagonist, aprepitant (APR), was evaluated for the prevention of chemotherapy-induced nausea and vomiting (CINV) with moderately emetogenic chemotherapy.

PATIENTS AND METHODS

Eligible breast cancer patients were naive to emetogenic chemotherapy and treated with cyclophosphamide +/- doxorubicin or epirubicin. Patients were randomly assigned to either an aprepitant regimen (day 1, APR 125 mg, ondansetron (OND) 8 mg, and dexamethasone 12 mg before chemotherapy and OND 8 mg 8 hours later; days 2 through 3, APR 80 qd) [DOSAGE ERROR CORRECTED] or a control regimen (day 1, OND 8 mg and dexamethasone 20 mg before chemotherapy and OND 8 mg 8 hours later; days 2 through 3, OND 8 mg bid). Data on nausea, vomiting, and use of rescue medication were collected with a self-report diary. The primary efficacy end point was the proportion of patients with complete response, defined as no vomiting and no use of rescue therapy, during 120 hours after initiation of chemotherapy in cycle 1. The secondary end point was the proportion of patients with an average item score higher than 6 of 7 on the Functional Living Index-Emesis questionnaire.

RESULTS

Of 866 patients randomized, 857 patients (99%) were assessable. Overall complete response was greater with the aprepitant regimen than with the control regimen (50.8% v 42.5%; P = .015). More patients in the aprepitant group reported minimal or no impact of CINV on daily life (63.5% v 55.6%; P = .019). Both treatments were generally well tolerated.

CONCLUSION

The aprepitant regimen was more effective than the control regimen for prevention of CINV in patients receiving both an anthracycline and cyclophosphamide.

Delayed emesis: moderately emetogenic chemotherapy

Data on the incidence and efficacy of antiemetic prophylaxis against delayed emesis induced by moderately emetogenic chemotherapy are scanty. An overview of the literature has been done that showed the efficacy of dexamethasone in two of three randomized trials. Its optimal dose and duration of administration has not been defined. Only one of four randomized studies showed a statistically significant efficacy of 5-HT(3) antagonists. Finally, only weak evidence has been published on the efficacy of dopamine receptor antagonists.

Options for the prevention and management of acute chemotherapy-induced nausea and vomiting in children

The current standard of care with respect to preventing acute chemotherapy-induced nausea and vomiting (CINV) in children includes the administration of a 5-HT(3) antagonist with or without a corticosteroid, depending on the emetogenicity of the chemotherapy to be given. Problems in assessing the emetogenicity of chemotherapy regimens and nausea severity in children may influence the degree of success of CINV prophylaxis. Nevertheless, the majority of children who receive chemotherapy today experience moderate to complete control of acute CINV when given appropriate antiemetic prophylaxis. If children vomit or experience nausea despite appropriate prophylaxis, then measures must be taken to treat these symptoms since these children are likely to go on to experience delayed or anticipatory CINV. However, appropriate selection of interventions to treat acute CINV in children is limited by the lack of rigorous evidence to support one approach over another. Lorazepam is suggested as an immediate agent for the treatment of acute CINV. Doses and frequencies of the 5-HT(3) antagonist and corticosteroid administered for initial prophylaxis should also be maximized. Further treatment must be tailored to the circumstances and preferences of each child and family. Options include crossover to another 5-HT(3) antagonist, or administration of an adjunctive antiemetic such as metopimazine, low dose metoclopramide, domperidone, alizapride, nabilone, scopolamine, prochlorperazine, or chlorpromazine. Complementary interventions such as acupuncture, hypnosis, counseling, or ginger may also be of benefit. Further study is required to establish optimal antiemetic strategies in children.

Improving the care of patients with regard to chemotherapy-induced nausea and emesis: the effect of feedback to clinicians on adherence to antiemetic prescribing guidelines

PURPOSE

To evaluate the effect of performance and outcomes feedback on adherence to clinical practice guidelines regarding chemotherapy-induced nausea and emesis (CINE).

METHODS

Institutional CINE clinical practice guidelines were developed based on American Society of Clinical Oncology guidelines. Consecutive administrations of moderately/highly emetogenic chemotherapy were assessed for errors. Baseline statistical process control (SPC) charts were created and mean errors per administration were calculated. Prospective SPC charts were used to measure the effect of guideline development and distribution, a visiting lecturer, and ongoing feedback regarding compliance with guidelines employing SPC charts. Patients were surveyed regarding the extent and severity of CINE for 5 days postadministration. These outcomes were then shared with physicians.

RESULTS

Baseline compliance was poor (mean, 0.87 omissions per chemotherapy administration), largely because of inadequate adherence to recommendations for delayed CINE management. Most patients experienced delayed nausea, particularly on day 3 postchemotherapy. Physician prescribing performance did not undergo sustained improvement despite guideline development or distribution, a lecture by a visiting expert, or sharing of adherence data with clinicians. Once patient outcomes were shared, physicians accepted the need for compliance and instituted nurse practitioner antiemetic prescribing, with almost complete compliance and concurrent measurable reduction in day 3 nausea. SPC charts documented improvements in both outcomes.

CONCLUSIONS

SPC charts effectively monitor ongoing compliance and patient symptoms and represent appropriate outcome measurement and change facilitation tools. However, physician participation in guideline development and evidence of poor compliance alone did not improve prescribing performance. Only evidence of patient CINE experience coupled with noncompliance improved results.

Is delayed chemotherapy-induced emesis well managed in oncological clinical practice? An observational study

Nausea and vomiting have a negative influence on the quality of life of patients receiving chemotherapy. The Consensus Conference held in 1997 outlined the therapeutic procedure to prevent delayed emesis that might otherwise be induced by chemotherapy. So far, no study has evaluated the correct management of delayed emesis in clinical practice. This study was performed in an attempt to verify the conformity of the delayed emesis therapy administered in some oncological centres with the Consensus Conference guidelines. A total of 149 patients were observed for a minimum of one up to a maximum of four chemotherapy cycles; analysis of the data took account of whether the chemotherapy had a high (HEC), moderate (MEC) or low (LEC) emetogenic potential. Among 42 patients who received HEC, 18 (43%) received antiemetic prophylaxis conforming to standards; 23 (54.7%) of these 42 had delayed emesis, only 8 (34.7%) of whom were treated with adequate antiemetic protection. MEC was administered to 72 patients, 46 (64%) of whom received adequate prophylaxis; delayed emesis was observed in 31 (43%) of the 72 patients, 20 (64.5%) of whom received antiemetic prophylaxis according to established guidelines. Of 35 patients treated with LEC, 22.8% manifested delayed emesis; a high percentage of these patients, 68.5%, received prophylaxis, even though it was unnecessary. Of all patients observed, only 50.3% received correct antiemetic protection. We deduce from the study that antiemetic treatment for delayed emesis in clinical practice needs more attention. Correct prophylaxis is necessary when HEC is given, and antiemetic protection for patients receiving MEC must be improved; among patients treated with LEC those at high risk must be identified so that overtreatment can be avoided.

Delayed nausea and vomiting in children receiving antineoplastics

BACKGROUND

The nature and prevalence of delayed antineoplastic-induced nausea and vomiting have not been well-described in children. This study describes the extent of delayed nausea and vomiting in children receiving antineoplastic agents as well as the drug therapies initiated in an attempt to prevent or manage it.

PROCEDURE

All children receiving antineoplastics were eligible for study entry. The date and time of each emetic episode were recorded on each day antineoplastics were given and for 3 days thereafter. Nausea was self-assessed daily by children who were older than 3 years and were not developmentally delayed. Diet was also assessed daily. The emetic response, median nausea rating and median diet achieved were described.

RESULTS

The emetic response of 124 children who received 174 antineoplastic cycles was evaluated. Most cycles (137/174;79%) were not associated with delayed vomiting. Cycles which included cisplatin, carboplatin, or cyclophosphamide; involved antineoplastic therapy given over 2 or more consecutive days; or were accompanied by vomiting during the acute phase were associated with a significantly higher incidence of delayed vomiting. Moderate to severe nausea was reported on 58% (267/459) of study days. No antiemetics were given on most study days (412/522;79%); nevertheless, most of the study days (381/412;93%) which were unaccompanied by antiemetic support during the delayed phase were completely free from vomiting. Antiemetics were most often given as single agents (ondansetron: 54 study days; dimenhydrinate: 17 study days; dexamethasone: 6 study days). Diet was largely unaffected during the study period.

CONCLUSIONS

Antineoplastic-induced delayed nausea and vomiting may be less prevalent in children than in adults. Routine antiemetic administration during the delayed phase may not be warranted in all patients. Med Pediatr Oncol 2001;37:115-121.

Dexamethasone alone or in combination with ondansetron for the prevention of delayed nausea and vomiting induced by chemotherapy

BACKGROUND

The prevention of delayed nausea and vomiting caused by moderately emetogenic chemotherapy for cancer has not been studied systematically.

METHODS

We enrolled patients who were scheduled to receive chemotherapy for the first time in a double-blind, randomized, multicenter study. All the patients received ondansetron combined with dexamethasone for prophylaxis against emesis that might occur within 24 hours after the start of chemotherapy (acute emesis). They were then divided into two groups: patients who did not have either vomiting or moderate-to-severe nausea (the low-risk group) and patients who had one or both (the high-risk group). Patients in the low-risk group were then randomly assigned to one of the following regimens, given on days 2 through 5 after the start of chemotherapy: oral placebo, 4 mg of dexamethasone given orally twice daily, or 8 mg of ondansetron in combination with 4 mg of dexamethasone, given orally twice daily. Patients in the high-risk group were randomly assigned to receive oral dexamethasone alone or in combination with ondansetron at the same doses as those used in the low-risk group.

RESULTS

Among the 618 patients in the low-risk group, there was a complete absence of both delayed vomiting and moderate-to-severe nausea in 91.8 percent of those who received ondansetron combined with dexamethasone, 87.4 percent of those who received dexamethasone alone, and 76.8 percent of those who received placebo. The proportions of patients who were protected by dexamethasone combined with ondansetron or by dexamethasone alone were significantly greater than the proportion protected by placebo (P<0.001 and P<0.02, respectively). Of the 87 patients in the high-risk group, complete protection was achieved in 40.9 percent of those treated with ondansetron and dexamethasone and in 23.3 percent treated with dexamethasone alone (P not significant).

CONCLUSIONS

The best way to prevent delayed nausea and vomiting in patients receiving moderately emetogenic chemotherapy is to control these complications within the first 24 hours after the start of chemotherapy. Dexamethasone alone provides adequate protection against delayed emesis in patients at low risk (those who have not had acute emesis).