Management of platinum-based chemotherapy-induced acute nausea and vomiting: is there a superior serotonin receptor antagonist?

Molecular mechanisms underlying cisplatin-induced nephrotoxicity and the potential ameliorative effects of essential oils: A comprehensive review

Since the Middle Ages, essential oils (EO) have been widely used for bactericidal, virucidal, fungicidal, insecticidal, medicinal and cosmetic applications, nowadays in pharmaceutical, agricultural and food industries. Recently, EO have emerged as promising adjuvant therapies to mitigate the toxicities induced by anti - cancerous drugs; among them cisplatin induced renal damage amelioration remain remarkable. Cisplatin (cis-diaminedichloroplatinum II, CDDP) is renowned as one of the most effective anti-neoplastic agents, widely used as a broad-spectrum anti-tumor agent for various solid tumors. However, its clinical use is hampered by several side effects, notably nephrotoxicity and acute kidney injury, which arise from the accumulation of CDDP in the proximal tubular epithelial cells (PTECs). To better understand and analyze the molecular mechanisms of CDDP-induced renal damage, it is crucial to investigate potential interventions to protect against cisplatin-mediated nephrotoxicity. These EO have shown the ability to counteract oxidative stress, reduce inflammation, prevent apoptosis, and exert estrogenic effects, all contributing to renal protection. In this review, we have made an effort to summarize the molecular mechanisms and exploring new interventions by which we can pave the way for safer and more effective cancer management in the future.

Effects of auricular acupressure on chemotherapy-induced nausea and vomiting in breast cancer patients: a preliminary randomized controlled trial

BACKGROUND

Auricular acupressure (AA) has been viewed as a promising approach to managing chemotherapy-induced nausea and vomiting (CINV) but relevant research evidence has been inconclusive. This study aimed to examine the effects of AA on CINV in breast cancer (BC) patients undergoing chemotherapy.

METHODS

A preliminary randomized controlled trial was conducted in 114 BC patients. Participants were randomly allocated to a true AA group (n = 38), a sham AA group (n = 38), and a standard care group (n = 38). All the participants were provided with standard antiemetic treatment and care, while the true AA group and the sham AA group received an additional 5-day true AA and a 5-day sham AA, respectively. Acute and delayed CINV were assessed by using the MASCC Antiemesis Tool (MAT), anticipatory nausea and vomiting were measured by the Index of Nausea, Vomiting, and Retching (INVR), and patients' quality of life (QoL) was evaluated by the Functional Assessment of Cancer Therapy-Breast (FACT-B).

RESULTS

Both the true and sham AA groups reported improved CINV outcomes than the standard care group, with the true AA demonstrating larger effects than the sham comparison. The true and sham AA groups had higher complete response (CR) rates of CINV when compared with the standard care group, with the difference in the CR of acute CINV achieving statistical significance (p = 0.03). Both the true and sham AA groups demonstrated lower incidence and severity of acute CINV compared with the standard care group with the among-group difference reaching statistical significance for the occurrence (p = 0.04) and severity (p = 0.001) of acute nausea. No significant differences in anticipatory CINV and QoL were found among the groups.

CONCLUSION

The use of AA plus standard antiemetic treatment and care was superior to the use of standard antiemetic treatment and care alone in managing CINV among BC patients receiving chemotherapy. The antiemetic effects of AA were identified to be more profound in improving acute CINV, particularly acute nausea. The antiemetic effects of AA were deemed to be a mixture of specific treatment effects and placebo effects, and the placebo effects were very large and even reached clinical significance.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT02403037 ; Registered March 31, 2015.

Pharmacists' Role in Managing Patients with Chronic Lymphocytic Leukemia

Chronic lymphocytic leukemia (CLL) is a hematologic malignancy that has seen significant advances in care over the last 5 years with the approval of oral agents such as ibrutinib and venetoclax for the treatment of this disease. As such, there has been a substantial shift away from the traditional chemotherapy infusions which have allowed patients greater autonomy with oral cancer therapies. This paradigm shift poses new challenges for the medical team, including drug-drug interactions, adherence counseling, and financial toxicity. Pharmacists are uniquely trained and equipped to help to manage the changing landscape of CLL care. From identifying common medications which may impair ibrutinib clearance to ensuring patients are on the appropriate anti-infective prophylaxis while receiving obinutuzumab, pharmacists can play a vital role in ensuring the highest quality of patient care. Furthermore, additional credentialing of clinical pharmacists in select states allows for independent visits with the pharmacists, allowing for greater involvement, particularly for initiation of venetoclax and management of ibrutinib-induced toxicities. Pharmacists are essential to both expanding and enhancing the care of patients with CLL and should be leveraged to improve patient outcomes whenever possible.

The effects of body position on chemotherapy-induced nausea and vomiting: a single-blind randomized controlled trial

Background:

Chemotherapy is the cornerstone of cancer treatment; however, alongside therapeutic effects, nausea and vomiting are two common complications of chemotherapy.

Objectives:

The aim of this study was to investigate the effects of body position on chemotherapy-induced nausea and vomiting.

Materials and Methods:

This was a single-blind randomized controlled clinical trial. We recruited a convenience sample of 79 patients and randomly allocated them to either experimental or control groups. Patients in the control group received chemotherapy in supine position while the experimental group received chemotherapy in semi-Fowler’s position. All patients were assessed for the severity, duration, and frequency of nausea and vomiting episodes every three hours up to 24 hours, ie, in nine time-points. Study data was analyzed by SPSS v. 16.

Results:

The severity, duration, and frequency of nausea and the severity and frequency of vomiting episodes in the control group differed significantly across the nine measurement time-points (P < 0.001). In the experimental group, the severity (P = 0.254) and frequency of nausea (P = 0.002) episodes as well as the frequency of vomiting (P = 0.008) episodes differed significantly across the measurement time-points. Moreover, the study groups differed significantly across the measurement time-point in terms of the severity (P < 0.001), duration (P < 0.001), and frequency of nausea (P = 0.002) and the severity (P < 0.001) and frequency (P < 0.001) of vomiting episodes.

Conclusions:

Compared to supine position, semi-Fowler’s position is more effective in relieving chemotherapy-induced nausea and vomiting.

Acceptable but limited efficacy of capecitabine-based doublets in the first-line treatment of metastatic triple-negative breast cancer: a pilot study

BACKGROUND

This open-label, nonrandomized phase II clinical trial investigated the efficacy of capecitabine-based doublets in the first-line treatment of metastatic triple-negative breast cancer (mTNBC).

METHODS

Eligible mTNBC women with measurable diseases were recruited to receive either TX regimen (docetaxel 75 mg/m(2) i.v. on day 1 plus capecitabine 1,000 mg/m(2) b.i.d. on days 1-14 every 3 weeks) or NX regimen (vinorelbine 25 mg/m(2) i.v. on days 1 and 8 plus capecitabine 1,000 mg/m(2) b.i.d. on days 1-14 every 3 weeks) for up to 6 cycles until disease progression or unacceptable toxicity. The primary end point was objective response rate (ORR) and secondary end points included progression-free survival (PFS), overall survival (OS) and clinical benefit rate (CBR).

RESULTS

Forty-five mTNBC patients, 27 in TX and 18 in NX were recruited. The total ORR was 20.0% and CBR was 40%. After a median follow-up of 28 months, PFS was 5.2 months (95% CI, 4.1-6.3 months) and OS was 18.2 months (95% CI, 8.7-27.7 months). The response rate was numerically but not statistically lower in the TX group than in the NX group (27.8 vs. 14.8%, p = 0.449). No difference was found in either PFS (4.9 vs. 5.2 months, p = 0.483) or OS (21.5 vs. 18.3 months, p = 0.964) between the two regimens.

CONCLUSIONS

Although the OS seems to be reasonable, the efficacy of capecitabine-containing TX or NX regimen was limited in terms of response and PFS in mTNBC patients, suggesting capecitabine-based doublet may be acceptable but has limited potency in this subtype.

Impact of 5-HT3 receptor antagonists on chemotherapy-induced nausea and vomiting: a retrospective cohort study

BACKGROUND

1st generation 5-hydroxytryptamine receptor antagonists (5-HT3 RAs), and palonosetron, a 2nd generation 5-HT3 RA, are indicated for the prevention of chemotherapy (CT)-induced nausea and vomiting (CINV) associated with moderately (MEC) and highly emetogenic CT agents (HEC). This study explores the impact of step therapy policies requiring use of an older 5-HT3 RA before palonosetron on risk of CINV associated with hospital or emergency department (ED) admissions.

METHODS

Patients who received cyclophosphamide post breast cancer (BC) surgery or who were diagnosed with lung cancer on carboplatin (LC-carboplatin) or cisplatin (LC-cisplatin) were selected from PharMetrics' (IMS LifeLink) claims dataset (2005-2008). Patients were followed for 6 months from initial CT administration for CINV events identified through ICD-9-CM codes. Patients were grouped into those initiated with older, generic 5-HT3 RAs (ondansetron, granisetron, and dolasetron) and those initiated and maintained on palonosetron throughout study follow-up. CINV events and CINV days were analyzed using multivariate regressions controlling for demographic and clinical variables.

RESULTS

Eligible patients numbered 3,606 in BC, 4,497 in LC-carboplatin and 1,154 in LC-cisplatin cohorts, with 52%, 40%, and 34% in the palonosetron group, respectively. There was no significant difference between the two 5-HT3 RA groups in age or Charlson Comorbidity Index among the two MEC cohorts (BC and LC-carboplatin). Among the LC-cisplatin cohort, palonosetron users were older with more males than the older 5-HT3 RA group (age: 60.1 vs. 61.3; males, 66.9% vs. 56.9%). Compared to the older 5-HT3 RAs, the palonosetron groups incurred 22%-51% fewer 5-HT3 RA pharmacy claims, had fewer patients with CINV events (3.5% vs. 5.5% in BC, 9.5% vs. 12.8% in LC-carboplatin, 16.4% vs. 21.7% in LC-cisplatin), and had lower risk for CINV events (odds ratios 0.62, 0.71, or 0.71, respectively; p<0.05). The BC and LC-carboplatin palonosetron groups experienced 50% and 30% fewer CINV days than the generic 5-HT3 RA group (p<0.05).

CONCLUSIONS

Patients with breast or lung cancer initiated and maintained on palonosetron were at significantly lower risk for potentially costly CINV versus those on older 5-HT3 RAs. Further studies on impact of step therapy policy are warranted in order to minimize the clinical and economic burden of CINV.

Reappraisal of the role of dolasetron in prevention and treatment of nausea and vomiting associated with surgery or chemotherapy

Chemotherapy-induced nausea and vomiting and postoperative nausea and vomiting are one of the most frequent but also very concerning consequences for patients undergoing chemotherapy or surgical procedures under general anesthesia. There are a variety of mechanisms involved in the activation of nausea and vomiting. Serotonin, a ubiquitous central and peripheral neurotransmitter, is thought to be the predominant mediator of the perception of nausea and triggering of the vomiting response in both the brain and the periphery via the 5-hydroxytryptamine type 3 (5-HT₃) receptor pathways. 5-HT₃ receptor antagonists disrupt this pathway, largely at the level of the vagal afferent pathways, to decrease nausea and vomiting. This review will focus on dolasetron, an older but sill commonly used 5-HT₃ receptor antagonist and its multimodal mechanism of action, safety and tolerability, patient considerations, and a review of the current literature on its use to combat both chemotherapy-induced and postoperative nausea and vomiting in these two important patient populations.

Association of ABCB1, 5-HT3B receptor and CYP2D6 genetic polymorphisms with ondansetron and metoclopramide antiemetic response in Indonesian cancer patients treated with highly emetogenic chemotherapy

OBJECTIVE

Suboptimal treatment of chemotherapy-induced nausea and vomiting and unsatisfactory response to antiemetic drugs cause impairment of cancer patient's daily functioning. This study was aimed to investigate the association of selected germline polymorphisms with ondansetron and metoclopramide response in Indonesian cancer patients treated with highly emetogenic chemotherapy.

METHODS

We enrolled 202 chemotherapy naïve patients treated with cisplatin at a dosage of ≥50 mg/m(2) as monotherapy or as combined chemotherapy. Ondansetron 8 mg and dexamethasone 8 mg intravenously were the standard antiemetic therapy for prevention of acute chemotherapy-induced nausea and vomiting. Metoclopramide 10 mg orally, three times per day as fixed prescription, was given until 5 days after chemotherapy to prevent delayed chemotherapy-induced nausea and vomiting. Primary and secondary outcomes were the occurrence of chemotherapy-induced nausea and vomiting in the acute and delayed phase. The following single-nucleotide polymorphisms were determined in ABCB1: rs1045642, rs2032582 and rs1128503; in 5-HT3B-R: rs45460698, rs4938058 and rs7943062; and in CYP2D6: rs16947 (CYP2D6 2), rs3892097 (CYP2D6 4) and rs1065852 (CYP2D6 10) using Taqman assays.

RESULTS

During the acute phase, 21.8 and 30.2% patients experienced Grade 3 and 4 nausea and vomiting, respectively, whereas 38.6% patients experienced nausea and/or vomiting in the delayed phase. Carriers of the CTG haplotype of the ABCB1 gene experienced Grade 3 and 4 chemotherapy-induced nausea and vomiting more often than other haplotypes in the delayed phase (P< 0.05). No associations were found with the 5-HT3B receptor haplotypes and CYP2D6-predicted phenotypes.

CONCLUSIONS

Our study shows that in Indonesian cancer patients treated with highly cytostatic emetogenic, carriership of the CTG haplotype of the ABCB1 gene is related to an increased risk of delayed chemotherapy-induced nausea and vomiting.

Reducing excessive toxicity in ovarian cancer treatment: a personalized approach

The management of ovarian cancer is not only multifactorial, but also patient-specific. Different treatment modalities lead to varying levels of toxicity and individual patient responses, necessitating a personalized approach to each treatment plan. Surgical treatment along with first-line and salvage chemotherapies, are standard modalities but recent innovations in chemotherapy delivery and innovative therapy with mechanism of action are reviewed in this article. Extensive experience with standard chemotherapy has outlined algorithms for managing various toxicities. The focus of treatment may ultimately point towards palliative care and clinicians must be comfortable and well versed in addressing this important option. Overall, management of ovarian cancer requires a multi-faceted approach, keeping the patients’ overall health, curative goals and well-being at the forefront. It is nearly impossible to detail exact management plans for every possible toxicity for every patient; formulating personalized treatment plans should be based on evidence and clinician experience, all part of the art of medicine. The objective of this article is to highlight the most frequently encountered and most limiting toxicities of current standard therapies for epithelial ovarian cancer.

Comparative clinical effectiveness of various 5-HT3 RA antiemetic regimens on chemotherapy-induced nausea and vomiting associated with hospital and emergency department visits in real world practice

PURPOSE

The aim of this study was to compare the risk of chemotherapy-induced nausea and vomiting (CINV) events for various 5-HT(3) RAs in patients who received moderately (MEC) or highly emetogenic chemotherapy (HEC) by evaluating hospital or emergency department (ED) admissions.

METHODS

PharMetrics claims database was used to identify patients diagnosed with breast cancer (BC) who were initiated on cyclophosphamide-based adjuvant chemotherapy or with lung cancer (LC) initiated on carboplatin-based or cisplatin-based chemotherapy between 2005 and 2008. Patients were stratified in two groups: those initiated and maintained on palonosetron versus those treated with any other 5-HT(3) RA regimens in the 6-month post first chemotherapy. Risk for CINV events, identified by ICD-9-CM for nausea, vomiting, and/or dehydration, were estimated using logistic regressions, controlling for age, gender, comorbidity, and total chemotherapy doses or days.

RESULTS

Of the 4,868 cyclophosphamide-treated BC, 5,414 carboplatin-treated LC, and 1,692 cisplatin-treated LC identified, there were 1,864 BC (38.5%), 1,806 carboplatin-treated LC (33.4%), and 390 cisplatin-treated LC (23.0%) in the palonosetron-only group. Palonosetron-only group had significantly lower probability of CINV events associated with ED/hospital admissions in all three cohorts (3.5% vs. 6.3% in BC, 9.5% vs. 13.8% in carboplatin-treated LC, and 16.4% vs. 22.6% in cisplatin-treated LC, all at p < 0.05). Logistic regressions found palonosetron-only group had significantly lower risk of CINV events (odds ratios = 0.550, 0.653, and 0.689 in BC, carboplatin-treated LC and cisplatin-treated LC, respectively, p < 0.05).

CONCLUSION

Patients with lung or breast cancer receiving MEC or HEC had significantly lower risk of CINV events associated with hospital/ED admissions if initiated and maintained on palonosetron relative to patients receiving 5-HT(3) RA regimens.

Tools for assessing nausea, vomiting, and retching

BACKGROUND

Chemotherapy-induced nausea, vomiting, and retching are recognized as having an impact on patients' overall physical well-being, quality of life, and treatment decisions. Although there are many tools available to measure aspects of these symptoms, few offer a complete and concise clinical assessment.

OBJECTIVE

The purpose of this article was to provide a comprehensive overview of the various instruments available for the assessment of cancer-related nausea, vomiting, and retching. Analysis included symptoms measured, period evaluated, type of questions posed, and aspects of each symptom measured.

METHODS

Searches were conducted to find relevant articles using nationally recognized oncology Web sites and 4 electronic databases including PubMed, MEDLINE/CINAHL and CINAHL/EBSCO, and Cochrane.

RESULTS

This review includes a total of 25 instruments that were identified as meeting the inclusion criteria of having been developed, or adapted, for the adult population, with an oncology focus.

CONCLUSION

The ideal instrument would include measurement of all 3 symptoms while remaining clear, concise, and clinically relevant.

IMPLICATIONS FOR PRACTICE

Although only 1 instrument came close to meeting these criteria, this review provides nurses with specific information on a variety of instruments to assist providers in selecting the most appropriate instrument for their specific clinical setting. This comprehensive critique of instruments is important for nurses attempting to select a tool to guide optimum care for patients in the clinical setting.

A review of granisetron, 5-hydroxytryptamine3 receptor antagonists, and other antiemetics

Nausea and vomiting are 2 of the most upsetting adverse reactions of chemotherapy. Current guidelines propose 5-hydroxytryptamine3 (5-HT3) receptor antagonists as a pharmacologic intervention for acute and delayed nausea and vomiting [chemotherapy-induced nausea and vomiting (CINV)] associated with moderately and highly emetogenic chemotherapy. Meanwhile, both postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting are challenging situations after surgeries and procedures. Prophylactic and therapeutic combinations of antiemetics are recommended in patients at high risk of suffering from PONV and postdischarge nausea and vomiting. Granisetron (Kytril) is a selective 5-HT3 receptor antagonist that does not induce or inhibit the hepatic cytochrome P-450 system in vitro. There are also 4 other antagonists of 5-HT3 receptor (dolasetron, ondansetron, palonosetron, and tropisetron) being metabolized via the CYP2D6 and are subject to potential genetic polymorphism. The launch of a new class of antiemetics, the substance P/neurokinin1 receptor antagonists, was attributed to the scientific update on the central generator responsible for emesis and role of substance P. There has been mounting interest in exploring integrative medicine, either acupuncture or acustimulation of P6 (Nei-Kuwan), to complement the western medicine for prevention and management of nausea and vomiting. The potential application of cannabinoids, either alone or in combination with other agents of different mechanism, could contribute further to improve outcome in CINV. Implementation of future treatment guidelines for more effective management of CINV and PONV could certainly improve the efficacy and outcome of cancer and postoperative care.

FabAct®: a decision-making tool for the anticipation of the preparation of anticancer drugs

RATIONALE

Due to the increase of new cancer cases, our chemotherapy compounding unit must face with ever-growing production needs. To support this increasing workload, we decided to anticipate the preparation of several anti-cancer drugs.

AIMS AND OBJECTIVES

To help us in the decision making, we needed a modern tool able to combine several criteria for selecting appropriate medications for an anticipated preparation. The aim of this study was to assess the decision-making software, FabAct(®) (Version 1.0).

METHODS

FabAct(®) ranked all of the anti-cancer drugs used in our chemotherapy compounding unit according to price, chemical stability, compounding difficulties, dosage and production per year. Then, we started to anticipate currently the preparation of four medications and conducted a follow-up of destroyed preparations between January and May 2007. We tried to identify the destruction causes and calculated the time saved for the patients and for the pharmacy technicians.

RESULTS

According to the decision-making software, the first four drugs for an anticipated preparation were: fluorouracil, cisplatin, carboplatin and paclitaxel. A total of 3913 (50.2%) anticipated preparations were performed and among those, 470 (12%) were destroyed. The main cause of destruction was due to the preparation expiration. Finally, the mean waiting time per patient was reduced from 118 minutes to 68 minutes after the application of the anticipated model.

CONCLUSION

According to this 5-month follow-up, FabAct(®) helped us to select appropriate anti-cancer drugs to anticipate the compounding. Most of the anticipated preparations were administrated to patients and the patient waiting time was significantly reduced.