Lorazepam in cancer patients treated with cisplatin: a drug having antiemetic, amnesic, and anxiolytic effects

Antiemetic Activity of Oral Lorazepam in Addition to Methylprednisolone and Metoclopramide in the Prophylactic Treatment of Vomiting Induced by Cisplatin. A Double-Blind, Placebo-Controlled Study with Crossover Design

Aims and Backgorund

It has been suggested that lorazepam has a definite role as an antiemetic drug in antiemetic cocktails. In this study we examined the antiemetic efficacy of metoclopramide (200 mg) and methylprednisolone (1000 mg) with or without lorazepam.

Methods

Sixty patients treated with cisplatin-containing regimens were entered into a randomized, double-blind study with cross-over. Lorazepam 2.5 mg or placebo were administered orally the evening before therapy and just after the beginning of fluid infusion for chemotherapy. Degree of nausea and number of vomiting episodes, together with somnolence, were recorded on a data flow sheet and visual-analogue scales.

Results

100 cycles (50 patients) are evaluable. In 39 cycles there was no nausea and vomiting, in 74 cycles acceptable control of emesis was reached (0-2 episodes of vomiting), without significant differences among the two arms. However, nausea was shorter in lorazepam arm (p < 0.01), and 80 % of the patients preferred treatment with lorazepam (p < 0.003). Anxiety was reduced in the patients treated with lorazepam (p < 0.4).

Conclusions

Lorazepam improves tolerability to cisplatin-containing chemotherapy, mainly by influencing the psychological status of the patient and favoring the amnestic process.

Prophylactic antiemetic effect of midazolam after middle ear surgery

Objective

To investigate the prophylactic antiemetic effect of midazolam after middle ear surgery.

Study Design

A prospective, randomized, double-blind, placebo-controlled study.

Subjects and Methods

Ninety women patients undergoing middle ear surgery with general anesthesia received intravenously either midazolam 0.075 mg/kg or normal saline (n = 45 each) after induction of anesthesia. The incidence and severity of postoperative nausea and vomiting, rescue antiemetics, pain intensity, and side effects such as headache, dizziness, and drowsiness were assessed during the first 24 hours after anesthesia.

Results

Midazolam groups showed total incidence and severity of nausea and vomiting. Patients who required rescue antiemetics were significantly lower than in saline group ( P < 0.05), but there were no significant differences in pain intensity and side effects such as headache, dizziness, and drowsiness between groups.

Conclusions

Midazolam 0.075 mg/kg is effective for reducing nausea and vomiting after middle ear surgery.

Cannabinoid hyperemesis syndrome

BACKGROUND

The purpose of this review is to describe cannabinoid hyperemesis syndrome (CHS), which is thought to be induced by long-term cannabis use, and provide clinical pharmacists with information to manage the hyperemetic phase of CHS.

METHOD

Published literature was searched and reviewed using PubMed.

RESULTS

CHS is characterized by intractable nausea and vomiting without an obvious organic cause and associated learned compulsive hot water bathing behavior. Patients often seek care in the emergency department (ED) for symptomatic relief.

CONCLUSION

CHS is potentially underrecognized and underdiagnosed in the ED, and it should be considered in the differential diagnosis in long-term cannabis use patients with CHS symptoms to avoid unnecessary extensive diagnostic workup including invasive radiologic imaging. Pharmacists have an important role in CHS recognition, education, and symptom management.

Effect of Sedation with Midazolam or Propofol on Patient's Comfort During Cancer Chemotherapy Infusion: A Prospective, Randomized, Double-Blind Study in Breast Cancer Patients

Nausea, vomiting and anxiety related to administration of cancer chemotherapy remain significant problems. This randomized, clinical trial was undertaken to evaluate the effect of sedation on the patient's comfort during chemotherapy infusion in patients with breast cancer. Forty-five breast cancer patients were randomized into three groups: Group I--chemotherapy, control, Group II--midazolam+chemotherapy, and Group III--propofol+chemotherapy. Nausea occured in 87% and vomiting in 13% of the patients in the control group, while none of the sedated subjects had these side-effects, although 76% of them had experienced then during previous cycles of chemotherapy. Compared with the control group, post-chemotherapy anxiety scores also improved with the addition of midazolam or propofol. Eighty percent of the subjects declared that they would prefer the sedative-containing regimen for their further cycles. Sedation with midazolam or propofol may improve the patient's comfort, and provide better control of chemotherapy-related side effects during chemotherapy infusion in breast cancer patients.

Treatment of chemotherapy-induced nausea and vomiting

BACKGROUND

Recent improvements in medical oncology include both development of anticancer and supportive therapy. Serotonin receptor antagonists were introduced in clinical practice 20 years ago. Since then, the prevention and treatment of chemotherapy-induced nausea and vomiting allows continuing efficacious chemotherapy that earlier had to be stopped sometimes for intolerance.

AIM

This anniversary review summarises the current antiemetic arsenal focussing on the most potent antiemetic drugs such as serotonin and substance P receptor antagonists.

RESULT

Antiemetic treatment improves quality of life under chemotherapy and contributes to the survival benefit as well. In spite of the use of these new drugs, a significant number of patients still experience nausea and vomiting. Special complications like delayed emesis can be alleviated by combination therapies.

CONCLUSION

Prevention and optimal management of chemotherapy-induced nausea and vomiting should be a goal for most patients receiving emetogenic chemotherapy.

Cannabinoid hyperemesis syndrome: case report of a paradoxical reaction with heavy marijuana use

Cannabinoid hyperemesis syndrome (CHS) is a rare constellation of clinical findings that includes a history of chronic heavy marijuana use, severe abdominal pain, unrelenting nausea, and intractable vomiting. A striking component of this history includes the use of hot showers or long baths that help to alleviate these symptoms. This is an underrecognized syndrome that can lead to expensive and unrevealing workups and can leave patients self-medicating their nausea and vomiting with the very substance that is causing their symptoms. Long-term treatment of CHS is abstinence from marijuana use-but the acute symptomatic treatment of CHS has been a struggle for many clinicians. Many standard medications used for the symptomatic treatment of CHS (including ondansetron, promethazine, and morphine) have repeatedly been shown to be ineffective. Here we present the use of lorazepam as an agent that successfully and safely treats the tenacious symptoms of CHS. Additionally, we build upon existing hypotheses for the pathogenesis of CHS to try to explain why a substance that has been used for thousands of years is only now beginning to cause this paradoxical hyperemesis syndrome.

Clonazepam use for prevention of acute and delayed vomiting induced by Cisplatin-based chemotherapy for lung cancer

We investigated the efficacy of clonazepam as an antiemetic in cisplatin-based chemotherapy for lung cancer. Seven patients experienced cisplatin-induced vomiting despite antiemetic therapy including 5-hydroxytryptamine(3) (5-HT(3)) antagonist and dexamethasone. Therefore, the antiemetic therapy including clonazepam, 5-HT(3) antagonist and dexamethasone was subsequently explored in the next course for the same seven patients. We administered clonazepam (0.5 or 1.0 mg/kg) once a day orally for 5 d from day one prior to chemotherapy. The grade of delayed vomiting, evaluated according to Common Terminology Criteria for Adverse Events Version 3.0, in the courses of therapy with clonazepam was significantly lower than without clonazepam (p=0.013). The patients whose serum clonazepam concentrations were below the lower limit of detection (3.0 ng/ml) experienced vomiting in three of three courses, whereas the patients whose serum clonazepam concentrations were higher than 4.3 ng/ml experienced no vomiting in six of seven courses. We observed that the symptom of cisplatin-induced delayed vomiting is controlled with serum clonazepam levels in the order of 10.0 ng/ml.

Use of antipsychotic medication in chemotherapy-induced nausea and vomiting

Nausea and vomiting continue to present significant problems for cancer patients undergoing chemotherapy. Initial work suggested an important role for central dopamine transmission in the underlying pathophysiology. However, recent evidence has implicated central and peripheral serotonin release. Although the implementation of 5-HT(3) receptor antagonists has resulted in significant improvement in acute symptoms of nausea and vomiting, they have not demonstrated optimal efficacy in anticipatory and delayed emetic syndromes and are significantly more expensive than other antiemetic therapies. The use of typical antipsychotic medication to reduce nausea and vomiting in cancer patients is discussed, as is the potential efficacy of newer atypical antipsychotics, which have activity at receptors implicated in the control of chemotherapy-induced nausea and vomiting and demonstrate an improved side-effect profile.

Treatment of nausea and vomiting in terminally ill cancer patients

Nausea and vomiting is a common and distressing symptom complex in patients with far-advanced cancer, affecting up to 60% of individuals at some stage of their illness. The current approach to the palliative care of patients with nausea and vomiting is based on identifying the cause, understanding its pathophysiology and knowing the pharmacology of the drugs available for its amelioration. The following six main syndromes are identified: gastric stasis, biochemical, raised intracranial pressure, vestibular, mechanical bowel obstruction and ileus. A careful history, focused physical examination and appropriate investigations are needed to elucidate the syndrome and its cause, so that therapy is rational. Drugs are the mainstay of treatment in terminal cancer, and the main classes of antiemetic agents are prokinetics, dopamine antagonists, antihistamines, anticholinergics and serotonin antagonists. Dexamethasone and octreotide are also used, especially in bowel obstruction. Non-drug measures are important in relieving the associated distress. Patients should be able to die comfortably, without tubes. Despite decades of practice affirming this approach, the evidence base is weak and well designed studies are urgently needed.

[Prophylaxis of chemotherapy-induced vomiting and nausea]

Chemotherapy-induced vomiting and nausea is the most common adverse event of anticancer therapy. In different guide-lines (MASCC, NCCN, ESMO and ASCO) antiemetic prophylaxis is directed toward the emetogenic potential of the chemotherapy and the type of vomiting and nausea. Chemotherapeutic agents are classified into four emetic risk groups: high, moderate, low, and minimal. Steroids, dexamethasone, metoclopramide, cannabinoids, benzodiazepines, 5-HT3 receptor antagonists (ondansetron, granisetron, tropisetron) and a new group of antiemetics, the neurokinin1 receptor antagonists are used to prevent anticipatory, acute and delayed vomiting and nausea. This paper examines evidence-based recommendations for optimal use of antiemetics.

The antiemetic interaction of Delta9-tetrahydrocannabinol when combined with tropisetron or dexamethasone in the least shrew

5-HT3 receptor antagonists (e.g. tropisetron) combined with dexamethasone are effective for the acute phase of cisplatin (CIS)-induced emesis. This study determined the possible additive or synergistic antiemetic efficacy of Delta9-THC when combined with tropisetron or dexamethasone (DEX). Delta9-THC (0-10 mg/kg i.p.) was injected in combination with tropisetron (0-5 mg/kg i.p.) or dexamethasone (0-20 mg/kg i.p.) prior to CIS (20 mg/kg i.p.) in the least shrew, and the induced emesis was recorded for 60 min. CIS-induced vomiting was dose-dependently and significantly attenuated by individual administration of Delta9-THC (59-97% reductions) and tropisetron (79-100% attenuation), but not dexamethasone (26-40%), although a trend (p<0.1) towards reduced vomiting frequency following DEX was noted. Low doses of Delta9-THC (0.25 or 0.5 mg/kg) when combined with low doses of tropisetron (0.025, 0.1, or 0.25 mg/kg) were more efficacious in reducing emesis frequency than when given individually, but Delta9-THC had no antiemetic interactions with DEX. However, no tested combination provided a significantly greater effect on the number of animals vomiting than their individually-administered counterparts. The modest interaction of Delta9-THC with tropisetron suggests they activate overlapping antiemetic mechanisms, while the lack of interaction with dexamethasone needs further clarification.

Midazolam for acute emesis refractory to dexamethasone and granisetron after highly emetogenic chemotherapy: a phase II study

GOALS OF THE WORK

To assess whether the addition of midazolam to dexamethasone and granisetron could ameliorate the refractory acute nausea and/or vomiting caused by a highly emetogenic platinum-based chemotherapy.

PATIENTS AND METHODS

Enrolled in the study were 30 consecutive adult patients with refractory acute emesis. Nausea and vomiting were assessed by physicians and graded according to the NCI common toxicity criteria. Nausea was further self-assessed by patients using a visual analogue scale. Statistical analysis was performed by nonparametric tests.

RESULTS

With the introduction of midazolam, 73% of patients had a reduction of at least one grade in nausea and vomiting intensity in comparison with the previous cycle of chemotherapy. From the second cycle, six patients (23%) had complete control of acute vomiting, a benefit that usually persisted in the subsequent cycles. Five more patients achieved complete control of acute vomiting during the third course; this effect persisted in the subsequent courses as well. The average relative reduction in acute nausea and vomiting grade from the first to the second course was 48% (95% CI 34-62%) and 48% (95% CI 31-65%), respectively. A significant difference in acute nausea and vomiting over all the six courses of chemotherapy administered was recorded (Friedman ANOVA, P <0.0001). Comparing each course with any subsequent course, a significant reduction in acute nausea and vomiting was observed between the first and second course, the first and third course, and the first and fourth course.

CONCLUSIONS

Our results suggest that midazolam may be a useful adjunct to standard antiemetic drugs for patients receiving highly emetogenic cisplatin-based chemotherapy. A randomized trial is warranted to confirm these results.

Treatment of nausea and emesis during cancer chemotherapy. Discrepancies between antiemetic effect and well-being

The purpose of this study was to describe the relationship between antiemetic effect and well-being in patients receiving four different antiemetic treatment strategies, representing developments in the field during the past 15 years. A total of 162 women with ovarian cancer receiving cisplatin-based chemotherapy and participating in two comparative antiemetic trials were enrolled and studied for up to four cycles. In study I, a combined antiemetic strategy including a nursing intervention program (increased access to support and increased information) and antiemetics based on high-dose metoclopramide and dexamethasone was compared with the standard antiemetic treatment during the 1980s. In study II, ondansetron plus dexamethasone/placebo was evaluated. The assessment methods used were similar for all patients. Questionnaires were used to assess frequency, intensity, and duration of nausea, emesis, anxiety, pain, and well-being at baseline, and for acute (24 hours after chemotherapy) and delayed (up to 2 weeks after chemotherapy) symptoms. The mean intensity of acute nausea during the first cycle was higher in the groups in study I, as compared to the groups in study II. The group receiving a nursing intervention reported better well-being than the other groups. Duration of nausea was an important predictor of well-being, even when nausea intensity was controlled. Apart from nausea intensity, nausea duration and nursing interventions may be important determinants for well-being during chemotherapy.

Clinical evaluation of Ramosetron injections in the treatment of cisplatin-induced nausea and vomiting

A phase III, double-blind, placebo-controlled study was performed to examine the safety and efficacy of ramosetron in cancer patients with cisplatin-induced nausea/vomiting. Patients were divided into two groups: group R received 0.3 mg ramosetron intravenously and group P received placebo. Eighty-eight patients were enrolled, 44 in each group; 84 (43 in group R, 41 in group P) were included in the clinical efficacy analysis and 86 (44 in group R, 42 in group P) in the safety analysis. Ramosetron was significantly more clinically effective than placebo against nausea, vomiting and anorexia; 65.1% of patients in group R experienced no vomiting in the first 6 h of observation compared with 7.3% of those receiving placebo. No serious adverse reactions or significant differences in safety were observed between the groups. Based on these results, ramosetron injection is effective in the treatment of cisplatin-induced nausea/vomiting and its clinical usefulness is demonstrated here.

Prevention and Management of Chemotherapy-Induced Nausea and Vomiting, Part 2

Credit

This lesson is good for 0.3 CE units, with a passing grade of 70%.

Goal

The goal of this program is to inform the participant about cost-effective ways to prevent, identify, and manage nausea and vomiting induced by antineoplastic agents.

Objectives

At the completion of this program the participant will be able to: 1. List antineoplastic agents associated with a high incidence of nausea and vomiting. 2. Identify patient-specific risk factors for developing chemotherapy-induced nausea and vomiting (CINV) and how these factors may influence treatment of this syndrome. 3. Compare the three major types of CINV, including the pathophysiologic mechanism, time of onset, and symptom duration of each type. 4. Explain the mechanism of action and appropriate place in therapy for each type of antiemetic agent. 5. Differentiate between pharmacologic regimens for the prevention and treatment of CINV in adults. 6. Identify drug-specific factors that must be considered when developing a formulary management strategy for the antiemetic agents. 7. Describe specific information that the pharmacist can share with patients to help them understand and manage CINV.

Granisetron plus or minus alprazolam for emesis prevention in chemotherapy of lymphomas: a randomized multicenter trial. Granisetron Trialists Group

Anxiety can increase the risk of chemotherapy related emesis. We have studied the role of a benzodiazepine (alprazolam: A) in addition to granisetron for controlling emesis in patients treated with moderately emetogenic chemotherapy for malignant lymphomas according to an anxiety scale (Covi score). Two hundred twenty-five patients receiving at least 3 cycles of chemotherapy including adriamycin and/or cyclophosphamide and/or epirubicin and/or dacarbazine were randomized. Patients in arm G (n = 111) received 3 mg i.v. granisetron 10 min before chemotherapy at cycles (C) 1, 2 and 3 while in arm G+A (n = 114), alprazolam (A) was added per os 1 mg 1 hour before chemotherapy (H-1) and 0.5 mg at H+6 for C1. At C2 and C3, A was given 0.75 or 1.5 mg at H-48, H-24, H-1 and 0.5 mg at H+6. Patients characteristics were comparable between the 2 arms. Complete response rates (i.e. no emesis or at least slight nausea) were similar in both arms: G: 83, 94 and 93% versus G+A: 89, 93 and 97% in C1, C2 and C3 respectively. Nevertheless, the Covi score of the population was low rendering difficult the study of the factor "anxiety". Somnolence was significantly more frequent in the G+A arm (p < 0.0001).

Do oncologists have an increasing interest in the quality of life of their patients? A literature review of the last 15 years

The aim of this review is to evaluate the extent to which Quality of Life (QoL) assessment has been incorporated into clinical oncological trials in the last 15 years. All phase II and III trials published in the Journal of Clinical Oncology, Cancer, The British Journal of Cancer and the European Journal of Cancer during the years 1980, 1985, 1990 and 1995 were reviewed (n = 827). During this period, while the number of studies assessing performance status (PS) increased from 15% in 1980 to 56% in 1995, the number of trials noting a QoL assessment increased only slightly, from 0% in 1980 to 3% in 1995. Moreover, only four of the 13 studies with a QoL evaluation met our criteria for adequate QoL assessment. Thus, despite an increasing interest in QoL, it is still rarely included as an objective in clinical trials, or adequately assessed.

Cancer-related issues for women

Tobacco and diet account for almost two-thirds of all cancer-related deaths and are among the most correctable risk factors. Up to 35% of cancer-related deaths could be avoided if appropriate screening measures were used. Research on the use of vaccines to treat or prevent cancer has intensified. Pharmacists can play a major role in women's health by acting as patient advocates, serving as referral sources, and recommending supportive care.

Nausea and vomiting in patients with cancer

Nausea and vomiting in advanced cancer, occurring as a manifestation of the disease process or as a complication of drugs used for symptom control, can be controlled rapidly in most instances using the protocol described. This involves an informed appraisal of the cause or causes of nausea and vomiting, combined with application of knowledge of the mechanisms of emesis and the action of antiemetics. Different mechanisms appear to responsible for emesis after chemotherapy and irradiation and for anticipatory vomiting. Ondansetron combined with dexamethasone appears to be the most effective regimen for post-cisplatin emesis. For less emetogenic agents, dexamethasone alone, or in combination with ondansetron for refractory cases, gives good control. For the control of vomiting induced by single-fraction radiotherapy to the upper abdomen, ondansetron is very effective. Management of anticipatory vomiting should concentrate on prevention, but once vomiting is established, behavioral therapy and the amnesic properties of lorazepam may be used.

Nausea, vomiting, and retching: the management of the symptom experience

OBJECTIVES

To examine the physiology of nausea, vomiting, and retching (NVR); the impact of NVR on the patient: current measures to control NVR; and selfcare interventions.

DATA SOURCES

Research studies, abstracts, and review articles relating to NVR associated with cancer treatment as well as pharmacological and nonpharmacological interventions.

CONCLUSIONS

Management of the individual symptoms of NVR require expert, ongoing assessment of the patient's symptom experience that extends beyond the clinic or hospital visit. Although a number of pharmacological antiemetic agents are currently available and additional antiemetic drugs are in phase II or II trials, nonpharmacological interventions are essential to achieve effective management.

IMPLICATIONS FOR NURSING PRACTICE

Continual assessment of the individual's symptom experience is imperative. Effective management of the symptom experience depends on the oncology nurses's ability to implement current knowledge of antiemetic, and other drugs; non-pharmacological interventions; and cost-effective and clinically useful patient outcomes.

Progress in reducing nausea and emesis. Comparisons of ondansetron (Zofran), granisetron (Kytril), and tropisetron (Navoban)

BACKGROUND

Nausea and vomiting are the most distressing side effects associated with the administration of chemotherapy for neoplastic diseases. Nausea, in particular, often had been ignored in studies of chemotherapy side effects. Recently, progress has been made in the control of chemotherapy-induced nausea and vomiting, due, in part, to a better understanding of the physiologic mechanisms involved.

METHODS

This paper reviews recent advances in the control of emesis, focusing on pharmacologic treatments.

RESULTS

The efficacy and safety of the serotonin (5-HT3) receptor antagonists granisetron, ondansetron, and tropisetron in the control of acute and delayed emesis and emesis induced by repeat-cycle chemotherapy are summarized. Although differences in study design and definitions of response criteria have made it difficult to compare the studies that have evaluated these three agents, the overall body of literature supports several clinical findings.

CONCLUSIONS

(1) The 5HT3 antiemetic agents have been shown to be clinically more effective in the control of nausea and emesis than previously used agents. (2) No one of the three has demonstrated consistently greater efficacy. (3) Efficacy appears to be more pronounced for cisplatin-containing regimens than for moderate or less emetogenic chemotherapy regimens. (4) Effectiveness of the 5HT3 agents appears to be less for delayed nausea and emesis than for acute symptoms. Potential control of anticipatory nausea and emesis has not been investigated. (5) Control over nausea appears to be significantly less than control over emesis. In the studies in which it has been measured, nausea control remains incomplete for approximately half the patients given 5HT3 agents. (6) The efficacy of the agents appears to diminish across repeated days and, perhaps, across repeated chemotherapy cycles. (7) The addition of a steroid such as dexamethasone increases the efficacy of both 5HT3 and other antiemetic agents. This effect also seems to apply to delayed nausea and emesis.

Enhancing the effectiveness of the specific serotonin antagonists. Combination antiemetic therapy with dexamethasone

Combinations of drugs have become standard therapy for the prevention of vomiting caused by anticancer drugs like cisplatin. Recently, a new class of antiemetic agents, the potent and specific 5-HT3 receptor antagonists such as ondansetron, granisetron, and tropisetron, have been shown to be more effective and better tolerated than metoclopramide. This report describes the rationale for combination antiemetic therapy, details the testing of metoclopramide-based regimens as a model for combination therapy development, reviews completed trials of ondansetron plus dexamethasone, and offers strategies to further alleviate vomiting during anticancer chemotherapy. The reported trials testing metoclopramide-based combinations were reviewed and that experience was applied to the ongoing studies of ondansetron when used with dexamethasone and other agents. Combinations of metoclopramide, dexamethasone, and lorazepam prevented acute emesis caused by high-dose cisplatin in 63% of patients, lessened side effects, and were convenient enough to administer to outpatients. Completed trials of ondansetron and dexamethasone demonstrated improved vomiting control over ondansetron alone while using less cumbersome schedules. Attempts to improve ondansetron-based antiemetic regimens by developing optimal drug doses and schedules and adding adjuvant and different classes of antiemetic agents are now in clinical testing. Based on previous experience and current results, combinations of a specific serotonin agonist and dexamethasone are the best treatment for prevention of vomiting induced by chemotherapy. Future clinical research should aim to refine antiemetic regimens and improve emetic control through the use of new antiemetic and adjuvant agents.

Midazolam in patients receiving anticancer chemotherapy and antiemetics

Benzodiazepines lessen anxiety and improve comfort in cancer patients. Midazolam is an effective benzodiazepine with a rapid onset and short duration of action, properties that could permit its use in outpatient areas or in short but stressful situations. Two consecutive trials were undertaken to study midazolam as an adjunct in patients receiving anticancer chemotherapy. Each studied midazolam given as a short infusion 30 min prior to chemotherapy at dose levels ranging from 0.01 to 0.05 mg/kg. Trial I determined the safety, sedation, and dose of midazolam in patients receiving chemotherapy of low to moderate emetic potential. Twenty-two patients were entered. No significant respiratory depression or oxygen desaturation was observed. At the optimal dose level (0.04 mg/kg), sedation began a median of 3 min following administration and continued for a median of 38 min. Sixty-four percent of patients experienced mild sedation. Trial II studied the same doses of midazolam when used in combination with intravenous metoclopramide and dexamethasone in patients receiving cisplatin > or = 100 mg/m2. Nineteen patients were entered; 79% experienced mild sedation. At the 0.04-mg/kg dose level, sedation began a median of 18 min following administration and continued for a median of 170 min. Midazolam can be given safely to patients receiving chemotherapy with and without concomitant antiemetics. The predictability and duration of its sedative effects suggest it can be used in outpatients.

The cancer patient with pain: psychiatric complications and their management

The most common psychiatric complications in the cancer population are depression, anxiety, and delirium. All are more likely to occur in the cancer patient who has pain. This review outlines the normal responses to cancer and the psychiatric disorders frequently encountered in clinical practice. The influence of pain on the incidence and presentation of these disorders is described. Multimodal treatment, which includes pharmacologic, psychotherapeutic, and behavioral interventions, is outlined.

Five-drug antiemetic combination for cisplatin chemotherapy

A combination of metoclopramide, dexamethasone, droperidol, lorazepam, and diphenhydramine was used in prophylaxis of high-dose (greater than or equal to 100 mg/m2) or moderate dose (greater than or equal to 50 mg/m2) cisplatin. Sixty minutes prior to starting cisplatin, 16 mg dexamethasone, 50 mg diphenhydramine, and 0.5 mg lorazepam were given orally (PO). Droperidol 1 mg was given intramuscularly (IM) 15 minutes prior to beginning cisplatin. Repetitive doses of intravenous (IV) metoclopramide, 2 mg/kg in 75 ml 5% dextrose in water over 15 minutes was given 30 minutes prior to, and at 1 1/2, 4 1/2, and 7 1/2 hours after beginning cisplatin chemotherapy. Only patients with nausea and/or vomiting received subsequent doses of 2 mg/kg metoclopramide IV every 3 hours as needed. Patients refractory to metoclopramide were given 1 mg droperidol IM and 50 mg of diphenhydramine PO every 6 hours. There were 19 men and 9 women with a median age of 58 (range 31-75) years. Complete protection from nausea and vomiting in all courses of treatment occurred in 17 (61%) patients. In 63% and 70% of the 57 evaluable courses, there was neither nausea nor vomiting, during the first 24 hours after cisplatin. When present, nausea was mild and the median number of vomiting episodes was 2 (range 1-3). This antiemetic regimen was well tolerated. Toxicities were mild and occurred in 3 patients (angioneurotic edema, transient episode of facial twitching, and heaviness of tongue, respectively). The 5-drug antiemetic combination can prevent cisplatin-induced nausea and vomiting in a majority of patients.

A randomised trial of dexamethasone, lorazepam and prochlorperazine for emesis in patients receiving chemotherapy

To define further the place of dexamethasone in antiemetic combinations, lorazepam, prochlorperazine and placebo (LP) were compared with lorazepam, prochlorperazine and dexamethasone (DLP) in a randomised, double-blind, crossover study. Both patient and observer assessments were documented in 84 patients receiving both cisplatin and non-cisplatin chemotherapy. The addition of dexamethasone significantly reduced the severity of nausea (P = 0.002) and vomiting (P less than 0.0001), duration of nausea (P = 0.01) and vomiting (P = 0.002) and the number of vomiting episodes (P = 0.003). DLP was the superior regimen in subsets of patients receiving cisplatin and the non-cisplatin chemotherapy. The improvements produced by the dexamethasone regimen were large and of major benefit to our patients. Patients documented significantly improved tolerance to chemotherapy with DLP courses (P = 0.0006). Overall, significantly more patients preferred DLP (P less than 0.0001). Patient assessments produced results similar to observer assessments but gave a broader understanding of their experience. The addition of dexamethasone to prochlorperazine and lorazepam significantly improved our patients' experience while receiving chemotherapy.

High-dose metoclopramide + lorazepam versus low-dose metoclopramide + lorazepam + dehydrobenzperidol in the treatment of cisplatin-induced nausea and vomiting

In a randomized double-blind, cross-over trial of 34 patients receiving cisplatin-based chemotherapy (20-100 mg/m2), the antiemetic effect of high-dose metoclopramide (HDM) (10 mg/kg iv. loading dose + 7 hours continuous infusion) + lorazepam (L) (2.5 mg x 4 po) was compared with low-dose metoclopramide (LDM) (70 mg) + L (2.5 mg x 2 po) + dehydrobenzperidol (5 mg x 2 im). Among the 29 patients who completed the cross-over, HDM significantly reduced the number of vomiting episodes (p = 0.002) and the degree of nausea (p = 0.004). Seventeen patients preferred the HDM and 4 the LDM regimen (p = 0.01). Sedation was seen in all but 1 patient, and was graded as severe in 6 patients receiving the HDM and in 2 patients receiving the LDM regimen. No extrapyramidal adverse reactions were seen. We conclude that high-dose metoclopramide + lorazepam is a safe antiemetic regimen and significantly superior to low-dose metoclopramide + lorazepam + dehydrobenzperidol. Owing to the severe sedation which occurs in some patients, the dose of lorazepam should be individually adjusted.

Antiemetic regimens in outpatients receiving cisplatin and non-cisplatin chemotherapy. A randomized trial comparing high-dose metoclopramide plus methylprednisolone with and without lorazepam

Results of a randomized trial on antiemesis for cisplatin (CDDP) and non-CDDP chemotherapy-induced vomiting are reported. One hundred and sixty-three outpatients received 282 chemotherapy courses (141 with CDDP and 141 without CDDP). Patients were randomly assigned to receive either high-dose metoclopramide plus methylprednisolone (arm A) or the same drugs plus lorazepam (arm B). In both arms a high protection rate for vomiting was obtained, on the whole without statistically significant differences. Patients who received lorazepam had, however, significantly fewer nausea episodes during first day post-chemotherapy (p less than 0.05). Arm B was also superior in anxiety control during the first day of chemotherapy (p less than 0.01). Both regimens were significantly more effective in patients who had not been given chemotherapy previously (p less than 0.01). No differences in antiemetic protection were found between CDDP and non-CDDP courses. No significant differences were found in premonitory vomiting control between the two arms of the trial. Toxicity was very mild with both regimens, although sedation was significantly higher in arm B (p less than 0.001). We conclude that high-dose metoclopramide plus methylprednisolone is a highly effective combination for chemotherapy-induced nausea and vomiting, and that it is quite suitable for outpatient use. Lorazepam did not significantly increase the antiemetic potency of the combination, nor did it improve premonitory vomiting control, although it gave a better control of acute nausea and anxiety.

Double-blind randomized trial of lorazepam versus placebo with methylprednisolone for control of emesis due to non-cisplatin containing chemotherapy

Fifty-three breast cancer patients receiving adjuvant chemotherapy entered a double-blind randomized trial of lorazepam 2.5 mg orally prior to chemotherapy and repeated after 12 hours (Arm A) versus placebo (Arm B) with methylprednisolone (MPN) 375 mg in 3 equal doses: 125 mg i.v. prior to chemotherapy and repeated i.m. 6 and 12 hours later. Adjuvant therapy with 5-fluorouracil 600 mg/m2, 4'-epi-doxorubicin 60 mg/m2, cyclophosphamide 600 mg/m2 (FEC) day 1 was alternated every 21 days with cyclophosphamide 600 mg/m2, methotrexate 40 mg/m2, 5-fluorouracil 600 mg/m2 (CMF) day 1 for a total of 12 courses. The majority of patients experienced greater than or equal to 5 emetic episodes with FEC therapy (Arm A = 52%; Arm B = 55%). Mild and moderate nausea were reported by 60% and 68% of patients in Arms A and B, respectively. With CMF therapy complete control of emesis was observed in 33% (Arm A) and 35% (Arm B) of patients. The addition of lorazepam did not improve results either with FEC or CMF. Sedation was experienced by 86 to 92% of patients treated with lorazepam and amnesia was observed in 48-50% of cases. FEC therapy must be considered a highly emetic regimen and antiemetic therapy planned accordingly.

A randomized, double-blind comparison of the antiemetic effect of metoclopramide and lorazepam with or without dexamethasone in patients receiving high-dose cisplatin

Thirty-seven patients with advanced incurable malignancies who were receiving their first course of cisplatin (greater than or equal to 90 mg/m2 bolus), alone or in combination with other antineoplastic agents, were entered in this randomized, double-blind study to determine the antiemetic efficacy of the addition of high-dose dexamethasone to lorazepam plus metoclopramide. All patients received lorazepam (1.5 mg/m2) and metoclopramide (2.0 mg/kg) intravenously (IV) 30 minutes before cisplatin, with the same dose of metoclopramide repeated 1.5, 3.5, 6.5, and 9.5 hours after the 30-minute cisplatin infusion. Patients were randomized to receive dexamethasone (0.5 mg/kg) or placebo by slow bolus injection 30 minutes before cisplatin. All patients were hospitalized for 24 hours and evaluated by observation after cisplatin and a patient questionnaire before discharge. Eighteen patients received metoclopramide and lorazepam without dexamethasone: six (33%) reported no vomiting and four (22%) reported no nausea or vomiting. Nineteen patients also received dexamethasone: 14 (74%) had no vomiting and 13 (68%) reported no nausea or vomiting. These differences were statistically significantly different (P = 0.013 and 0.005, respectively). The side effects attributable to the antiemetic regimen were somnolence (100%), confusion (8%), and diarrhea (46%), and were the same in both arms. Dexamethasone significantly improved the antiemetic efficacy of metoclopramide plus lorazepam without adding toxicity. This three-drug combination gave a high rate of control of acute emesis induced by high-dose cisplatin.

Changes in the prescription patterns of psychotropic drugs for cancer patients during a 10-year period

The use of psychotropic drugs was studied in 200 cancer patients admitted to a medical oncology unit at Memorial Sloan-Kettering Cancer Center, New York, in December 1987. When compared with a similar survey that studied prescription practices 10 years ago, there was a 30% increase in the use of psychotropic agents. Whereas prescription rates for different drug classes remained relatively stable, psychotropic drugs are now used for a greater range of reasons. The introduction of several new agents, especially short-acting benzodiazepines, has altered the physician's choices. Despite awareness of the different properties of psychotropic medications and their increased use, they are still underused, especially the antidepressants and antipsychotics when prescribed for psychologic distress.

Antiemetic therapy for chemotherapy-induced vomiting: metoclopramide, benztropine, dexamethasone, and lorazepam regimen compared with chlorpromazine alone

Twenty-six children aged 4 to 15 years who were to receive cancer chemotherapy were enrolled in a double-blind, randomized, crossover trial that compared the antiemetic efficacy of a four-drug regimen (the MBDL regimen: metoclopramide, 8 mg/kg; benztropine, 0.04 mg/kg; dexamethasone, 0.7 mg/kg; lorazepam, 0.1 mg/kg), given over 24 hours, with the efficacy of chlorpromazine, 3.3 mg/kg, given in four doses over 24 hours. The MBDL regimen was more effective than chlorpromazine in both objective and subjective measures of antiemetic control. Of 26 children, 23 (89%) had less vomiting on the MBDL regimen, and 20 (77%) of 26 patients or parents preferred this regimen (p less than 0.01). The MBDL regimen reduced the number of vomiting episodes by a mean of 4.0 (p less than 0.01) and reduced the duration of vomiting by a mean of 3.7 hours (p less than 0.01). A moderate level of sedation was documented at some stage in the 24-hour period of observation in 27% on the MBDL regimen and in 35% receiving chlorpromazine. Dystonia was seen in 1 (4%) of 26 children. We conclude that the MBDL regimen is safe in children and more effective than chlorpromazine.

Antiemetic therapy: management of chemotherapy-induced nausea and vomiting

Physicians and nurses involved in the care of oncology patients share the responsibility for proper management of chemotherapy-induced nausea and vomiting. Oncology nurses have taken an active part in the research and investigation of new antiemetic agents and the sharing of this knowledge with others. Identifying patient characteristics, using specific guidelines for antiemetic selection, and a knowledge of the antiemetic agents that are active singly or in combination can mean the difference between success and failure in preventing or controlling vomiting induced by chemotherapy. Proper dosing and scheduling of antiemetics using recommendations that have proved efficacious can further decrease a patient's discomfort during a most difficult time in his or her life.

Lorazepam pharmacodynamics and pharmacokinetics in children

We evaluated the effects of low doses of lorazepam on episodic versus long-term memory, attention, and somatic and affective symptoms, as well as its pharmacokinetics, in a group of 16 children aged 2.8 to 14.2 years. Psychologic assessments of each child were performed twice before intravenous administration of lorazepam (0.03 mg/kg), and 1 1/2 hours and 24 hours after lorazepam; there were no significant changes in long-term memory, attention, or somatic symptoms. There was a significant decrease in affective symptoms at 1 1/2 hours (p = 0.011), with a trend toward decreased anxiety at 1 1/2 and 24 hours after lorazepam (p = 0.026 and 0.028, respectively). There was also a selective anterograde amnestic effect in 5 of 16 children after lorazepam (p = 0.06). Mean (+/- SD) lorazepam systemic clearance was 1.3 +/- 0.4 ml/min/kg, with a terminal half-life of 10.5 +/- 2.9 hours and an unbound clearance of 15.9 +/- 5.2 ml/min/kg. A group of healthy adult volunteers who were given lorazepam had a mean systemic clearance of 1.0 +/- 0.4 ml/min/kg, somewhat less than that of the children (p = 0.069). There were no significant differences in any lorazepam pharmacokinetic parameter between those children who did versus those who did not have changes in affective symptoms or amnesia. These data should be helpful in establishing the dose of lorazepam in children, as the drug becomes more widely used as an antiemetic, premedicant, and anticonvulsant agent.

Metoclopramide versus metoclopramide and lorazepam. Superiority of combined therapy in the control of cisplatin-induced emesis

Sixty-four patients treated with cisplatin-containing regimens were entered into a randomized, double-blinded study examining the antiemetic efficacy of metoclopramide with and without lorazepam for control of cisplatin-induced emesis. Metoclopramide was administered to all patients at 2 mg/kg, intravenously, 30 minutes before chemotherapy and 1.5, 3.5, and 5.5 hours posttreatment. Patients randomized to receive combined antiemetic therapy were administered lorazepam at 2 mg/m2 (maximum, 4 mg dose) intravenously, 30 minutes before chemotherapy. Those patients not receiving lorazepam were given normal saline placebo. Degree of nausea and number of vomiting episodes were recorded on a data flow sheet with a visual analogue scale. Drug toxicities were evaluated before each administered dose. Patients receiving both metoclopramide and lorazepam experienced significantly less vomiting episodes (P less than 0.05) and nausea (P less than 0.01) when compared to patients given metoclopramide alone. Forty-four percent of those receiving the combined therapy reported no nausea or vomiting episodes compared to only 22% receiving metoclopramide alone. Sedation was significantly more common in patients receiving lorazepam (88%) as opposed to patients receiving only metoclopramide (43%), P less than 0.01. Amnesia was seen in 25% receiving lorazepam. No significant difference in diarrhea, dystonia, or disinhibition was observed between the two arms. The authors conclude that the combination of lorazepam and metoclopramide was superior to metoclopramide alone in the prevention of cisplatin-induced nausea and vomiting, with sedation and amnesia more commonly observed in the combined regimen.

Preoperative hyperthermia and radiation for soft tissue sarcomas: advantage of two vs one hyperthermia treatments per week

As part of an ongoing Phase II trial at Duke University Medical Center (DUMC), patients with Stage IIB-IVA soft tissue sarcomas (STS) potentially amenable to wide local excision were treated with preoperative hyperthermia (HT) plus radiation therapy (RT), with HT randomized to one versus two treatments per week, stratified with respect to tumor volume. 17 patients were treated and analyzed. HT was given 30-60 minutes after RT, with heating maintained for 1 hour after 42.0 degrees C was reached. In patients treated with 2 HT per week, treatments were separated by 48 hrs. Concurrent RT was given with 180-200 cGy fractions, five treatments per week, to a nominal tumor dose of 5000-5040 cGy. Surgical extirpation was performed 4 weeks after completion of HT/RT. Treatment effect was evaluated by histopathologic examination of the resected lesions, according to a previously reported system. The mean number of HT given in the 1 and 2/wk groups was 4.4 and 7.3, respectively (p less than 0.01). Tmax for the 1 and 2 HT/wk groups was 42.4 +/- 2.1 degrees C and 43.5 +/- 1.8 degrees C, and T min was 38.1 +/- 0.8 degrees C and 38.6 +/- 0.5 degrees C, respectively. The increase in T min from first to last treatment was 0.5 +/- 1.2 degrees C and 1.0 +/- 0.8 degrees C, respectively. The T min from the best treatment was 39.1 +/- 1.2 degrees C and 40.0 +/- 1.0 degrees C, and the Tmax from the best treatment was 44.5 +/- 3.4 degrees C and 45.4 +/- 2.5 degrees C for the 1 and 2 HT/wk groups, respectively. There were no statistically significant differences between the 2 treatment groups for any of the above temperature parameters. Severe histopathologic changes were found in 71% (12 of 17) of the lesions. T min and Tmax and highest T min and Tmax were between 0.4-1.1 degrees C higher in patients with severe changes (p = NS). All 9 patients in the 2 HT/wk group had extensive changes, versus only 3 of the 8 patients in the 1 HT/wk group. This difference was highly statistically significant (p = 0.009, two-tailed Fisher's exact test). These findings suggest an advantage to twice weekly, as opposed to weekly, HT in the setting of this study. Whether there is a corresponding therapeutic gain, or whether these results can be extrapolated to other settings requires further investigational efforts. It is recommended that treatment parameters, particularly temperature parameters, continue to be examined in Phase II trials.

Combination antiemetics for cisplatin chemotherapy

Nausea and vomiting occur in a majority of patients receiving cisplatin chemotherapy despite prophylactic single agent antiemetic therapy. Three potent antiemetics, metoclopramide, droperidol and dexamethasone, and diphenhydramine to prevent potential extrapyramidal reactions, were combined in prophylaxis of 67 patients receiving cisplatin chemotherapy. Of the patients studied, 76.1% experienced complete protection from both nausea and vomiting in their first course and 62.7% in all their courses of treatment. In 73.3% of 161 evaluable courses, there was neither nausea nor vomiting. Vomiting did not occur in 79.5% of courses. There was no evidence to suggest tachyphylaxis. The efficacy in preventing nausea and vomiting was independent of primary disease site, age, sex, performance status, prior chemotherapy, and prior vomiting. Toxicities were mild and infrequent. Reversible transient extrapyramidal reactions, sweating or twitches occurred in 5.6% of courses. The combination of metoclopramide, diphenhydramine, droperidol and dexamethasone was highly efficacious in preventing nausea and vomiting in moderate or high-dose cisplatin chemotherapy with little toxicity.

Contributions of benzodiazepines to cancer therapy

We have reviewed the therapeutic effects of benzodiazepines employed as adjuncts to cancer treatment. These agents have been used primarily for alleviating or attenuating situational anxiety, insomnia, chemotherapy-induced nausea and vomiting, and anticipatory nausea and vomiting. Situational anxiety not corrected by psychosocial support, symptom control, or time may be successfully treated with benzodiazepines. Procedure-related anxiety, for example, that related to bone marrow biopsy, venipuncture, intrathecal therapy, and the insertion of subclavian and femoral catheters, is a serious problem that may be alleviated by the use of benzodiazepines. Insomnia not caused by a depression serious enough to warrant treatment with a tricyclic antidepressant also may be successfully treated with benzodiazepines. Many clinicians have found benzodiazepines to be useful adjuncts to a cancer chemotherapy regimen because of their anxiolytic, sedative, and amnesic properties and also because of their suspected antiemetic properties when these drugs are used in conjunction with known antiemetic agents. The ability of lorazepam to induce antegrade amnesia has proved particularly useful in alleviating anticipatory nausea and vomiting connected with repeated courses of cytotoxic chemotherapy. Furthermore, since benzodiazepines are relatively safe drugs, their continued and probably expanded uses as cancer therapy adjuncts can be anticipated.

Antiemetic control and prevention of side effects of anti-cancer therapy with lorazepam or diphenhydramine when used in combination with metoclopramide plus dexamethasone. A double-blind, randomized trial

Combinations of metoclopramide and dexamethasone given intravenously control vomiting caused by high doses of cisplatin. Lorazepam and diphenhydramine are useful adjuncts to antiemetics. In a double-blind trial, 120 patients receiving high-dose cisplatin (120 mg/m2) for the first time were randomly assigned to receive either lorazepam (1.5 mg/m2) or diphenhydramine (50 mg) intravenously, 45 minutes prior to cisplatin. In addition, all patients received intravenous dexamethasone (20 mg) 40 minutes prior to chemotherapy along with metoclopramide (3 mg/kg) 30 minutes before and 90 minutes after cisplatin. Patients were directly observed in the hospital after cisplatin administration and completed a subjective assessment questionnaire. Overall, 60% of patients experienced no vomiting, and 83% had two or fewer emetic episodes during the study. There were no significant differences in objective antiemetic control between the two regimens. Only 3% of patients receiving lorazepam experienced treatment-related restlessness as opposed to 19% given diphenhydramine (P = 0.007). Less recall of chemotherapy administration (P less than 0.001), more sedation (P = 0.003), and transient enuresis while sedated (P = 0.0002) were characteristic of patients receiving lorazepam. Patient-generated ratings revealed less anxiety (P = 0.0001) for those individuals given the lorazepam-containing combination. Both regimens were well accepted, with 89% of patients receiving the lorazepam combination and 83% of those given the diphenhydramine regimen wishing to receive the same drugs in the future. Some degree of delayed vomiting occurred in 85% of patients during the 4-day period following this study. During the time that patients are at the greatest risk for emesis, the 24 hours immediately following cisplatin, three drug antiemetic combinations of either lorazepam or diphenhydramine with metoclopramide plus dexamethasone stopped cisplatin-induced emesis for the majority of patients and lessen other treatment-related side effects. Less restlessness and anxiety were observed among individuals receiving the lorazepam-containing combination.