Risk–benefit of antiemetics in prevention and treatment of chemotherapy-induced nausea and vomiting

Simotang Alleviates the Gastrointestinal Side Effects of Chemotherapy by Altering Gut Microbiota

Simotang oral liquid (SMT) is a traditional Chinese medicine (TCM) consisting of four natural plants and is used to alleviate gastrointestinal side effects after chemotherapy and functional dyspepsia (FD). However, the mechanism by which SMT helps cure these gastrointestinal diseases is still unknown. Here, we discovered that SMT could alleviate gastrointestinal side effects after chemotherapy by altering gut microbiota. C57BL/6J mice were treated with cisplatin (DDP) and SMT, and biological samples were collected. Pathological changes in the small intestine were observed, and the intestinal injury score was assessed. The expression levels of the inflammatory factors IL-1β and IL-6 and the adhesive factors Occludin and ZO-1 in mouse blood or small intestine tissue were also detected. Moreover, the gut microbiota was analyzed by high-throughput sequencing of 16S rRNA amplicons. SMT was found to effectively reduce gastrointestinal mucositis after DDP injection, which lowered inflammation and tightened the intestinal epithelial cells. Gut microbiota analysis showed that the abundance of the anti-inflammatory microbiota was downregulated and that the inflammatory microbiota was upregulated in DDP-treated mice. SMT upregulated anti-inflammatory and anticancer microbiota abundance, while the inflammatory microbiota was downregulated. An antibiotic cocktail (ABX) was also used to delete mice gut microbiota to test the importance of gut microbiota, and we found that SMT could not alleviate gastrointestinal mucositis after DDP injection, showing that gut microbiota might be an important mediator of SMT treatment. Our study provides evidence that SMT might moderate gastrointestinal mucositis after chemotherapy by altering gut microbiota.

The Effects of Peppermint Oil on Nausea, Vomiting and Retching in Cancer Patients Undergoing Chemotherapy: An Open Label Quasi-Randomized Controlled Pilot Study

OBJECTIVES

The current study evaluated the effects of peppermint oil on the frequency of nausea, vomiting, retching, and the severity of nausea in cancer patients undergoing chemotherapy.

DESIGN

A quasi-randomized controlled study.

SETTING

Patients were recruited from the ambulatory chemotherapy unit of a public hospital located (Batman, Turkey) between September 2017 and September 2018.

INTERVENTIONS

The participants in the intervention group applied one drop the aromatic mixture on the spot between their upper lip and their nose, three times a day for the five days following chemotherapy administration, in addition to the routine antiemetic treatment. Participants in the control group underwent only the routine antiemetic treatment. Main outcome measures VAS-the severity of nausea and the Index of Nausea, Vomiting, and Retching.

RESULTS

The VAS nausea score was significantly lower after peppermint oil applying in the patients receiving Folfirinox (treatment effect (mean dif.): 4.00±2.28; P<0.001), Paclitaxel-Trastuzumab (treatment effect (mean dif.): 1.70±0.90; P=0.014), Carboplatin-Paclitaxel (treatment effect (mean dif.): 3.71±1.41; P<0.001), and Cyclophosphamide-Adriamycin (treatment effect (mean dif.): 1.41±0.73; P=0.005) excluding cisplatin scedule (treatment effect (mean dif.): 0.56±2,18; P=0.642). We detected a statistical significant difference in the change in frequency of nausea, vomiting, retching in the other all schedules excluding cisplatin schedule (P<0.05).

CONCLUSIONS

The peppermint oil was significantly reduced the frequency of nausea, vomiting, retching and the severity of nausea in cancer patients undergoing chemotherapy. Therefore, usage of peppermint oil together with antiemetics after chemotherapy with moderate and low emetic risk may be recommended to cope with CINV.

The side effects of platinum-based chemotherapy drugs: a review for chemists

The platinum chemotherapy drugs cisplatin, carboplatin, and oxaliplatin are known to cause seven different types of side effects in patients.

Effect of GLP-1 receptor agonist treatment on body weight in obese antipsychotic-treated patients with schizophrenia: a randomized, placebo-controlled trial

AIMS

Schizophrenia is associated with cardiovascular co-morbidity and a reduced life-expectancy of up to 20 years. Antipsychotics are dopamine D₂ receptor antagonists and are the standard of medical care in schizophrenia, but the drugs are associated with severe metabolic side effects such as obesity and diabetes. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are registered for treatment of both obesity and type 2 diabetes. We investigated metabolic effects of the GLP-1RA, exenatide once-weekly, in non-diabetic, antipsychotic-treated, obese patients with schizophrenia.

MATERIAL AND METHODS

Antipsychotic-treated, obese, non-diabetic, schizophrenia spectrum patients were randomized to double-blinded adjunctive treatment with once-weekly subcutaneous exenatide (n = 23) or placebo (n = 22) injections for 3 months. The primary outcome was loss of body weight after treatment and repeated measures analysis of variance was used as statistical analysis.

RESULTS

Between March 2013 and June 2015, 40 patients completed the trial. At baseline, mean body weight was 118.3 ± 16.0 kg in the exenatide group and 111.7 ± 18.0 kg in the placebo group, with no group differences ( P = .23). The exenatide and placebo groups experienced significant ( P = .004), however similar ( P = .98), weight losses of 2.24 ± 3.3 and 2.23 ± 4.4 kg, respectively, after 3 months of treatment.

CONCLUSIONS

Treatment with exenatide once-weekly did not promote weight loss in obese, antipsychotic-treated patients with schizophrenia compared to placebo. Our results could suggest that the body weight-lowering effect of GLP-1RAs involves dopaminergic signaling, but blockade of other receptor systems may also play a role. Nevertheless, anti-obesity regimens effective in the general population may not be readily implemented in antipsychotic-treated patients with schizophrenia.

The Effectiveness of Hologram Bracelets in Reducing Chemotherapy-Induced Nausea and Vomiting Among Adult Patients With Cancer

BACKGROUND

Chemotherapy-induced nausea and vomiting (CINV) affects cancer patients' quality of life, despite the provision of antiemetic medication.

OBJECTIVES

The aim of this study is to assess the clinical effectiveness of the hologram bracelet in the management of CINV among adult patients with cancer.

METHODS

An experimental, double-blinded design spanning 3 courses of chemotherapy was used; 175 oncology patients were randomly assigned to 3 groups: placebo (n = 53), control (n = 54), and intervention (hologram bracelet) (n = 68). Daily diaries were used to detect the severity and the frequency of CINV and to detect the frequency of using antiemetic medications. The Functioning Living Index-Emesis was used to examine the impact of CINV on the activities of daily living.

RESULTS

Significant CINV differences existed between groups. The mean total Functioning Living Index-Emesis score was significantly lower in the intervention group for total vomiting and total nausea.

CONCLUSION

Hologram bracelet use among patients with cancer had a positive effect on CINV. The level of CINV decreased and activity of daily living scores increased. However, effects varied among the types of CINV.

IMPLICATIONS FOR PRACTICE

Further study is recommended to explore the benefits of the bracelet.

Cigarette smoke synergizes lipopolysaccharide-induced interleukin-1β and tumor necrosis factor-α secretion from macrophages via substance P-mediated nuclear factor-κB activation

A recent study has indicated that alveolar macrophages from smokers incubated with lipopolysaccharide (LPS) secrete much more IL-1β and TNF-α than those from healthy nonsmokers, but the mechanisms underlying this augmented secretion by cigarette smoke (CS) remain unknown. CS and LPS reportedly promote macrophages' secreting substance P (SP) that could up-regulate these cytokines' secretion from macrophages by acting on neurokinin 1 receptor (NK1R). Moreover, NF-κB from macrophages participates in NK1R intracellular signaling and synthesis of these cytokines. The present in vitro study was undertaken to examine whether CS is able to synergize these cytokines' response to LPS in macrophages, and if so, whether an amplified SP secretion is responsible for this synergistic cytokines' response via a NK1R-driven NF-κB pathway. THP-1-derived and MH-S macrophages were exposed to control medium and CS condensate (CSC) without or with LPS. We found that LPS, CSC, and CSC+LPS significantly increased IL-1β, TNF-α, and SP secretion and that SP secretion markedly preceded cytokines' secretion. CSC+LPS-induced responses were markedly greater than the sum of the responses to CSC and LPS alone, suggesting a synergistic effect. Blocking NK1R reduced the responses of IL-1β, TNF-α, and NF-κB activation to CSC+LPS by 41, 40, and 46%, respectively. NF-κB inhibitors decreased the CSC+LPS-induced cytokines' responses by 70%. Our findings suggest that CS amplifies the LPS-induced macrophages' secretion of IL-1β and TNF-α through synergizing SP secretion, which activates NF-κB via binding with NK1R.

Chemotherapy-induced nausea and vomiting: contemporary approaches to optimal management. Proceedings from a symposium at the 2008 Multinational Association of Supportive Care in Cancer (MASCC) Annual Meeting

INTRODUCTION

Chemotherapy-induced nausea and vomiting remains a significant problem for cancer patients.

DISCUSSION

Patient factors such as polypharmacy, medication costs, mucositis, and depression may hinder good antiemetic control, while high workloads, poor communication, and underestimation of the problem on the part of healthcare professionals also play a role. Improving outcomes requires accurate assessment of risk factors, use of guidelines, and better adherence to antiemetic regimens.

CONCLUSION

Extended-release formulations and new delivery systems such as transdermal patches, nasal sprays, and pumps provide a new strategy that may improve patient outcomes.

Anti-emetic therapy in cancer chemotherapy: current status

Nausea and vomiting are ranked as the most severe side effects to chemotherapy by cancer patients. Twenty years ago, treatment of nausea and vomiting from chemotherapy only had moderate effect and often unpleasant side effects. The drugs used included dopamine(2)-receptor antagonists and corticosteroids alone or combined. This review summarizes the development of anti-emetic therapy, but will focus on the importance of two new classes of anti-emetics: the serotonin(3)- and the neurokinin(1)-receptor antagonists. Furthermore, evidence-based guidelines for the treatment of chemotherapy-induced nausea and vomiting will be given. The serotonin(3)-receptor antagonists, the first group of drugs developed specifically as anti-emetics, have significantly improved the prophylaxis of chemotherapy-induced emesis especially in combination with a corticosteroid. The improvement in the prophylaxis of nausea with this combination is however modest. A new group of anti-emetics, the neurokinin(1)-receptor antagonists, has now been developed, and the first drug, aprepitant, was marketed in 2003. Aprepitant increases the effect of a serotonin(3)-receptor antagonist plus a corticosteroid against acute emesis induced by highly or moderately emetogenic chemotherapy and aprepitant is also active in the protection against delayed emesis. The importance of drug-drug interactions with anti-emetics and other drugs, especially cytotoxins, through their competition for cytochrome P450 enzymes, have been studied. At present, there is no evidence that such interactions are of major clinical importance. Evidence-based clinical guidelines are now available and regularly updated, but unfortunately clinical implementation is slow. Recommendations for some types of chemotherapy-induced emesis such as delayed emesis, is based on a low level of evidence. Furthermore, the majority of clinical trials include highly selected groups of patients not permitting definite conclusions for other and more heterogeneous patient groups. Development of new anti-emetics with other mechanisms of action is awaited with interest.

Comparative activity of antiemetic drugs

Nausea and vomiting continues to be an important problem for cancer patients receiving chemotherapy. Chemotherapy-induced nausea and vomiting (CINV) are classified as acute, occurring within the first 24h, or delayed, occurring after the first 24h. A number of antiemetic agents are available for the management of nausea and vomiting, including 5-HT3-receptor-antagonists, corticosteroids, NK-1-receptor-antagonists, dopamine-receptor antagonists, benzodiazepines, neuroleptics and cannabinoids. With modern antiemetic therapy, vomiting can be prevented in 70-80% of patients, whereas the control of nausea remains suboptimal. The development of acute emesis is known to depend on serotonin. The pathophysiology of delayed emesis is less well understood, and multiple mechanisms may contribute, including substance P. Here, the most recent developments in the antiemetic therapy, including new antiemetic drugs and the latest guidelines for antiemetic prophylaxis, are reviewed.

Delayed nausea and vomiting continue to reduce patients' quality of life after highly and moderately emetogenic chemotherapy despite antiemetic treatment

PURPOSE

Chemotherapy-induced nausea and vomiting (CINV) are major adverse effects of cancer chemotherapy. We compared the impact of acute (during the first 24 hours postchemotherapy) and delayed (days 2 through 5 postchemotherapy) CINV on patients' quality of life (QoL) after highly or moderately emetogenic chemotherapy (HEC and MEC, respectively).

PATIENTS AND METHODS

This prospective, multicenter, multinational study was conducted in 14 medical practices on cancer patients undergoing either HEC or MEC treatment. Patients recorded episodes of nausea and vomiting in a diary. Patients completed the Functional Living Index-Emesis (FLIE) questionnaire at baseline and on day 6.

RESULTS

A total of 298 patients were assessable (67 HEC patients, 231 MEC patients). Emesis was reported by 36.4% of patients (13.2% acute, 32.5% delayed) and nausea by 59.7% (36.2% acute, 54.3% delayed). HEC patients reported significantly lower mean FLIE total score than MEC patients (95.5 v 107.8 respectively; P = .0049). Among all patients, the nausea score was significantly lower than the vomiting score (50.0 and 55.3, respectively; P = .0097). Of the 173 patients who experienced neither vomiting nor nausea during the first 24 hours postchemotherapy, 22.9% reported an impact of CINV on daily life caused by delayed CINV.

CONCLUSION

CINV continues to adversely affect patients' QoL despite antiemetic therapy even after treatment with only moderately emetogenic chemotherapy regimens, and even in the subgroup of patients who do not experience nausea and vomiting during the first 24 hours. On the basis of the FLIE results in this study, nausea had a stronger negative impact on patients' daily lives than vomiting.

Neurokinin-1-receptor antagonists: a new approach in antiemetic therapy

Aprepitant (Emend), the first neurokinin-1-receptor antagonist (NK-1-RA), represents a new class of antiemetics. Aprepitant has been approved for the prevention and treatment of acute (0-24 h after chemotherapy) and delayed (1-5 days after chemotherapy) emesis resulting from cisplatin-based chemotherapy and moderately emetogenic chemotherapy. The addition of aprepitant to standard antiemetic therapy in cisplatin-based chemotherapy significantly improves emesis protection in general and, in particular, in the delayed phase by approximately 20%. Results from a recently published study in patients receiving moderately emetogenic chemotherapy suggest a benefit of aprepitant when combined with dexamethasone and a 5-HT(3) receptor antagonist for the prevention of acute emesis, followed by aprepitant as a single agent in the prevention of delayed emesis. Altogether, the addition of aprepitant to the standard antiemetic regimen (5-HT(3) receptor antagonist and dexamethasone) significantly improves the protection against vomiting in the acute as well as in the delayed phase in highly and moderately emetogenic chemotherapies. Therefore, the combination of a 5-HT(3) receptor antagonist, dexamethasone and aprepitant should be considered as a new standard antiemetic therapy.

Effects of ganoderma lucidum extract on chemotherapy-induced nausea and vomiting in a rat model

Chemotherapy is highly cytotoxic, causing a number of severe adverse effects such as nausea and vomiting. Herbal medicines, which can often be used on a daily basis for prolonged treatment, may be clinically beneficial. Ganoderma lucidum or Lingzhi mushroom has been recognized as a remedy in treating a number of medical conditions, including balancing immunity and decreasing drug-induced side effects. It has been shown that rats react to emetic stimuli, like the chemotherapy agent cisplatin, by increased consumption of kaolin, known as pica; and this rat model has been utilized to evaluate novel anti-emetic compounds. In this study, we evaluated the effects of a G. lucidum extract (SunRecome, the most commonly used Lingzhi mushroom extract in China) in attenuating cisplatin-induced nausea and vomiting in the rat pica model. We observed that intraperitoneal cisplatin injection caused a significant increase in kaolin intake at 24, 48, 72 and 96 hours, reflecting cisplatin's nausea and vomiting action. This cisplatin-induced kaolin intake dose-dependently decreased after 1, 3 and 10 mg/kg G. lucidum extract injection (p < 0.01). In addition, there was a significant reduction of food intake after cisplatin. The cisplatin-induced food intake reduction improved significantly after G. lucidum extract administrations in a dose-related manner (p < 0.01), suggesting a supportive effect of the extract on general body condition. Future controlled clinical trials are needed to evaluate the safety and effectiveness of this herbal medication.

Chemotherapy-induced nausea and vomiting: current and new standards in the antiemetic prophylaxis and treatment

Nausea and vomiting are considered as two of the most distressing side-effects of chemotherapy. Chemotherapy-induced nausea and vomiting have been classified into acute, delayed and anticipatory based on the time of onset. The frequency of nausea and vomiting depends primarily on the emetogenic potential of the chemotherapeutic agents used. With the introduction of the 5-HT3 receptor-antagonists in combination with dexamethasone in the early 1990s approximately 70% of patients receiving highly emetogenic chemotherapy were protected from acute emesis. However, 40% of patients have symptoms in the delayed phase. Another group of antiemetics, the neurokinin-1-receptor-antagonists, have recently been introduced. The addition of neurokinin receptor (NK1 receptor)-antagonists to standard therapy significantly improves emesis protection in the acute and in particular in the delayed phase by approximately 20%. Due to these new developments, revised antiemetic guidelines have been set. Here, the most recent developments in antiemetic therapy, including these guidelines, are reviewed.

New aspects of supportive care: The MASCC vision

The Multinational Association of Supportive Care in Cancer (MASCC) was founded in 1991, and joined forces with the International Society of Oral Oncology (ISOO) in 1998. The "mission" of MASCC is to optimize supportive care in cancer patients worldwide, stimulate multi-disciplinary research, encourage international scientific exchange of information, expand professional expertise in supportive care, educate health care professionals worldwide in supportive care, and to serve as a resource for patients, families, and caregivers. Ten years ago, the most frequently addressed supportive care symptoms included pain, febrile neutropenia, and the prevention of nausea and vomiting. These topics are still indeed relevant for cancer patients, but today focus has also turned to topics such as mucositis, and specific supportive care problems in the elderly. Recent, studies have indicated that individually targeted supportive care therapy might become an important part of clinical practice in the near future.