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

The Use of Complementary and Integrative Medicine in Combination With Pharmacological Antiemetics to Address Chemotherapy-Induced Nausea and Vomiting in Pediatric Oncology: A Scoping Review

Background: Chemotherapy is a common treatment in childhood cancer but causes significant side effects, among the most notable being nausea and vomiting, known as chemotherapy-induced nausea and vomiting (CINV). Pharmacological antiemetics and complementary and integrative medicine (CIM) have been studied separately to manage CINV, but a gap exists in understanding their use together. We aimed to investigate the potential multimodal effects of CIM and pharmacological antiemetics on CINV in pediatric oncology patients undergoing chemotherapy. Method: Systematic searches were conducted in four databases to identify studies evaluating the efficacy of CIM in combination with pharmacological antiemetics in patients ages 0-21 with cancer undergoing chemotherapy. Relevant data were extracted from each study and evaluated. Results: Eighteen sources examining CIM therapies in three distinct categories (herbal, physical, and psychological) were identified. Three of four herbal interventions yielded significant results, all of which implemented oral ginger. Physical interventions included manual and wristband acupressure, auricular acupuncture, and needle and laser acupuncture. Significant results were found in only four of these 10 studies. Among psychological interventions, two of four yielded significant results. Discussion: There is no clear evidence of benefit from CIM therapies in addition to pharmacological antiemetics to better control CINV. However, this review provides support and direction for future research to examine potential effects. Complementary therapies generally have little potential for harm, are relatively low cost, and low burden. Therefore, if there is a perceived benefit for patients and families, complementary and integrative therapies should be considered.

[Prevention and treatment of antineoplastic drug-induced nausea and vomiting in pediatric onco-hematology: An update]

Antineoplastic drug induced nausea and vomiting are common adverse events in cancer care of paediatric patients ; therefore, prevention and management of these adverse events is a major concern for healthcare professionals. There are common features between paediatric and adult patients in terms of the emetogenic level depending on antineoplastic agents or about available medicines. However, there are also specificities for paediatric population including individual risk factors of emesis or nausea assessment for example. Knowledge relative to available medicines is also limited in the paediatric population, especially for recent medicines. This review aims to provide a comprehensive overview about antiemetics in paediatric oncology to clinicians and other healthcare professionals involved in paediatric cancer care. First of all, we describe physiopathological paediatric specificity, risk factors and clinical assessment of antineoplastic drug induced nausea and vomiting. Secondly, we focus on available medicines and also address the issue of complementary and alternative medicines.

Gastric electrical stimulation: An emerging therapy for children with intractable gastroparesis

Management of gastroparesis remains challenging, particularly in pediatric patients. Supportive care and pharmacological therapies for symptoms remain the mainstay treatment. Although they are effective for mild and some moderately severe cases, often time they do not work for severe gastroparesis. There are a few prokinetics available, yet the use of these drugs is limited by a lack of persistent efficacy and/or safety concerns. Currently, the only modality for adult patients with severe intractable gastroparesis is surgery, e.g., pyloroplasty and partial gastrectomy, however, this option is generally considered too radical for a growing child. Novel therapeutic approaches, particularly those which are less invasive, are needed. This article explores gastric electrical stimulation (GES), a new therapy for gastroparesis. Unlike others, it neither needs medications nor gastrectomy; rather, it treats through the use of microelectrodes to deliver high-frequency low energy electric stimulation to the pacemaker area of the stomach. Thus, it is tolerated and safe in children. Like in adult patients, GES appears to work in releasing symptoms, improving nutrition, and enhancing the quality of life; it also helps wean off medications and eliminate many needs for hospitalization. Considering the transient nature of gastroparesis in children in many occasions, GES is considered a “bridging” therapy after failed medical interventions and before surgery.

Evolution of antiemetic studies for radiation-induced nausea and vomiting within an outpatient palliative radiotherapy clinic

PURPOSE

Radiation-induced nausea and vomiting (RINV) is a common side effect of radiotherapy and can affect up to 50-80% of patients, potentially causing detrimental effects to physical health, clinical efficacy, and patient quality of life. Antiemetic drugs act on receptors involved in the emesis pathway to block the uptake of neurotransmitters and inhibit stimulation of vomiting centers in the brain to prevent and treat RINV. The most commonly prescribed antiemetics for RINV are 5-hydroxytryptamine receptor antagonists (5-HT3 RA). Guidelines describing the optimal management of RINV are produced by the Multinational Association for Supportive Care in Cancer, the European Society of Medical Oncology, the American Society of Clinical Oncology, and the National Comprehensive Cancer Network. This review will present findings from research on antiemetic management for RINV conducted at our center.

METHODS

A selective review of research conducted in a palliative outpatient radiotherapy clinic relating to antiemetic management for RINV was performed.

RESULTS

Several studies investigating the efficacy of different routes of administration, new antiemetic drug types, and novel combinations of antiemetics have been tested at our clinic to elucidate which approach provides the best response. These include studies on the use of ondansetron rapidly dissolving film, palonosetron, and the addition of a neurokinin-1 receptor antagonist to traditional 5-HT3 RA regimens.

CONCLUSIONS

These studies provide a framework for future research and could potentially inform changes to future guidelines to include the use of these novel regimens and techniques.

Integrative Approaches in Pediatric Palliative Care

Pediatric palliative care is a field which focuses on caring for and treating the symptoms and distress typically associated with life-limiting illness. Integrative medicine is supported by evidence and aims to heal the whole person, including all aspects of one’s lifestyle. Therapies offered by integrative medicine often empower patients and families, allowing for a sense of control. This review addresses the merging of integrative medicine philosophy and modalities with the care given to children with life-limiting illness. We review an introduction to integrative medicine, trends in its incorporation in the healthcare setting, application to patients receiving palliative care and the management of specific symptoms. A case study is offered to illustrate these principles.

Medical marijuana in pediatric oncology: A review of the evidence and implications for practice

Medical marijuana (MM) has become increasingly legal at the state level and accessible to children with serious illness. Pediatric patients with cancer may be particularly receptive to MM, given purported benefits in managing cancer-related symptoms. In this review, we examine the evidence for MM as a supportive care agent in pediatric oncology. We describe the current legal status of MM, mechanism of action, common formulations, and potential benefits versus risks for pediatric oncology patients. We offer suggestions for how providers might approach MM requests. Throughout, we comment on avenues for future investigation on this growing trend in supportive care.

Integrative Therapeutic Approaches for the Management and Control of Nausea in Children Undergoing Cancer Treatment: A Systematic Review of Literature

Chemotherapy-induced nausea and vomiting (CINV) continues to be a common symptom experienced by children undergoing cancer treatment despite the use of contemporary antiemetics. Integrative therapeutic approaches in addition to standard pharmacologic antiemetic regimes offer potential to control CINV. The purpose of this review was to identify current evidence on integrative therapeutic approaches for the control of CINV in children with cancer. Online search engines (PubMed, CINAHL, PsychINFO) were queried using MESH terms. Titles, abstracts, and then full-text articles were reviewed for relevance to the review. The search resulted in 53 studies. Twenty-one studies met our review criteria. Integrative therapies identified included acupuncture/acupressure, aromatherapy, herbal supplements, hypnosis, and other cognitive behavioral interventions. Our review identified little information on the effectiveness and safety of most integrative therapeutic approaches for the control and management of CINV in children with cancer. However, evidence from adult cancer studies and some pediatric studies identify promising interventions for further testing.

Prevention and management of chemotherapy-induced nausea and vomiting

Nausea and vomiting are among the most frequently experienced toxic side-effects associated with chemotherapy. Although nausea and vomiting can result from surgery or radiotherapy, chemotherapy-induced nausea and vomiting (CINV) is potentially the most severe and most distressing. Estimates regarding the incidence of CINV vary depending on the treatment administered and individual patient characteristics.The impact of CINV on quality of life (QoL) and daily activities is considerable. Pharmacological treatments are considered routine for CINV. Clinical guidelines now recommend that patients receiving moderate emetic chemotherapy (MEC) regimens be preferentially treated with palonosetron, the 5-hydroxytryptamine type 3 (5-HT3) receptor antagonist, in combination with dexamethasone. In addition, it has shown that single-dose fosaprepitant is equivalent to the standard 3-day aprepitant regimen (the neurokinin 1 (NK1) receptor antagonist). Despite these advances in antiemetic management, approximately 50% of patients receiving chemotherapy still experience nausea and/or vomiting. Further improvements are still desirable, particularly in the prevention and treatment of delayed CINV. Non-pharmacological interventions can be possible adjuncts to standard anti-emetic therapy. Using new technologies to collect patient-reported outcomes may improve the accuracy of assessment, provide a better picture of the patient's experience of these symptoms, and provide a means to simultaneously monitor symptoms, educate patients, and collect longitudinal data.

Poor chemotherapy-induced nausea and vomiting control in children receiving intermediate or high dose methotrexate

PURPOSE

Chemotherapy emetogenicity is the most important known determinant of chemotherapy-induced vomiting (CIV) in children. However, direct evidence regarding the emetogenic potential of chemotherapeutic agents in children is limited. This study describes the prevalence of complete control of acute and delayed phase chemotherapy-induced nausea and vomiting (CINV) in children receiving methotrexate. The prevalence of anticipatory CINV is described, and risk factors for CINV are explored.

METHODS

English-speaking children (4 to 18 years) receiving intermediate-dose (ID-MTX: >1 to <12 g/m(2)/dose) or high-dose methotrexate (HD-MTX: ≥12 g/m(2)/dose) participated in this prospective study. Emetic episodes, nausea severity, and antiemetic administration were documented for 24 h from the start of the methotrexate infusion (acute phase) and for up to a further 168 h (delayed phase). CINV prophylaxis was provided at the discretion of the treating physician. Anticipatory CINV was assessed in the 24 h preceding chemotherapy. Complete CINV control was defined as no emetic episodes and no nausea.

RESULTS

Thirty children (mean age, 11.8 ± 4 years; ID-MTX, 20; HD-MTX, 10) completed the study. CINV prophylaxis included the following: ondansetron/granisetron plus dexamethasone or nabilone. Few patients experienced complete CINV control (ID-MTX: acute phase 20%, delayed phase 5%; HD-MTX: acute phase 0%, delayed phase 30%). Complete emesis control was higher (ID-MTX: acute phase 70%, delayed phase 50%; HD-MTX: acute phase 70%, delayed phase 60%). Anticipatory CINV was reported by 6/28 patients (21%). Patient age, sex, and history of motion sickness were not significant predictors of CINV.

CONCLUSIONS

The poor complete CINV control rate in children receiving methotrexate confirms the classification of HD-MTX as highly emetogenic chemotherapy (HEC) and suggests that ID-MTX be reclassified as HEC.

Comparative effectiveness research in antineoplastic-induced nausea and vomiting control in children

Antineoplastic-induced nausea and vomiting (AINV) is one of the most distressing adverse effects experienced by adult and pediatric patients receiving antineoplastic agents. Despite this, evidence of the efficacy and safety of antiemetic interventions in children is limited, and prevention and treatment approaches vary widely between centers. The purpose of this review is: first, to describe the barriers to comparative antiemetic effectiveness research in AINV control in children; second, to highlight limitations of the currently available pediatric AINV evidence; third, to summarize and discuss comparative effectiveness research specific to AINV control in children, with a focus on agents recommended in evidence-based guidelines developed for acute phase AINV control; and finally, to offer guidance regarding future comparative effectiveness research in this field.

An overview of the clinical use of ondansetron in preschool age children

The introduction of 5-HT₃ receptor antagonist has revolutionized the prevention and treatment of nausea and vomiting in preschool aged children. These distressing symptoms, arising from multiple etiologies such as anesthesia, chemotherapy, and viral infection, are a major concern of patients and their families. Clinical research has demonstrated the antiemetic effectiveness of ondansetron in children. Although most of these studies focus primarily on preventing vomiting across the pediatric age group, they provide strong evidence for the use of ondansetron in preschool age children. For children at high risk, pediatric practice guidelines recommend ondansetron in conjunction with other antiemetics to achieve complete control of symptoms.

Differences in symptom occurrence, frequency, intensity, and distress in adolescents prior to and one week after the administration of chemotherapy

PURPOSE/OBJECTIVES

The purpose of this study was to describe differences in occurrence, frequency, intensity, and distress of symptoms prior to (T1) and one week following (T2) the administration of intravenous chemotherapy.

DESIGN

Longitudinal, descriptive.

SETTINGS

Two regional children's cancer centers in the Pacific Northwest.

SAMPLE

A total of 51 adolescents 10 to 19 years old receiving cancer chemotherapy.

METHODS

Memorial Symptom Assessment Scale (MSAS 7-12).

FINDINGS

No significant differences were found in symptom occurrence rates between T1 and T2. Fatigue was the only symptom with significantly greater frequency and intensity, and nausea was the only symptom with significantly greater distress at T2 compared with T1.

CONCLUSIONS

Adolescents receiving chemotherapy experience multiple symptoms that persist over time.

IMPLICATIONS FOR NURSING

In monitoring for symptoms, nurses need to be aware of the extent to which symptoms are present throughout treatment, as evidenced by these findings that symptom occurrence was significant even prior to receiving a subsequent course of chemotherapy.

Optimizing emetic control in children receiving antineoplastic therapy: beyond the guidelines

Existing guidelines for the prevention of antineoplastic chemotherapy-induced nausea and vomiting (CINV) in children are constrained by the lack of robust evidence. Current guidelines recommend the use of a serotonin 5-HT(3) receptor antagonist plus a corticosteroid to prevent acute CINV. Consequently, antiemetic agents that are recommended for use in adult cancer patients do not appear in the current pediatric guidelines. In addition, there is no information to guide the selection of alternative antiemetic agents for children who either cannot receive the recommended agents or who do not respond adequately to the treatment. Possible barriers to adherence to the pediatric antiemetic selection guidelines that are currently available are discussed, and published pediatric experience with antiemetic agents recommended in the current adult antiemetic selection guidelines (dolasetron, tropisetron, palonosetron, aprepitant) is summarized in this review. The use of novel and emerging antiemetic therapeutic interventions {metopimazine, diphenhydramine (Benadryl)-lorazepam (Avitan)-dexamethasone (Decadron) [BAD], nabilone, acupuncture, midazolam, olanzapine, mirtazapine, gabapentin, droperidol} in children are explored.

Effectiveness of hypnotherapy with cancer patients' trajectory: emesis, acute pain, and analgesia and anxiolysis in procedures

Clinical hypnosis in cancer settings provides symptom reduction (pain and anxiety) and empowers patients to take an active role in their treatments and procedures. The goal of this paper is to systematically and critically review evidence on the effectiveness of hypnotherapy for emesis, analgesia, and anxiolysis in acute pain, specifically in procedures with an emphasis on the period from 1999 to 2006. Further, it aims to provide a theoretical rationale for the use of hypnosis with cancer populations in the whole spectrum of illness/treatment trajectory in several clinical contexts. Finally, a treatment protocol for management of overt anxiety and phobic reactions in the radiotherapy suite is presented, with the intent of having such a protocol empirically validated in the future.

Perioperative hypnosis reduces hospitalization in patients undergoing the Nuss procedure for pectus excavatum

PURPOSE

To assess whether perioperative hypnosis can reduce the length of hospitalization and alter the need for postoperative analgesics in patients undergoing the Nuss procedure.

MATERIALS AND METHODS

Ten consecutive patients (age range, 12-18 years) underwent the Nuss procedure with the same operative technique. For pain management they were divided into two sequential groups: the 5 patients in the nonhypnosis group were managed with an epidural catheter, and analgesia was supplemented with intravenous or oral narcotics as requested. These patients all required Foley catheters for bladder drainage while the epidural was in place. The second group of 5 patients was prepared by teaching them self-hypnosis for postoperative pain management in one or two brief sessions. Postoperative self-hypnosis was prescribed and encouraged. These patients were allowed patient controlled analgesia and were supplemented with intravenous or oral narcotics as requested. Four of the patients in this group required a straight catheterization of the bladder the evening of surgery. Data collected included hospitalization and analgesia requirements as well as other unusual findings.

RESULTS

The patients in the hypnosis group spend an average of 2.8 days in the hospital compared with 4.6 days in the nonhypnosis group (p < 0.01). There was also a trend toward less parenteral narcotic use. Postoperative discomfort was better controlled with oral analgesics in the hypnosis group. There were no adverse effects from the hypnosis.

CONCLUSION

In this small study, perioperative hypnosis was associated with a reduced hospital stay in patients undergoing the Nuss procedure for pectus excavatum.

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.

Ginger significantly decreased the oral bioavailability of cyclosporine in rats

Ginger (roots of Zingiber officinale ROSCOE) is a popular spice and herbal medicine worldwide. Cyclosporine is clinically used as an important immunosupressant with narrow therapeutic index. This study attempted to investigate the effect of ginger juice on the pharmacokinetics of cyclosporine in rats. Rats were orally administered cyclosporine alone and in combination with ginger juice (5 ml/kg) concomitantly, as well as 2 hours after the ginger juice, respectively, in crossover designs. In addition, rats were intravenously administered cyclosporine with and without an oral dose of ginger juice (5 ml/kg). The blood samples were withdrawn via cardiopuncture at determined time points and cyclosporine concentrations were determined by a specific monoclonal fluorescence polarization immunoassay. The pharmacokinetic parameters of cyclosporine were calculated using a non-compartment model of WINNONLIN. The results indicated that concomitant intake of ginger significantly decreased C(max) and AUC(0-t) of oral cyclosporine by 70.9% and 63.1%, respectively. The intake of ginger 2 hours before cyclosporine significantly decreased C(max) and AUC(0-t) by 51.4% and 40.3%, respectively. In contrast, the pharmacokinetics of intravenous cyclosporine not altered by orally in combination with ginger juice. In conclusion, ginger significantly decreased the oral bioavailability of cyclosporine, and the interaction should occur at the absorption phase. Patients treated with cyclosporine should be discouraged from using ginger products to ensure the efficacy of cyclosporine.

The Pathophysiology of Chemotherapy-Induced Nausea and Vomiting

Chemotherapy-induced nausea and vomiting is a major debilitating side effect of oncology treatment despite recent advances in pharmaceutical management. Nurses who provide care to patients experiencing nausea and vomiting are often only marginally aware of the pathophysiological processes involved in the treatment. A better understanding of the science behind current interventions to reduce nausea and vomiting may help nurses use those interventions more effectively. This article reviews current knowledge about the pathophysiology of chemotherapy-induced nausea and vomiting. By understanding the pathophysiology behind this patient experience, gastroenterology nurses can develop a better understanding of the common symptoms of nausea and vomiting in general. When a nurse understands the complexity of factors causing nausea and vomiting, he or she will be better able to provide appropriate interventions to reduce these symptoms.

Evaluating physical function in an adolescent bone tumor population

BACKGROUND

Survival rates for patients with bone tumors have increased dramatically over the past few decades. Unfortunately, many patients face functional limitations resulting from disease management, but there is little evidence regarding physical functioning in adolescents with bone tumors. This lack is largely due to the absence of a standardized measure for evaluating adolescent sarcoma physical functioning. This review discusses considerations in searching for a measure of adolescent physical functioning, evaluates measures previously used in assessing functional outcome in young sarcoma patients, reviews self-report measures of pediatric physical functioning, and makes recommendations for future research.

PROCEDURE

Electronic databases were searched for studies published between 1980 and 2004. Studies examining physical functioning in adolescent sarcoma patients and those describing measures of pediatric physical functioning were included.

RESULTS

The study includes measures previously used in the adolescent bone tumor literature (Musculoskeletal Tumor Society, Mankin, Groningen Activity Restriction Scale, Toronto Extremity Salvage Score [TESS]), and three measures of pediatric physical function (Functional Disability Inventory, Pediatric Outcomes Data Collection Instrument [PODCI], Activities Scale for Kids [ASK]). The TESS, PODCI, and ASK each met at least four of the outlined applicability and feasibility components.

CONCLUSION

The search for a measure of physical functioning for adolescent sarcoma patients requires an exploration of many developmental and measurement issues. Based on the sensibility review presented, the TESS, PODCI, and ASK are recommended for further evaluation of content and of the measurement properties of reliability, validity, and responsiveness, prior to their use in evaluating adolescent sarcoma patients.

A pilot study of ondansetron plus metopimazine vs. ondansetron monotherapy in children receiving highly emetogenic chemotherapy: a Bayesian randomized serial N-of-1 trials design

GOALS OF WORK

Chemotherapy-induced nausea and vomiting is problematic in paediatric brain tumour treatment protocols which often discourage the use of corticosteroids as anti-emetics. The dopamine receptor antagonist, metopimazine, is an effective anti-emetic in combination with ondansetron in adults. The present study was designed to assess its efficacy in children with cancer, a group in which it has not been studied previously.

PATIENTS AND METHODS

We conducted a series of randomized, multiple-crossover, double-blind, placebo-controlled N-of-1 trials comparing ondansetron/metopimazine with ondansetron monotherapy in children with brain tumours receiving highly emetogenic therapy and combined the individual results using Bayesian statistical modeling.

MAIN RESULTS

Ten of twelve enrolled patients completed at least one chemotherapy cycle on study (median=2.5 cycles, range 1-11). Two patients were unable to complete any cycles, and a further three patients withdrew from the study prior to completing all cycles because of an inability to tolerate the taste of the study drug. Combination therapy increased the proportion of days during which patients had no emesis (overall odds ratio=1.52, 95% credible region=0.32-6.40, probability of odds ratio>1=72%), decreased the number of emetic episodes per day (overall rate ratio=0.67, 95% credible region=0.15-3.14, probability of rate ratio<1=75%) and decreased parents' ratings of their child's distress. The drug was more effective during the delayed chemotherapy phase than the acute phase. No adverse events were attributed to metopimazine.

CONCLUSIONS

Based on this pilot study, we believe that the high likelihood that metopimazine is an effective adjunct to ondansetron monotherapy suggests that this combination therapy is worthy of further study in children receiving emetogenic chemotherapy.

Integrative Medicine in Hematology/Oncology: Benefits, Ethical Considerations, and Controversies

Integrative Medicine (IM), a newly emerging field, has evolved from Complementary and Alternative Medicine (CAM). CAM refers to diverse medical and health care systems, practices, and products that are not presently considered part of conventional medicine and generally have limited scientific evidence. In the US, CAM is a multi-billion dollar, unregulated industry with potential benefits and risks to consumers, including cancer patients, who are high utilizers of complementary therapies. Patients’ CAM use often is unsupervised by physicians, yet patients need the advice and guidance of their hematologists/oncologists as part of total cancer care. Ethical and legal issues physicians need to address include inquiring about and educating patients regarding potential interactions (e.g., drug-herb, radiation-antioxidant) or product contaminants, while discussing other therapies that may alleviate symptoms and/or improve quality of life. Administratively, CAM offerings in medical settings require relevant policies and procedures, such as properly credentialing practitioners and providing financial assistance counseling for those who cannot afford fee-for-service. Unlike “Alternative Medicine,” the goal of IM is to combine mainstream medical therapies and CAM therapies (e.g., acupuncture, meditation, music therapy) that have some high-quality scientific evidence of safety and effectiveness. The Society for Integrative Oncology (SIO), a new international organization of oncology professionals studying and integrating effective complementary therapies in cancer care, serves as a forum for presenting scientific data on these therapies while emphasizing the importance of developing infrastructure that promotes IM principles and practices. The ultimate goal is to develop multidisciplinary expertise and therapeutic synergy between conventional and complementary therapies.