Reduction of carboplatin induced emesis by ondansetron

[Management of chemotherapy-induced emesis: what is the standard after 20 years of clinical research]

BACKGROUND

The knowledge of the importance, the physiopathological mechanisms, and the management of the chemotherapy-induced emesis has increased exponentially during the last 20 years. High-dosage metoclopramide (MCP) therapy has been introduced in the eighties and serotonine type-3 receptor antagonists (5-HT(3) antagonists) have been used since the late eighties and early nineties. Due to both classes of substances the results of the antiemetic therapies have improved drastically. After 20 years of intensive clinical research it seems to be appropriate to come to an intermediate conclusion.

METHOD

With the aid of an overview and a new analysis of the literature published on this topic so far, the current state of research is shown (including the fields in which further improvement will be necessary), and suggestions are made, wherever it seemed possible, to attain the "gold standard" in antiemetic therapy.

RESULTS AND CONCLUSIONS

In connection with all highly or very highly emetogenic chemotherapies, an antiemetic prophylaxis should be initiated on the day of therapy, especially when using platinum or most of the cyclophosphamide-based regimes for cancer treatment. The recommended prophylaxis consists of a combination of 5-HT(3) antagonists with a corticosteroid. To combat the so-called delayed emesis on the days following therapy, all patients should undergo an oral corticoid therapy, possibly in combination with MCP (especially platinum-therapy patients), less frequently with 5-HT(3) antagonists. With these means of prophylaxis emesis can be prevented/avoided completely in most patients, and nausea can at least be reduced. It is sufficient to administer a single dose of 5-HT(3) antagonists prior to chemotherapy. For ondansetron and granisetron, the best documented substances within this class of drugs, 8 mg (ondansteron) and 3 mg (granisetron) are considered standard dosages. Among the corticoids, most data have been accumulated for dexamethasone. A standard dose of 10 to 20 mg can be administered prior to chemotherapy. Right after and especially on the days following chemotherapy higher dosages seem to be indicated.

PROSPECT

Further therapy improvements, especially concerning emesis and nausea on the days following chemotherapy, are necessary and are currently object of clinical research.

Effectiveness of serotonin-receptor antagonist antiemetic therapy over successive courses of carboplatin-based chemotherapy

PURPOSE

There are extremely limited data available in the general oncology or gynecologic cancer literature to document the effectiveness of antiemetic therapy over multiple courses of cytotoxic chemotherapy.

METHODS

To examine this highly clinically relevant issue, we analyzed the complete treatment course of patients with gynecologic cancers receiving carboplatin-based chemotherapy regimens who had participated in one of four institutional serotonin-receptor antagonist antiemetic trials, which had specifically evaluated the benefits of such therapy during only the first treatment course. Medical records were reviewed to examine the development of emesis during subsequent chemotherapy treatment cycles.

RESULTS

The 91 patients included in this analysis received a median of 6 courses (range 1-18) of carboplatin (initial AUC dose 4, 5, and 6 in 29, 29, and 32 patients, respectively). All received ondansetron or granisetron plus dexamethasone with every treatment course. Complete control of emesis (no acute or delayed nausea or vomiting) was experienced by 56 (62%) patients during every cycle. Conversely, 20% of women noted one or more episodes of nausea without vomiting and 19% developed at least one incidence of vomiting. In no case was emesis considered to be severe (grade 3), and no patient required either discontinuation of carboplatin or a dose reduction due to the development of emesis.

CONCLUSION

In the large majority of patients, serotonin-receptor antagonist antiemetic therapy, administered in combination with dexamethasone, is highly effective over multiple courses in preventing significant carboplatin-induced nausea and vomiting.

Evidence-based management of constipation in the oncology patient

Constipation is suffered by over 50% of cancer patients and is regarded as one of the most distressing symptoms causing both physical and emotional distress. A need to treat constipation is often due to a failure to prevent it. There is little literature in this area and research based on clinical trials as to best treatment is virtually non-existent. It is suggested that many health-care professionals dismiss constipation as a relatively trivial problem, resulting in a lack of attention to the subject. There is a lack of consensus on the definition of constipation and confusion regarding effective methods for prevention and treatment. It could be argued that health-care professionals are more intent on monitoring the direct effects rather than the secondary effects of treatment. Since constipation is largely preventable, there is a need to highlight the importance of prevention in addition to establishing effective treatment guidelines. Oncology nurses are in an ideal position to identify cancer patients in a high-risk category and utilize preventive strategies. The study described has led to the development of evidence-based drug guidelines to be used in the prevention of constipation and acute/chronic constipation to ensure that patients receive the best treatment possible.

The antiemetic efficacy of oral ondansetron plus intravenous dexamethasone in patients with gynecologic malignancies receiving carboplatin-based chemotherapy

PURPOSE

The purpose of this study was to develop a cost-effective prophylactic antiemetic regimen for the prevention of carboplatin-induced emesis.

METHODS

Patients being treated in the Gynecologic Cancer Program of the Cleveland Clinic Taussig Cancer Center with a carboplatin-based chemotherapy regimen received a prophylactic antiemetic program consisting of a single dose of oral ondansetron (16 mg) plus intravenous dexamethasone (20 mg) approximately 30 min prior to chemotherapy. Evaluation of the effectiveness of this antiemetic regimen was performed during a single treatment course.

RESULTS

A total of 27 patients (median age, 62; range, 41-83) participated in this phase 2 trial. Three patients received single-agent carboplatin, and 24 were treated with either a carboplatin/paclitaxel or carboplatin/docetaxel regimen. The carboplatin AUC dosing level was 4, 5, or 6 in 6, 5, and 16 individuals, respectively. No patient developed vomiting; 2 (7%) individuals experienced nausea during the 24-h period following chemotherapy administration.

CONCLUSION

The combination of a single dose of oral ondansetron (16 mg) plus intravenous dexamethasone (20 mg) is an effective prophylactic antiemetic regimen for patients receiving carboplatin-based chemotherapy.

Ondansetron versus placebo for the control of nausea and vomiting during Caesarean section under spinal anaesthesia

This prospective, randomised, placebo-controlled, double-blind study was performed to evaluate the effects of ondansetron on nausea and vomiting during elective Caesarean section under spinal anaesthesia. Seventy-four full-term parturients were studied. After umbilical-cord clamping, ondansetron 4 mg or 0.9% saline was injected intravenously and the study period continued for 2 h. The severity of nausea was graded from 0 = none to 10 = maximum, while that of vomiting was graded from single = once per min to continuous = multiple per min. The incidence of vomiting was lower following ondansetron (36%) compared with the control group (58%, p < 0.028). Neither the severity of vomiting nor the incidence of nausea was influenced by ondansetron. However, for those who experienced nausea, ondansetron reduced its severity (p = 0.05). We conclude that the intra-operative administration of 4 mg ondansetron intravenously during Caesarean section under spinal anaesthesia significantly reduces the incidence of vomiting and the severity of nausea.

Low-dose oral granisetron (1 mg) plus intravenous dexamethasone: efficacy in gynecologic cancer patients receiving carboplatin-based chemotherapy

OBJECTIVE

The objective of this study was to determine the efficacy of a low-dose oral granisetron plus intravenous dexamethasone prophylactic antiemetic regimen in patients receiving carboplatin-based chemotherapy.

PATIENTS AND METHODS

Patients with gynecologic malignancies being treated with either single-agent carboplatin or a carboplatin-paclitaxel regimen received a single 1-mg oral dose of granisetron 30 min prior to chemotherapy plus intravenous dexamethasone (20 mg) as prophylaxis for emesis. Patients either had not previously been treated with chemotherapy or had not received any cytotoxic drugs for >/=4 months prior to study entry. Effectiveness was evaluated based on the degree of control of nausea and vomiting during the 24 h following treatment.

RESULTS

Of the 32 patients participating in this phase 2 trial, only 2 (6%) experienced any degree of nausea or vomiting within the first 24 h of chemotherapy administration. Both of these individuals had carcinomatosis and were experiencing emesis prior to chemotherapy. One patient developed mild delayed nausea >24 h after treatment. No major or minor toxic effects of the antiemetic regimen observed.

CONCLUSION

A 1-mg dose of oral granisetron plus intravenous dexamethasone (20 mg) is a safe, effective, and relatively inexpensive prophylactic antiemetic regimen for patients receiving single-agent carboplatin or combination carboplatin-paclitaxel chemotherapy.

Low-dose intravenous ondansetron (8 mg) plus dexamethasone: an effective regimen for the control of carboplatin-induced emesis

Twenty-nine patients with gynecologic malignancies were treated with a fixed low dose of intravenous ondansetron (8 mg) plus dexamethasone (20 mg) in an effort to develop an effective and less expensive antiemetic regimen for the control of carboplatin-induced emesis. Twenty-six (90%) of the women participating in this trial experienced complete control of both acute nausea and vomiting (developing within the first 24 h after chemotherapy administration), while 27 (93%) patients exhibited either complete or major control (< or = 2 episodes of vomiting, < or = 5 episodes of retching, minimal interference with eating) of emesis. On the basis of our experience in this trial, we conclude that the combination of low dose (8 mg) intravenous ondansetron plus dexamethasone is a well-tolerated and highly cost-effective antiemetic strategy for individuals receiving carboplatin-based chemotherapy.

Constipation and diarrhea: the neglected symptoms

OBJECTIVE

To review the symptom experience of constipation and diarrhea related to cancer and its treatment.

DATA SOURCES

Published articles and book chapters relating to constipation and diarrhea in patients with cancer.

CONCLUSIONS

Constipation and diarrhea often represent a major concern and source of discomfort for the cancer patients. Research is needed to establish prevention and treatment protocols for patients at risk for constipation or diarrhea.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses are in an excellent position to recognize individuals who are at high risk for constipation and diarrhea. Preventive strategies and treatment protocols are of utmost importance.

Comparative adverse effect profiles of platinum drugs

Since the discovery of the biologically active platinum complexes 30 years ago, 2 agents have become widely established in clinical oncology practice. Both cisplatin and carboplatin are platinum(II) complexes with 2 ammonia groups in the cis- position. However, they differ in their solubility, chemical reactivity, dichloride or alicyclic oxygenated leaving groups, pharmacokinetics and toxicology. Cisplatin causes severe renal tubular damage and reduces glomerular filtration, and requires concurrent saline hydration and mannitol diuresis to eliminate potentially lethal and unacceptable damage to the kidneys. Carboplatin, at conventional doses, causes no decrease in glomerular filtration and only minor transient elevations in urinary enzymes. Cisplatin is the most emetic cancer drug in common use, while nausea and vomiting associated with carboplatin are moderately severe. Serotonin release from enterochromaffin gut mucosal cells and stimulation of serotonin 5-HT3-receptors mediates acute emesis. Selective inhibitors of the 5-HT3-receptor protect against cisplatin- and carboplatin-induced nausea and vomiting. Peripheral neurotoxicity is the most dose-limiting problem associated with cisplatin. Loss of vibration sense, paraesthesia and sensory ataxia comes on after several treatment cycles. Carboplatin, however, is relatively free from peripheral neurotoxicity. Audiometry shows cisplatin-induced ototoxicity in 75 to 100% of patients, which may be associated with tinnitus and hearing loss. Ototoxicity is rare with conventional dose carboplatin therapy. Monitoring hearing with audiograms may identify early signs before significant impairment occurs. Cisplatin causes mild haematological toxicity to all 3 blood lineages. Haematological toxicity is dose-limiting for carboplatin, with thrombocytopenia being a greater problem than leucopenia. Although carboplatin is not toxic to the kidney, renal function markedly affects the severity of carboplatin-induced thrombocytopenia. The major clearance mechanism of cisplatin is irreversible binding in plasma and tissues, while carboplatin is cleared by glomerular filtration. Metabolism of cisplatin to aqua, amino acid and protein species is extensive, whereas carboplatin exists mainly as the free unchanged form. Strong relationships between carboplatin renal clearance, glomerular filtration rate, area under the plasma concentration-time curve (AUC) of filterable platinum and severity of thrombocytopenia have prompted dose adjustment according to renal function. New analogues such as JM216 offer the potential advantages of oral administration and few nonhaematological toxicities. Analogues based on the diaminocyclohexane ligand have encountered problematic neurotoxicity.

Comparison of ondansentron versus ondansentron plus methylprednisolone as antiemetic prophylaxis during cisplatin-containing chemotherapy

We compared the antiemetic efficacy of ondansentron versus ondansentron and corticosteroids in cisplatin-induced emesis. None of our patients had received prior chemotherapy. All patients received chemotherapy including cisplatin 100 mg/m2. Forty patients received ondansentron alone (Group A) and 40 the combination of ondansentron and methylprednisolone (Group B). Ondansentron was given at a dose of 8 mg in 100 mL N/S over 10 min by intravenous infusion. The initial dose was administered before the cisplatin and was followed by 8 mg orally in the afternoon and before sleeping the first day of chemotherapy. During the next 2 days, the patients received 8 mg orally 3 times daily. Methylprednisolone was given as an intravenous bolus of 40 mg before chemotherapy and then together with each dose of ondansentron at a dose of 16 mg orally. Group A had significantly longer duration of nausea after chemotherapy than group B (117 +/- 111 min, 62 +/- 71 min, P < 0.013). The response on emesis was also improved in group B, especially the day of chemotherapy [treatment failure: group A: 13 patients (30%) versus group B: 5 patients (11.6%), P < 0.03] and the next day [complete response: group A: 17 patients (39.5%) versus group B: 30 patients (69.7%), P < 0.005]. Patients in group B presented more sedative effects (P < 0.001) and better appetite (P < 0.02) than patients in group A. There were no other significant differences in side effects (activity, headache, constipation, etc). We conclude that corticosteroids improve the antiemetic efficacy of ondansentron in cisplatin-induced chemotherapy, and should be included in antiemetic regimens.

Ondansetron. An update of its therapeutic use in chemotherapy-induced and postoperative nausea and vomiting

Ondansetron is a selective 5-HT3 receptor antagonist which has previously been reported in the Journal to be a promising new agent for use as prophylaxis against nausea and vomiting caused by chemotherapy and radiotherapy. Since the publication of this original review, further studies have been published that show ondansetron to be an effective antiemetic agent in patients receiving chemotherapy and radiotherapy. Several studies have shown ondansetron to be a more effective antiemetic agent than high-dose metoclopramide in patients with emesis induced by high- and low-dose cisplatin treatment, and noncisplatin chemotherapy-induced emesis. The drug as mono-therapy does not appear to offer any advantage over alternative therapies against delayed high-dose cisplatin-induced nausea and vomiting; however, extremely limited data suggest that ondansetron plus dexamethasone may be useful in this indication. Trials have shown combination therapy with ondansetron and dexamethasone to be significantly more effective than both ondansetron monotherapy and a standard antiemetic regimen comprising metoclopramide, dexamethasone and diphenhydramine against acute high-dose cisplatin-induced emesis. Results from a number of small scale trials suggest that ondansetron may be an effective treatment for chemotherapy-induced emesis refractory to conventional antiemetic therapy. Ondansetron also appears to be more effective against refractory emesis induced by noncisplatin chemotherapy than that induced by cisplatin chemotherapy. Several trials have shown ondansetron to be more effective than placebo as prophylaxis against postoperative nausea and vomiting; a further trial has shown single-dose ondansetron to be significantly more effective than single-dose droperidol or metoclopramide in this indication. In addition, several trials have shown ondansetron to be more effective than placebo as treatment for nausea and vomiting that has commenced postoperatively. The overall incidence of adverse events in ondansetron recipients during chemotherapy-induced emesis studies was 36%. Headache and constipation are the most common adverse events during ondansetron therapy. Thus, recent data affirms the efficacy of ondansetron in the treatment of acute chemotherapy-induced nausea and vomiting and shows it to be especially efficacious when combined with dexamethasone. It appears that the drug will also have a substantial role in the prophylaxis and treatment of postoperative nausea and vomiting.

Ondansetron: a pharmacoeconomic and quality-of-life evaluation of its antiemetic activity in patients receiving cancer chemotherapy

Ondansetron is more effective than high-dose metoclopramide in the prevention of acute nausea and vomiting due to highly emetogenic chemotherapy, and, unlike metoclopramide, is rarely associated with extrapyramidal effects. Pharmacoeconomic analyses have demonstrated that, in specified clinical settings, ondansetron (8mg 4-hourly for 3 doses or 8mg followed by 1 mg/h for 24 hours) is equally cost-effective as high-dose metoclopramide (3 mg/kg followed by 0.5 mg/kg/h for 8 hours) in the prophylaxis of emesis in patients receiving highly emetogenic chemotherapy, at an acquisition cost 4- or 5-fold higher than that of the metoclopramide regimen. Furthermore, the combination of dexamethasone plus ondansetron has been shown to be more effective than ondansetron monotherapy in controlling emesis. In patients receiving high-dose ( greater than 50 mg/m2) cisplatin-based chemotherapy, antiemetic therapy with ondansetron (8mg intravenously as a single dose) plus dexamethasone (16mg total intravenous dose) was shown to be more cost-effective than the combination of high-dose metoclopramide (11 mg/kg total intravenous dose), dexamethasone (8mg intravenously as a single dose) plus lorazepam (1 to 1.5mg intravenously as a single dose). In a limited number of studies, quality-of-life scores, as assessed using the Rotterdam Symptom Checklist or the Functional Living Index--Emesis instrument, were significantly higher with ondansetron than with other antiemetic agents, including metoclopramide. Together, these results suggest that ondansetron, as an alternative to antiemetic regimens including high-dose metoclopramide, is appropriate cost-effective therapy for the prevention of acute nausea and vomiting in patients receiving highly emetogenic chemotherapy. Ondansetron is effective in controlling acute emesis associated with moderately emetogenic chemotherapy, and its use in this clinical setting may best be reserved for patients who have not responded well to previous antiemetic therapy with more traditional agents. However, poorly controlled emesis can lead to anticipatory nausea and vomiting in subsequent courses of chemotherapy, thus, consideration should also be given to the use of ondansetron in patients receiving moderately emetogenic chemotherapy, although further pharmacoeconomic investigations are required to clarify its use in this clinical setting.