Chemotherapy induced nausea and vomiting (CINV) is a side effect that can be mitigated or avoided by the appropriate prophylactic medications. Nausea and vomiting associated with cancer chemotherapy are experienced by 70%-80% of patients receiving chemotherapy and 10% to 44% experience anticipatory nausea and/or vomiting. (Morran 1978, Morrow 1991) This can result in significant morbidity. CINV impacts self-care and functional ability, and cause a decline in performance status. In addition, CINV can result in metabolic imbalances, anorexia, esophageal tears, and wound dehiscence. As a result, patients who may benefit from potentially effective therapy may display poor adherence or withdraw from further chemotherapy. (Ingle 1984, Ricahrdson 1988)
National Comprehensive Cancer Network (NCCN) Guidelines recommend that the choice of antiemetic therapy should be based on the emetic risk associated with the chemotherapy to be administered, the dosage, schedule, and route of administration, and the patient's prior experience with antiemetics. Consideration must also be given to patient-associated factors, including age, sex, prior chemotherapy, and history of alcohol consumption. The main goal is to prevent CINV. Patients need to be protected throughout the entire period of risk, as different chemotherapeutic agents have different emetogenic potentials postadministration. (NCCN 2009, Jordan 2007, Grote 2006)
The emetogenic potential of the specific chemotherapeutic agent being administered is directly related to the frequency of CINV. Although several classifications have been developed to define the emetogenic potential of chemotherapeutic agents, none has been universally accepted. (Moreno 2002) Hesketh et al. developed a classification system and an algorithm to define the emetogenic potential of combination regimens. (Grunberg 2005) This system was updated by Grunberg et al. and forms the basis of current consensus guidelines. Although implementation of guidelines provides a better control of CINV with higher complete response rate, data indicate that some practitioners still do not treat their patients according to the recommendations. Poor control of CINV and delayed emesis may lead to impaired quality of life and decreased compliance with treatment. (Jordan 2007)
Several classes of antiemetic drugs are available to prevent or treat CINV. Older agents include phenothiazines, antihistamines, and corticosteroids. Serotonin (5-HT3) receptor antagonists became available in the 1990s for use in preventing CINV. NK-1 receptor antagonists has also been introduced for use in combination therapy regimens. The development of the 5-HT3-receptor antagonists represent a significant advances in antiemetic therapy. However, despite this introduction of new and more effective antiemetic agents, emesis remains a significant complication of chemotherapy because clinicians are not knowledgeable of the multititue of treatment options and how best to incorporate them into clinical practice. (Jordan 2007, Jordan 2009)
To address concerns that patients are not receiving adequate prophylaxis for delayed emesis, guidelines and recommendations have been recently revised to incorporate control of both acute and delayed emesis into a single dosing schedule algorithm. In addition, as new data concerning antiemesis (eg, new agents, novel regimens, dosing and administration schedules) become available, it is recommended that clinicians and patients alike consider these data when initiating emetogenic chemotherapy. (Jordan 2009, Aziz 2008, Herrstedt 2008)
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The NCCN Clinical Practice Guidelines in OncologyTMAntiemesis (Version 3.2009). 2009 National Comprehensive Cancer Network, Inc. Available at: NCCN.org. Accessed May 1, 2009. To view the most recent and complete version of the NCCN Guidelines, go online to NCCN.org.