Download File - Kelly Jones RN

Running head: CHEMOTHERAPY-INDUCED NAUSEA AND VOMITING
Treatments of Chemotherapy-Induced Nausea and Vomiting in Cancer Patients
Kelly Jones
Ferris State University
1
CHEMOTHERAPY-INDUCED NAUSEA AND VOMITING
Abstract
This paper is an analysis of pharmacologic and non-pharmacologic treatments for
chemotherapy-induced nausea and vomiting (CINV). Medications that support the prevention
and treatment of this condition as well as the evidence that supports the research are discussed.
The effect of patients experiencing CINV on the nursing staff is outlined in this paper. Lastly,
non-pharmacologic methods are outlined as well as the evidence that supports those methods.
2
CHEMOTHERAPY-INDUCED NAUSEA AND VOMITING
3
Treatments of Chemotherapy-Induced Nausea and Vomiting in Cancer Patients
Chemotherapy-induced nausea and vomiting (CINV) in cancer patients is a common
issue. This problem can cause extreme distress to the patient. There are different levels of
CINV. The first is acute or anticipatory CINV which develops within 24 hours of receiving
chemotherapy. The next level is delayed CINV which can develop 24 hours after chemotherapy
and last several days after the treatment (Rice, 2011, p.1). When the patient is experiencing
CINV, this not only affects the plan of care that the nurse is attempting to adhere to, but it also
affects retention of education and information given to the patient during this time. The task of
the nurse to educate and treat the patient can become severely compromised when the patient is
experiencing these undesired side effects. The goal of this paper is to explain the different types
of pharmacological and non-pharmacological treatments for CINV, as well as present evidence
related to the treatments and analysis of the evidence.
Pharmacologic Treatments
There have been recent advances in medications that have increased the number of
pharmacologic medications used to treat CINV. There are four categories of antiemetic
therapies. These categories include 5-Hydoxytryptamine3 (5-HT3) Antagonists, Neurolkinin 1
(NK1) Receptor Antagonists, Corticosteroids, and Miscellaneous Agents (Rice, 2011, p.3).
There are several medications that fall within these categories. The 5-HT3 Antagonists
medications include dolasetron (Anzemet), granisetron (Kytril), ondansetron (Zofran),
palonosetron (Aloxi), and tropisetron (not available in the United States) ( Rice, 2011, p.3).
These 5-HT3 medications work by binding to 5-HT3 receptors within the central and peripheral
nervous system which blocks the chemoreceptor trigger zone (CTZ) (Rice, 2011, p.2). The next
group of medications is the NK1 Receptor Antagonists. This group includes aprepitant (Emend)
CHEMOTHERAPY-INDUCED NAUSEA AND VOMITING
and fosaprepitant. These medications are used in combination with other medication to decrease
or eliminate the CINV. They are utilized for delayed CINV by binding to the NK1 receptor and
blocking substance P (Rice, 2011, p.2). Corticosteroids are also used to relieve CINV.
Dexamethasone and methylprednisone are the medications that fall within this category. Both
are used in combination with either antagonist groups (Rice, 2011, p.2-3). Lastly, there is a
miscellaneous group of agents that can contribute to the prevention or treatment of CINV. The
medications that fall within this group are metoclopramide, compazine, cannabinoids,
benzodiazepines and antihistamines (Rice, 2011, p.3). Metoclopramide, compazine, and
cannabinoids are utilized only when other treatments are unsuccessful. Benzodiazepines and
antihistamines are also not recommended for single use agents but in combination with other
therapies (Rice, 2011, p.3).
Non-Pharmacologic Treatments
Non-pharmacologic treatments are not as well known as actual pharmacologic
treatments. There are a few interventions that could be effective in the treatment of CINV.
Some of these interventions are acupuncture, guided imagery, music therapy, and muscle
relaxation (Pieszak, 2011, p.4-5). Acupuncture is a “family of procedures involving the
stimulation of points on the body using a variety of techniques” (NCCAM, 2012, p.1). Guided
imagery is a technique used by focusing on pleasant images to override any unpleasant thoughts
and images. Music therapy can be utilized by simply listening to soothing music to reduce
unpleasant surroundings. Lastly, muscle relaxation is a technique used to “counteract the ill
effects of stress” (NCCAM, 2013, p.1). There are also a small group of non-pharmacological
treatments that effectiveness has not been established. The treatments include acustimulation
4
CHEMOTHERAPY-INDUCED NAUSEA AND VOMITING
5
with a wristband device, Chinese Herbal Medicine, exercise, ginger, hypnosis, massage therapy,
aromatherapy, yoga, and progressive muscle relaxation.
Evidence Related to Treatment
According to the evidence, prevention of CINV is critical in the management of patients
with cancer. The 5-HT3 receptor antagonists are known as the “gold standard” treatment in
providing the most effective control of CINV (Schnell, 2003, p.8). It also suggests that 5-HT3
antagonist effectiveness is further increased by the combination treatment with corticosteroids.
This treatment is now recommended by United States Guidelines (Schnell, 2003, p.8). The
proposed treatment regimen for anticipatory nausea and vomiting is using benzodiazepines along
with alprazolam and lorazepam the night prior to the treatment as well as the morning of the
treatment (Pieszak, 2011, p.3). According to Pieszak (2011, p.4), the treatment of acute or
delayed nausea and vomiting is detailed below.
Highly and moderately emetogenic




5-HT3 receptor antagonists
o Palonosetron
o Granisetron
o Ondansetron
o DolasetronM
o Tropisetron
Neurokinin 1 (NK1) receptor antagonist
o Aprepitant
o Fosaprepitant
Corticosteroid
o Dexamethasone
Benzodiazepine
o Lorazepam
CHEMOTHERAPY-INDUCED NAUSEA AND VOMITING
6
Low emetogenic




Corticosteroid
o Dexamethasone
Metoclopramide with or without diphenhydramine
Phenothiazine
o Prochlorperazine
Benzodiazepine
o Lorazepam
In addition to the above recommendations, the medical staff must also consider dosage, timing
and combinations of the medications (Pieszak, 2011, p.4).
Non-pharmacologic treatments are not as easy to come by. Acupressure evidence has
shown some reduction in CINV compared to no intervention at all (Pieszak, 2011, p.5). The
collection of guided imagery, music therapy, and muscle relaxation supports the reduction of
nausea and vomiting as well as retching for anticipatory CINV (Pieszak, 2011, p.5).
Analysis of the Evidence
According to the evidence found, the recommendation for the use of 5-HT3 medications
is the most appropriate selection for CINV. The information also presented supports the use of
corticosteroids with the use of 5-HT3 medication in patients suffering from CINV. In addition to
utilizing the best practices for CINV via pharmacologic interventions, other treatments could
also be effective as well as the use of benzodiazepines along with alprazolam and lorazepam the
night prior to chemotherapy treatment. Although there is not enough evidence to support other
treatments such as acupuncture and guided imagery, they could be used in combination with the
other pharmacological treatments to provide some assistance to decrease the effects of CINV.
Recommendations
Due to the substantial positive evidence utilizing the 5-HT3 treatments, I would defiantly
recommend using this group of medications. This treatment is not only the gold standard of
CHEMOTHERAPY-INDUCED NAUSEA AND VOMITING
7
treatments for CINV, but is also recommended by United States Guidelines (Schnell, 2003, p.8).
I would also feel comfortable recommending acupuncture in combination with the
pharmacologic treatments. I would utilize this treatment to decrease the effects of CINV.
Although there is no scientific evidence supporting this treatment, it could support the patient by
using a non-pharmacologic route.
Conclusion
This paper provided an opportunity to describe several pharmacologic and nonpharmacologic treatments for CINV. The evidence supports specific medications that are
effective for cancer patients that are experiencing CINV such as 5-HT3 treatments. Although
there are some non-pharmacologic methods of treating CINV, there is evidence lacking to
confirm exactly how these treatments assist with this condition. Lastly, an analysis of the
evidence was provided for both pharmacologic and non-pharmacologic treatment methods. In
conclusion, nursing will always need to advocate for the proper treatment for their patients as
well as implementing nursing interventions and treatment in the plan of care that is appropriate.
CHEMOTHERAPY-INDUCED NAUSEA AND VOMITING
8
References
National Center for Complementary and Alternative Medicine (NCCAM) (2012, September 10).
Acupuncture. Retrieved from
http://nccam.nih.gov/health/acupuncture
National Center for Complementary and Alternative Medicine (NCCAM) (2013, February).
Relaxation Techniques for Health: An Introduction. Retrieved from
http://nccam.nih.gov/health/stress/relaxation.htm?nav=gsa
Pieszak, S. (2011). Evidence-based interventions for chemotherapy-induced nausea and
vomiting. American Nurse Today, 6(10), 1-5.
Rice, M. M. (2011, July 16). Management of Chemotherapy-Induced Nausea and Vomiting.
Retrieved from
http://www.oncolink.org/resources/article1.cfm?c=425&id=1004#.UUHu0ldv7i4
Schnell, F. M. (2003). Chemotherapy-Induced Nausea and Vomiting: the Importance of Acute
Antiemetic Control. The Oncologist, 8(2), 187-198.
Schwartzberg, L. S. (2007, July 1). Chemotherapy-induced Nausea and Vomiting: Which
Antiemetic for Which Therapy. Retrieved from
http://0go.galegroup.com.libcat.ferris.edu/ps/retrieve.do?sgHitCountType=None&sort=DASORT&inPS=true&prodId=AONE&userGroupName=lom