Download Palonosetron plus Dexamethasone versus Ginger to Treat Nausea

Palonosetron plus Dexamethasone
Running head: PALONOSETRON PLUS DEXAMETHASONE VERSUS GINGER
Palonosetron plus Dexamethasone versus Ginger to Treat Nausea and Vomiting in Advanced
Cancer
Cheryl R. Klinkner
Ferris State University
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Palonosetron plus Dexamethasone
Abstract
This paper will compare the use of palonosetron plus dexamethasone versus ginger in treating
chemotherapy induced nausea and vomiting (CINV). It will review past and current research
regarding the treatment of CINV. CINV is a crippling symptom over 70% of all chemotherapy
patients’ experience. With over 100 different types of known cancer, research will continue to
improve treatments and symptoms which may accompany cancer treatments. As nurses it is our
responsibility to understand current treatment options and offer support and education to our
patients.
Keywords: palonosetron, dexamethasone, ginger, chemotherapy, nausea,
vomiting, CINV, cancer
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Palonosetron plus Dexamethasone
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Palonosetron plus Dexamethasone versus Ginger to Treat Nausea and Vomiting in Advanced
Cancer
Introduction
Nausea and vomiting are very common and disturbing complications related to
chemotherapy treatment. Individuals who have advanced cancer might need to undergo
chemotherapy treatment in order to have a better prognosis. “Between 500,000 and 1 million
Americans receive chemotherapy each year, and a high proportion -as many as- 80% experience
adverse effects” (Hawkins & Grunberg, 2009, p. 54). Chemotherapy induced nausea and
vomiting (CINV) is the most feared adverse effect from chemotherapy (Hawkins & Grunberg).
There are numerous treatments available for CINV but this paper will focus on the use of
palonosetron plus dexamethasone as the pharmalogical treatment and ginger as the nonpharmacological treatment for these symptoms. Nausea and vomiting can affect a patient’s
quality of life and make it hard for them to function on the daily basis. “In some cases, patients
may refuse to continue potentially beneficial treatment regimens because of treatment associated
nausea and vomiting” (Hawkins & Grunberg, p. 55). Despite improvements in the health care
industry CINV in patients continues to be a problem.
Nurses need to be aware of the treatment options available for CINV. As an advocate for
our patients, nurses need to clearly communicate the patients’ history to all medical personal. An
assessment of the patients’ current medication is important at each visit; since chemotherapy
might not be the only medication causing nausea and vomiting. “A careful initial patient history
can identify risk factors for CINV and may suggest a more or less aggressive approach
depending on the chemotherapy regimen being used” (Hawkins & Grunberg, 2009, p. 59).
Nurses need to understand the pharmalogical as well as the non-pharmalogical options available
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as well as provide support and education. Failure to understand the seriousness of CINV can
delay treatment and result in poor patient outcomes.
Descriptive Summary
Palonosetron plus Dexamethasone
There are numerous pharmalogical treatments available to help with CINV. “A key
advance in the prevention of CINV was the development of selective type three 5hydroxytryptamine (5-HT3) receptor antagonists, a drug class that has a high therapeutic index
for prevention of CINV” (Hesketh, 2013, p. 2). There are different generations of 5-HT3
receptor antagonists; first and second. “Dolasetron, granisetron, ondansetron and tropisetron are
all first-generation 5-HT3 receptor antagonists” (Hawkins & Grunberg, 2009, p. 57).
“Palonosetron is the only second generation 5-HT3 receptor antagonists” (Saito et al., 2009).
Depending on the patients chemotherapy dose and treatment will predict what medication or
combination of medication can assist in resolving symptoms. “Evidence shows palonosetron is
more effective than first-generation 5-HT3 receptor antagonists in preventing CINV” (Hesketh,
p. 2).
In 2003, “palonosetron was more effective than dolasetron for delayed CINV in a trial
conducted in 592 patients receiving moderately emetegic chemotherapy (MEC)” (Hawkins &
Grunberg, 2009, p. 57). Additional studies have proven the same results.
A double- bind trial with palonosetron versus ondansetron in 570
patients receiving MEC found that palonosetron was not only
significantly superior to ondansetron for prevention of delayed
CINV but also for acute CINV. Complete responses occurred in
81% of palonosetron-treated patients versus 68.6 % of ondansetron-
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treated patients for acute CINV and 74.1 % and 55.1% of those patients,
respectively for delayed CINV. (Hawkins & Grunberg, 2009, p. 57)
In addition to using 5-HT3 receptor antagonists, corticosteroids are used in combination
with antiemetics. The combination of these two drugs together can greatly reduce CINV
symptoms. “The mechanism is not known, but is has been speculated that it may involve
modification of capillary permeability of the chemoreceptor trigger zone, reduction in
inflammatory changes in the gut after chemotherapy” (Hawkins & Grunberg, 2009, p. 57).
Dexamethasone is the most common steroid used in addition to antiemetics. “A head-to-head
comparison of palonosetron plus dexamethasone versus ondansetron plus dexamethasone in 667
patients receiving highly emetogenic chemotherapy (HEC) found that regimen containing
palonosetron was more effective for delayed CINV than ondansetron, with a complete response
of 42% versus 28.6% for those agents, respectively” (Hawkins & Grunberg, p. 57). Numerous
studies and trials have gone on since the early 80’s to come to the same conclusion. According to
Hesketh (2013), “when used in combination with glucocorticoids, palonosetron provides superior
control of delayed emesis compared to first-generation 5-HT3 receptor antagonists combined
with glucocorticoids” (p.4).
Ginger
Ginger (Zingiber officinale) is an ancient spice which has been known to decrease nausea
and vomiting in ill patients. “Ginger has a long history of use as a home remedy against nausea,
including nausea caused by drugs. It is slowly earning a reputation for its ability to quell nausea
induced by some drugs-particularly chemotherapy” (Abascal & Yarnell, 2009, p. 232).
There was a study conducted in 2012, “which concluded ginger supplementation at daily
dose of 0.5g-1.0g significantly aids in reduction of the severity of acute chemotherapy-induced
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nausea in adult cancer patients” (Ryan et al., 2012, p. 1479). This study included 744 cancer
patients dividing them into 4 groups: placebo, .5g of ginger, 1.0g of ginger and 1.5 mg of ginger.
At the conclusion of the study 576 patients were included in the final analysis resulting in the
largest decrease in nausea for the patients in the .5g of ginger and 1.0g of ginger (Ryan et al., p.
1487).
According to a study in 2011, “composed of intervention (n=15) and control (n=30)
patients where control patients received antiemetic drugs for ethical reasons and intervention
patients received two ginger tablets 400mg each” (Alparslan et al., 2012, p. 16). Alparslan, 2012
concluded, “no nausea or vomiting was found to have occurred in those receiving ginger. The
rate of nausea and/or vomiting was 76.7 % in the group using only antiemetic drugs. A
significant difference was found between the group receiving ginger and the group receiving
antiemetic drugs, suggesting that ginger is effective for nausea and/or vomiting (p<0..05)” (p.
17).
Critical Appraisal
Palonosetron plus Dexamethasone
The evidence supporting the use of palonosetron plus dexamethasone as an antiemetic in
CINV patients shows improvement with nausea and vomiting in the studies stated above. The
main strength in these studies is the large sample size. With over 100 different types of cancers;
treatment with chemotherapy will continue. As the survival rate for cancer increases every year
research will continue to be done. Since CINV is different for every patient studies will continue
in order to find the exact treatment which works for each individual.
In the study by Hawkins and Grunberg (2009), evidence clearly states, “participants
talked about the difficulty of finding enough time to properly address assessment and
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documentation as well as follow up. 76% of the nurses ranked poor follow-up of patients as a top
10 issue” (p. 60). This weakness makes it difficult to conclude if the patients initial assessment
and follow up assessment as accurate. Neither of the studies listed gave a clear explanation of
how the patient felt at baseline. Both studies concluded how the patients were affected by
receiving medications to treat CINV.
The minor weakness listed does not make the studies themselves weak, research has
concluded palonosetron plus dexamethasone can decrease CINV. “Updated antiemetic guidelines
from the American Society of Clinical Oncology (ASCO) recommend palonosetron as the
preferred 5-HT3 antagonist for patients who receive moderately emetic chemotherapy” (Hesketh,
2013, p. 2).
Ginger
Both of the studies discussed how the use of ginger in CINV patients shows improvement
in nausea and vomiting. “Since 1986, only five articles published the use of ginger for CINV in
cancer patients receiving chemotherapy” (Ryan et al., 2012, p. 83). The fact there is only three
studies showing real information in relation to these components and improvement in nausea and
vomiting makes the evidence weak. The study by Alparslan et al had a small sample size while
the second study listed above has a large sample size. Despite the weaknesses, both studies
conclude ginger helps in reducing nausea and vomiting in cancer patients receiving
chemotherapy.
In the 2011 study, evidence clearly stated “results of the present study suggest that ginger
is more effective than an antiemetic drug for the prevention of nausea and/or vomiting in patients
receiving chemotherapeutic agents” (Alparslan et al., 2012, p. 17).
Palonosetron plus Dexamethasone
Recommendations
CINV is an individualized symptom in patients. There are many different types of
treatment available. Finding the right combination of antiemetic treatment is the true goal for
these patients. Based on past and current research, I would recommend using a combination of
both of these treatments. “Compared to conventional antiemetics, the addition of ginger in
conjunction with palonosetron and dexamethasone one hour before, and three and eight hours
after the start of chemotherapy significantly reduced the incidence of both acute and delayed
emesis” (Hesketh, 2013, p. 13). 5-HT3 receptor antagonists and corticosteroids have been used
for treatment of nausea and vomiting for quite some time. Ginger is a natural substance which
has been around for a very long time. I believe based on these studies and current research it
would be worth using a combination of all three medications.
Conclusion
CINV can be a very debilitating symptom for the advance stage cancer patient. Finding
the right medication or combination of medications can sometimes be difficult. Knowing what
treatments are available pharmacological and non-pharmacological is important to know. As
nurses, we are the patient advocate making sure all treatment plans are available. If a patient
suffering from CINV is fortunate enough to find what treatment works for them, it is our job as
nurses to support and educate them on the plan.
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References
Abascal, K., & Yarnell, E. (2009). Clinical Uses of Zingiber Officinale (Ginger). The Journal of
Alternative and Complimentary Medicine, 15(5), 231-237. doi:10.1089/act.2009.15501
Alparslan, G., Ozkarman, A., Eskin, N., Yilmaz, S., Akay, M., & Acikgoz, A. (2012). Effect of
ginger on chemotherapy-induced nausea and/or vomiting in cancer patients. Journal of
the Australian Traditional-Medicine Society, 18(1), 15-18.
Hawkins, R., & Grunberg, S. (2009). Chemotherapy-Induced Nausea and Vomiting: Challenges
and Opportunities for Improved Patient Outcomes. Clinical Journal of Oncology
Nursing, 13(1), 54-64.
Hesketh, P. (2013, March 8). Prevention and treatment of chemotherapy-induced nausea and
vomiting. Retrieved from Up To Date Web Site:
http://www.uptodate.com/contents/prevention-and-treatment-of-chemotherapy-inducednausea-and-vomiting?source=see_link
Ryan, J., Heckler, C., Roscoe, J., Dakhil, S., Kirshner, J., & Flynn, P. et al. (2012, July). Support
Care Cancer [White paper]. Retrieved from National Institutes of Health:
http://www.uptodate.com/contents/prevention-and-treatment-of-chemotherapy-inducednausea-and-vomiting?source=see_link
Saito, M., Aogi, K., Sekine, I., Yoshizawa, H., Yanagita, Y., & Sakai, H. et al. (2009, January 8).
Palonosetron plus dexamethasone versus granisetron plus dexamethasone for prevention
of nausea and vomiting during chemotherapy: a double-blind, double-dummy,
randomised, comparative phase III trial. The Lancet Oncology, 10(2), 115-124.