Understanding the Treatment Options Cancer Chemotherapy Associated Nausea and Vomiting Therapeutics

Chemotherapy-Induced Nausea and Vomiting: A Common Side Effect of Cancer Treatment

Chemotherapy is a widely used treatment for various types of cancers. However, one of the most common and debilitating side effects of chemotherapy is nausea and vomiting. Chemotherapy can trigger nausea and vomiting due to the toxic effects of the anticancer drugs on the gastrointestinal tract. This side effect is known as chemotherapy-induced nausea and vomiting Cancer Chemotherapy Associated Nausea And Vomiting Therapeutics Around 70-80% of cancer patients receiving highly emetogenic chemotherapy experience CINV. Even patients receiving moderately emetogenic chemotherapy have a 30-60% risk of developing CINV. Left untreated, CINV can negatively impact a patient's quality of life and tolerance to chemotherapy. Therefore, it is crucial to manage CINV effectively using antiemetic medications.

Classification of Chemotherapy-Induced Nausea and Vomiting

CINV is classified based on the risk levels associated with specific chemotherapy regimens:

- Highly Emetogenic Chemotherapy (HEC): Chemotherapy drugs that cause vomiting in over 90% of patients without preventive treatment. Examples include cisplatin, carboplatin, doxorubicin, etc.

- Moderately Emetogenic Chemotherapy (MEC): Chemotherapy drugs with moderate emetogenic potential that cause vomiting in 30-90% of patients without preventive treatment. Examples are oxaliplatin, irinotecan, paclitaxel, cyclophosphamide, etc.

- Low Emetogenic Chemotherapy (LEC): Chemotherapy drugs with low emetogenic potential that cause vomiting in less than 30% of patients. Examples include fluorouracil, methotrexate, etc.

Antiemetic Medications for CINV Prevention and Treatment

Several classes of antiemetic medications are used to prevent and treat CINV based on the risk classification:

- 5-HT3 receptor antagonists: Ondansetron, granisetron, palonosetron, etc. block the serotonin receptor mainly responsible for CINV arising from chemotherapy. Given before and after chemotherapy.

- NK1 receptor antagonists: Aprepitant, fosaprepitant, netupitant-palonosetron, etc. work against substance P that mediates nausea and vomiting signals to the brain. Given before chemotherapy.

- Corticosteroids: Dexamethasone aids in reducing inflammation in the gut caused by chemotherapy. Given before and after chemotherapy.

- Dopamine receptor antagonists: Metoclopramide, prochlorperazine, etc. inhibit dopamine receptors involved in vomiting response. Used to treat breakthrough vomiting.

- Benzodiazepines: Lorazepam, alprazolam provide anxiolytic effects and additional antiemetic coverage when needed.

Guidelines for Antiemetic Prophylaxis

Treatment guidelines from NCCN, MASCC/ESMO, and ASCO recommend antiemetic combinations based on chemotherapy emetogenicity:

- HEC: Combination of a 5-HT3 receptor antagonist, NK1 receptor antagonist, and dexamethasone for 3 days.

- MEC: Combination of a 5-HT3 receptor antagonist and dexamethasone for 1-2 days.

- LEC: No routine prophylaxis needed but patients with high risk factors may benefit from a single dose of 5-HT3 antagonist.

Breakthrough CINV should be treated with dopamine antagonists, corticosteroids, or benzodiazepines. The guidelines also recommend switching or adding agents for refractory cases not responding to initial antiemetic prophylaxis.

Newer Antiemetic Options

Several newer antiemetic medications have been developed in recent years to address unmet needs in CINV management:

- Netupitant-palonosetron (Akynzeo): A fixed-dose combination of an NK1 receptor antagonist and the 5-HT3 receptor antagonist palonosetron for HEC-associated CINV.

- Rolapitant (Varubi): Second generation oral NK1 receptor antagonist offering longer blockade duration compared to aprepitant.

- Fosaprepitant (Emend-IV): Water-soluble prodrug of aprepitant given as a single intravenous infusion for improved convenience over oral aprepitant.

- Olanzapine (Zyprexa): Atypical antipsychotic found to have antiemetic properties against both acute and delayed nausea when added to standard antiemetics.

- Cannabinoids (Dronabinol, Nabilone): May offer additional benefit in refractory CINV cases unresponsive to standard treatments.

various classes of antiemetic medications continue to improve management of CINV as a debilitating chemotherapy side effect. Treatment guidelines recommend optimizing antiemetic prophylaxis based on chemotherapy emetogenicity. Newer agents are further enhancing control of nausea and vomiting for cancer patients undergoing chemotherapy. With the availability of well-studied and effective antiemetic options, CINV need no longer be the dose-limiting factor for administering chemotherapy. 

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