Chemotherapy-Induced Nausea and Vomiting
Despite considerable progress in the management of chemotherapy-associated nausea and vomiting, these symptoms remain among the most feared by patients beginning cytotoxic chemotherapy. 5-HT3 antagonists have decreased the frequency of postchemotherapy vo
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11.1 Scope of the Problem, Risk Factors Despite considerable progress in the management of chemotherapy-associated nausea and vomiting, these symptoms remain among the most feared by patients beginning cytotoxic chemotherapy. 5-HT3 antagonists have decreased the frequency of postchemotherapy vomiting. However, emesis remains a problem for a significant minority of patients. In addition, nausea continues to be a formidable challenge despite the better control of vomiting with current treatment options [1]. The relative likelihood of significant emesis in a given individual is dependent upon both patient- and treatment-related factors. Patient factors with predictive value for decreased emesis include heavy alcohol consumption and male sex [2]. A number of other factors including younger age [3], poor performance status [3], severe emesis during pregnancy [4], and susceptibility to motion sickness [5] have all been noted to be predictive of increased emesis with chemotherapy. Treatment-related factors include the intrinsic emetogenicity of the cytotoxic agent(s), the dose and schedule, treatment setting, as well as additive effects of combinations [6]. At least three distinct syndromes of chemotherapy-related nausea and vomiting are encountered in clinical practice: acute chemotherapy-induced emesis, delayed emesis, and less commonly, anticipatory emesis.
11.2 Acute, Delayed, and Anticipatory Emesis Acute emesis is defined as emesis occurring during the first 24 h following administration of chemotherapy. In the absence of effective antiemetic pro-
E. E. Vokes et al. (eds.), Oncologic Therapies © Springer-Verlag Berlin Heidelberg 2003
phylaxis, it typically begins between 1 and 2 H after receiving chemotherapy. Acute emesis has been the most widely studied of the three emetic syndromes. Delayed emesis, as first described by Kris et al. [7], with high-dose cisplatin has arbitrarily been defined as emesis occurring more than 24 h after chemotherapy. While the frequency and number of episodes of emesis may be less during this period compared with acute emesis, it remains a formidable problem, occurring in 43%–89% of patients receiving cisplatin therapy [8]. The mechanisms of delayed emesis from cisplatin may differ from those underlying acute chemotherapy-induced emesis, and as such, the optimal antiemetic approach to these two syndromes differs (see “Mechanisms of Chemotherapy-Induced Vomiting”). While most often associated with cisplatin therapy, delayed emesis may also occur with carboplatin, cyclophosphamide, and anthracyclines, but this has been studied less extensively. Anticipatory emesis is a conditioned response in patients who have experienced severe nausea and vomiting with previous cycles of chemotherapy and is triggered by cues and cognitive activity related to subsequent chemotherapy [9].
11.3 Mechanisms of Chemotherapy-Induced Vomiting Although the precise mechanisms underlying chemotherapy-induced emesis remain incompletely defined, considerable progress has been made in recent years. A number of are
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