Motion and NVP
What are some non pharm therapies for motion sickness?
Avoid reading, focus sight straight ahead, avoid excess food or alcohol before travel, sit where there is less motion, avoid strong odors, drive
What meds can be used for N/V secondary to indigestion? Common AEs?
OTC antacids or H2RAs
AEs: diarrhea (Mg), constipation (Al or Ca)
What is corticosteroids place in therapy and which one is used most often? AEs?
mono or combo therapy for PONV, CINV, or RINV
Dexamethasone
AEs: insomnia, increase appetite, fluid retention, increase BP and BG with higher doses
What is BZDs place in therapy? Which 2 are most commonly used?
anticipatory CINV
Almost always used in combo, anxiolytic effects
Alprazolam and lorazepam
What can be done to try to prevent CINV? What are the subtypes?
Give prophylactic antiemetics 30 or more min before chemo
Acute: within 24 hrs
Delayed: 1-7 days after
Anticipatory: before chemo
What and who is acupressure good for?
P6 point
safe for pts 2 or older and to prevent NVP
avoid if pt has a pacemaker
anticholinergic: blocks M receptors in vestibular system
prevent motion sickness and PONV
Remove prior to MRI, wash hands before and after applying, avoid contact with eyes
AEs: anticholinergic, CI in narrow angle glaucoma
What are cannabinoids role in therapy? What are the meds? Some AEs and warnings?
Dronabinol and Nabilone
AEs: somnolence, euphoria, increase appetite, adverse CNS effects, GI, hypotension
What is olanzapine and what is its place in therapy? Possible AEs?
Blocks many neurotransmitters (DA, 5HT3, histamine)
May be used as adjunct therapy to prevent CINV if mod-high emesis risk
AEs: well tolerated when used short term, maybe sedation
Which chemo agents are high risk for emetogenic potential?
Cisplatin, cyclophosphamide, doxorubicin, dacarbazine, ifosfamide
What is some non pharm for NVP?
take prenatal, eat dry crackers before getting out of bed, get out of bed slowly, nibble on dry toast before breakfast, fresh air, small meals every 1-2 hrs, avoid excessive heat, small sips of carbonation, avoid greasy, fatty, spicy or acidic foods, avoid sensory stimuli and iron containing supplements
What are antihistamines and when are they indicated? What are some common AEs and who should we use these in with caution? What are some drugs?
Blocks histamine receptors in the vestibular system and VC
Prevents and treat N/V secondary to motion sickness, vertigo, and migraines
AEs: anticholinergic, sedation, CNS depression
Caution if pt had COPD/asthma, combo with CNS depressants, geriatric
Dimenhydrinate, hydroxyzine, diphenhydramine, meclizine
What is the MOA of benzamides and when are they indicated? What are some AEs and warnings? What is significant about metoclopramide?
Block D2 receptors in the CTZ
PONV and CINV
AEs: sedation, diarrhea, CNS depression, EPS, caution in children and elderly
Metoclopramide: also a peripheral D2 RA and has cholinergic activity, increases gastric motility (good for GERD or gastroparesis), BBW is pt has s/sx of TD (avoid Tx for more than 12 weeks)
Where is the vomiting center located and what is its function?
Located in the medulla oblongata
The VC receives incoming signals from the other parts of the brain and GI tract and then coordinates the emetic response by sending signals to the effector organs
The messages received are neurotransmitters (serotonin, dopamine, NK1) from the CTZ, GI tract, cerebral cortex, limbic system, and vestibular system
For CINV, what are the general antiemetic regimen if a patient is high and moderate risk? Low risk? Minimal risk?
(Not asking for specific drugs here)
High-mod: combo therapy
low: monotherapy
Minimal: prophylaxis not used
What is first line for NVP?
pyridoxine +/- doxylamine
Can get OTC, max Rx dose is 4 tabs/day
What are butyrophenones MOA and place in therapy? What are some possible AEs and BBW? What are the drugs?
blocks D2 receptors in the CTZ
used for PONV or CINV if intolerant to serotonin RA and steroids
AEs: sedation, EPS, QT prolongation
BBW: arrhythmias
Droperidol (PONV, high QT risk), haloperidol (breakthrough CINV)
*reserved alternatives
What is the MOA of 5HT3 RA and what is the place in therapy? AEs? What are the drugs?
Block serotonin stimulation peripherally in the GI tract and centrally in the CTZ
Standard of care for CINV, PONV, and RINV
AEs: migraine-like HA, constipation, dose related QT prolongation
Dolasetron (IV contraindicated), ondansetron (Zofran, CYP3A4), granisetron (comes in patch that gets placed 1-2 days before chemo), palonosetron (Aloxi, approved for acute and delayed CINV)
What is the CTZ and what is its function?
Also known as area postrema, contains receptors that detect emetic agents in the blood and and relays the info to the vomiting center
For a patient who is at moderate emetic risk, what are possible antiemetic regimens? Low risk?
Moderate: serotonin RA + dexamethasone, olanzapine + palonosetron + dexamethasone, NK1 RA + serotonin RA + dexamethasone
Low: dexamethasone, metoclopramide, prochlorperazine, serotinin RA
What are some alternative first line therapies for NVP?
H1 antagonists, phenothiazines, metoclopramide
ondansetron (last line)
What is the MOA of phenothiazines and what is their place in therapy? What are some warnings and precautions? What are some drugs? What is important to note about promethazine?
Blocks D2 receptors in the CTZ
Prevent N/V secondary to motion sickness, vertigo, gastroenteritis, NVP, PONV, and CINV
AEs: sedation, EPS, anticholinergic, QT prolong, seizures, parkinsons
Chlorpromazine, prochlorperazine, promethazine
Promethazine: Avoid IV and IM administration due to risk of severe tissue injury, SubQ contraindicated due to severe tissue necrosis, BBW of respi depression in peds (do not use if less than 2)
Substance P binds to NK1 receptors and induces acute and delayed N/V
Often used in combo with serotonin RA and dexamethasone for mod-high risk CINV
AEs: fatigue, hiccups, constipation, diarrhea, dyspepsia
DDIs: CYP3A4 inhibitors, dexamethasone (consider dose reduction)
Aprepitant (Emend), fosaprepitant, netupitant, rolapitant
N/V is caused by the vomiting center, what 4 pathways have the ability to start this process and what neurotransmitters are involved?
Peripheral gut pathways: serotonin (gastric irritants, mucosal injury, mechanical stretch, obstruction)
Area postrema: dopamine, serotonin, NK1 (outside BBB, drugs, metabolic changes, and bacterial toxins)
Vestibular system: Ach, histamine (movement)
Cerebral cortex: GABA, serotonin (meningeal irritation, hyponatremia, fear or anxiety)
What are some possible antiemetic regimens for high risk CINV patients?
Olanzapine + NK1 RA + serotonin RA + dexamethasone
Olanzapine + palonosetron + dexamethasone
NK1 RA + serotonin RA + dexamethasone