Adequate control of chemotherapy-induced emesis is crucial, because if left untreated it can lead to electrolyte imbalance, dehydration, poor nutrition, prolonged hospitalisation, significantly decreased compliance in subsequent chemotherapy cycles and reduced quality of life. It is much more difficult to prevent and control nausea than vomiting. Prevention of chemotherapy induced nausea and vomiting (CINV) is strongly correlated with better control of nausea, which occurs more often than vomiting [1].
Teenagers and young adults (TYA) are more likely to report poor control of nausea and vomiting than younger children and are more prone to anticipatory nausea and vomiting [2].
Risk factors
The severity of CINV is generally related to the emetogenic potential of the individual drugs however, certain risk factors may contribute to the patient’s experience [3].
- Patient specific - e.g. female, age > three years, anxiety, previous chemotherapy treatment, history of motion sickness, poor emesis control during previous chemotherapy treatment
- Treatment specific - e.g. emetic potential of chemotherapy agent, regimen, dose, route and administration rate of the chemotherapy
Types of CINV
- Acute: Occurs within 24 hours of chemotherapy administration
- Delayed: Occurs 24 hours after chemotherapy administration, lasting up to one week. Drugs more likely to cause delayed emesis are high dose cisplatin, carboplatin, cyclophosphamide, and doxorubicin. These drugs are less responsive to standard anti-emetic therapy, e.g. ondansetron and dexamethasone.
- Anticipatory: Occurs after the first cycle of chemotherapy and before subsequent ones. This generally occurs following a bad experience during the first course of chemotherapy where emesis was not well controlled. The child or young person starts to associate the clinical environment to the feeling of nausea and hence may start to feel nauseous or vomit before the administration of chemotherapy. This may cause weight loss, poor dietary intake, non-compliance with subsequent treatments or affect the patient’s quality of life [2].
- Breakthrough: Nausea, retching or vomiting which occurs during any phase of the chemotherapy cycle, despite anti-emetic treatment.
- Refractory: Nausea and / or vomiting that occurs during subsequent cycles of chemotherapy, when all previous preventative and rescue treatments have failed.
Vomiting
The emetic reflex protects humans from poisoning. Chemotherapy is technically a poison which provokes this natural emetic response in humans [1].
Stimulation of the vomiting centre in the brain results in the co-ordination of responses from the diaphragm, salivary glands, cranial nerves and gastro-intestinal muscles to produce the interruption of respiration and forced expulsion of stomach contents. 5HT3 inhibitors are the most effective anti-emetics, blocking one or more of the signals that cause nausea and vomiting.
Assessment of CINV
It is important to gain an accurate history of the degree of nausea and vomiting experienced by the child or young person in order to manage symptoms effectively.
The level of CINV experienced by the child or young person is determined through accurate assessment. In order to do this it is vital to have an effective assessment tool which grades the severity of symptoms. On admission, before the administration of chemotherapy, the severity of nausea and vomiting experienced by the patient is assessed using the following scoring system.
Parents/carers, children and young people are advised that if they score a three or above, or if they have any concerns, they should contact their ward as soon as possible for help or advice.
Toxicity scoring criteria (adapted from WHO toxicity scoring)
| Side-effect | 0 None | 1 Mild | 2 Moderate | 3 Severe | 4 Very severe |
| Nausea | none | Able to eat ok | Still able to eat but not as much as normal | Can’t eat but can drink | Can’t eat or drink |
| Vomiting | none | 1 vomit in 24 hours | 2-5 vomits in 24 hours | 6-10 vomits in 24 hours | > 10 vomits in 24 hours |
Management of CINV
Acute CINV prophylaxis
Pharmacological interventions – below are examples of anti-emetic drugs that may be used depending on the emetogenic potential of the chemotherapy. This guide provides a useful starting point for choosing antiemetic therapy but treatment must be tailored according to the individual patient’s needs.
Medicines that act on different areas of the vomiting reflex are combined to provide optimal control. Caution must be taken to ensure that medicines do not interact or have cumulative side-effects.
| Emetogenic potential | Antiemetic drugs which may be given |
| Very high | Combination of IV ondansetron, IV dexamethasone, IV metoclopramide and IV / oral levomepromazine |
| Moderately high | IV / oral ondansetron and IV /oral dexamethasone, IV / oral metoclopramide or cyclizine |
| Moderate | IV / oral ondansetron, IV /oral Metoclopramide or cyclizine |
| Low / minimal | none |
NB: Dexamethasone should not be prescribed as an anti-emetic for patients with leukaemia or lymphoma, where steroids are prescribed as part of their chemotherapy treatment.
Dexamethasone may be contraindicated during chemotherapy for patients with brain tumours, and it should be used with caution with some other tumours such as sarcomas.
Delayed CINV prophylaxis
NB: Ondansetron is not effective in treating delayed emesis.
Generally, for moderate emetogenic chemotherapy, anti-emetics are continued for three days post acute emesis prophylaxis.
Patients receiving drugs that have greater potential for delayed emesis (such as Carboplatin, Cisplatin, Cyclophosphamide and Doxorubicin) should be given up to five days anti-emetic treatment post acute emesis prophylaxis.
Anticipatory CINV
Effective prophylaxis for acute CINV would hopefully prevent anticipatory CINV. If it is already a problem, oral / sublingual lorazepam can be given within 24 hours before chemotherapy and has been beneficial, particularly in teenagers and young adults.
A full explanation of CINV management can be found in the appropriate cancer centre’s anti-emetic policy
Non-pharmacological interventions
- Rest
- Dietary advice
- Relaxation / Guided imagery
- Distraction
References
[1] NHS Lothian (2011) Anti-emetic guidelines: Management of chemotherapy induced nausea and vomiting
[2] McCulloch R, Hemsley J, Kelly P (2013) Symptom management during chemotherapy Paediatrics and Child Health 24:4 166- 171 Elsevier Ltd
[3] Gibson F and Soanes L ( 2010) Cancer in Children and Young People, Acute Nursing Care. Wiley & Sons Ltd
Further reading
Phillips RS,FriendAJ,Gibson F,Houghton E,Gopaual S,Craig JV,Pizer B. 2016. Antiemetic medication for prevention and treatment of chemotherapy induced nausea and vomiting in childhood..Cochrane Database of Systematic Reviews 2016 .Issue 2 Art:.No. CD007786.DOI:10.1002/1465 1858, CD007786.pub3.