10/13/2014

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Chemotherapy Induced Nausea and Vomiting Updates

Chemotherapy SIG ONS Congress

Patricia Jakel, RN, MN, AONC

Advance Practice Nurse

UCLA Healthcare System

Associate Professor of Nursing

UCLA School of Nursing

Patricia Jakel is a speaker for Merck.

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NCCN Updates for Version 1.2014

• High Emetic Risk

– Risk for CINV lasts for at least 3 days after last dose of chemotherapy

– Added daily granisetron 2 mg po or 1 mg PO BID

– Removed max 32mg/day IV for ondansetron

– Added olanzapine containing regimen

• Olanzapine 10 mg po days 1-4

• Palonosetron 0.25mg IV day 1

• Dexamethasone 20 mg IV day 1

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NCCN Updates for Version 1.2014

Moderate Risk

Risk for CINV lasts for at least 2 days after last dose of chemotherapy

– Added daily granisetron 2 mg po or 1 mg PO BID

– Removed max 32mg/day IV for ondansetron

– Added olanzapine containing regimen • Olanzapine 10 mg po days 1-4

• Palonosetron 0.25mg IV day 1

• Dexamethasone 20 mg IV day 1

– Days 2 & 3 if Fosaprepitant given on day 1 add dexamethasone 8 mg po or IV day 2 & 3

NCCN Updates for Version 1.2014

• Multi-day Chemotherapy • New Bullet Added

– Data from a small phase III study supports the use of: • Aprepitant 125 mg day 3, 80 mg day 4-7 • 5-HT3 days 1-5 • Dexamethasone 20 my day 1 & 2

– In patients with germ cell tumors receiving 5-day cisplatin combination chemotherapy

• Serotonin antagonists may increase the risk of prolongation of QT interval

• Consider PPI or H2blocker to prevent dyspepsia

• Albany, C. et al. 2012, JCO, 30: 3998-4003

ONS PEP 2014 Would Recommend

• Recommended for Practice

• Cannabis/Cannabinoids

• Neurokinin 1 Receptor Antagonist (NK1)

• Serotonin 5HT3 Receptor Antagonists (5HT3)

• Transdermal Granisetron

• Triple Drug Regimen

• https://www.ons.org/practice-resources/pep/chemotherapy-induced-nausea-and-vomiting

ONS PEP 2014 Likely to Be Effective

• Likely to Be Effective • 5HT3 and Dexamethasone in Pediatric Patients • Gabapentin • Hypnosis for Anticipatory CINV • Managing Patient Expectations • Olanzapine for Breakthrough CINV • Progestins • Progressive Muscle Relaxation and Guided Imagery • Single Agent Dexamethasone

• https://www.ons.org/practice-resources/pep/chemotherapy-induced-nausea-and-vomiting

ONS PEP 2014 CINV Effectiveness

• Benefits Balanced With Harm • Virtual Reality

• Effectiveness Not Established • Acupressure

• Acupuncture

• Acustimulation

• Electroacupuncture

• Exercise

• Ginger

• Grape Juice

• Guided Imagery/Imagery

• Haloperidol

• Herbal Medicine

• Massage/Aromatherapy Massage

• Metoclopramide (Prophylactic)

• Effectiveness not Established • Mirtazapine • Olanzapine • Ondansetron as Rescue Medication • Prochlorperazine for Breakthrough CINV • Progressive Muscle Relaxation (PMR) • Psychoeducation/Psychoeducational

Interventions • Thalidomide • Yoga

• Effectiveness Unlikely • Cocculine

• Not Recommended for Practice • Metopimazine

• https://www.ons.org/practice-resources/pep/chemotherapy-

induced-nausea-and-vomiting

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Conclusion on New Guidelines for CINV

• CINV remains a problem for chemotherapy patients

• Nurses need to continue assessment of CINV for all patients

• ASCO, NCCN, ONS the triple drug therapy for HEC and MEC

• Olanzapine recommend for HEC & MEC (NCCN) and breakthrough (ONS)

• Nurses are the keys to improve QOL