Management of Chemotherapy-Induced Nausea & Vomiting

chemotherapy-induced nausea and vomiting: chemotherapy-induced nausea and vomitingNEW YORK CITY—Chemotherapy-induced nausea and vomiting (CINV) is a common problem in oncology; interventions are needed to improve quality of life for patients as well as mitigate health care costs. During the Chemotherapy Foundation Symposium, held Nov. 8-10, experts discussed the importance of recognizing risk factors, as well as developing strategies to optimize patient outcomes through the management of this often costly and debilitating yet preventable complication. Therapeutic Interventions Several classes of antiemetics are available and in the past few years a number of new agents have been granted FDA approval, according to Beth Eaby-Sandy, MSN, CRNP, OCN, a nurse practitioner at the Abramson Cancer Center at the University of Pennsylvania, Philadelphia. “There have been new approvals of NK1 receptor antagonists, as well as 5-HT3 receptor antagonists.” Other classes of drugs that can be used for CINV include corticosteroids, benzodiazepines, and cannabinoids. Newer agents include NEPA, the first and only combination tablet, according to Eaby-Sandy, comprised of oral palonosetron and netupitant. Additionally, rolapitant recently received another indication. It is now approved by the FDA for IV use in combination with other antiemetic agents in adults for the prevention of delayed nausea and vomiting associated with initial and repeat courses of emetogenic cancer chemotherapy. “Many health care providers tend to believe that CINV is no longer an unmet need, but the reality is that more than half of patients treated with emetogenic chemotherapy experience delayed CINV, even when prescribed standard preventative therapies, such as a 5-HT3 receptor antagonist and dexamethasone,” said Lee Schwartzberg, MD, Professor of Medicine at University of Tennessee Health Science Center in Memphis. “The FDA approval of [rolapitant] IV gives doctors and nurses a new option to help protect their patients from these often preventable side effects.” CINV Guidelines NCCN offers a comprehensive set of guidelines to assist in the management of CINV. During her presentation, Eaby-Sandy emphasized the importance of following those guidelines across the spectrum of oncology care. Additionally, ASCO recently released updated clinical practice guidelines that cover new medicines for nausea and vomiting relating to cancer treatment. The update includes new evidence-based information on the appropriate use of olanzapine, NK1 receptor antagonists, and dexamethasone (J Clin Oncol 2017; doi:10.1200/JCO.2017.74.4789). “The adverse impact of inadequately controlled nausea and vomiting on patient's quality of life is well-documented,” said Paul J. Hesketh, MD, Co-Chair of the ASCO Expert Panel that developed the guideline update, in a statement. “By following the ASCO Antiemetics Guideline, clinicians have the opportunity to improve patient's quality of life by minimizing treatment-induced emesis.” The guidelines were developed by an Expert Panel who conducted a systematic review of the medical literature published between November 2009 and June 2016. Members of the panel offered an array of expertise in medical oncology, radiation oncology, nursing, pharmacy, and health services research; there was also a patient representative. “Forty-one publications were included in this systematic review. A phase III, randomized, controlled trial demonstrated that adding olanzapine to antiemetic prophylaxis reduces the likelihood of nausea among adult patients who are treated with high emetic risk antineoplastic agents,” according to the authors of the updated guidelines. “Randomized controlled trials also support an expanded role for neurokinin 1 receptor antagonists in patients who are treated with chemotherapy.” “Tremendous progress has been realized over the last 25 years in the prevention of chemotherapy-induced nausea and vomiting with the introduction of new classes of antiemetic agents,” noted Mark G. Kris, MD, Co-Chair of the Expert Panel. “The full benefit of these treatment advances will only be realized, however, if evidence-based guidelines are fully implemented.” The updated ASCO guidelines include the following recommendations: Olanzapine should be added to standard antiemetic regimens for adults receiving chemotherapy with a high risk for nausea and vomiting. Olanzapine also helps individuals who experience symptoms despite receiving medicines to prevent vomiting before chemotherapy is given. For adults receiving carboplatin-based chemotherapy or high-dose chemotherapy, and children receiving chemotherapy with a high risk for nausea and vomiting, an NK1 receptor antagonist should be added to the standard antiemetic regimen. Dexamethasone treatment can be limited to the day of chemotherapy administration in patients receiving the combination of an anthracycline and cyclophosphamide. FDA-approved cannabinoids dronabinol or nabilone are recommended by the Expert Panel to treat nausea and vomiting that is resistant to standard antiemetic therapies. Evidence remains insufficient to recommend medical marijuana for either prevention or treatment of nausea and vomiting in patients with cancer receiving chemotherapy or radiation therapy, ASCO noted. Patient Barriers While it is essential for oncology providers to adhere to the guidelines when addressing the prevention and management of CINV, they also must be aware of potential patient barriers. Eaby-Sandy emphasized the importance of communication between patient and provider. She highlighted the following, potential patient barriers: Patients may believe that CINV is simply part of treatment that must be dealt with. A patient may not want to be perceived as weak, so they do not bring up symptoms. Patients may fear additional medications and the potential side effects. Fear of cost. Communication barriers with the oncology provider. Patients may fear that if they complain the chemotherapy provider will stop treatment. It is important the oncology provider is aware of these potential barriers and works to ensure they do not interfere with the patient's treatment or quality of life. Managing Costs Nausea and vomiting are two of the top 10 drivers of potentially avoidable hospital admission for cancer patents, according to the CMS. Given that nausea and vomiting are complications that can be prevented, proper management of these common side effects could decrease health care costs for both patients and providers. According to a study presented at the 2017 Palliative and Supportive Care in Oncology Symposium, the average amount paid by insurers for each CINV-related hospitalization is more than $15,000 (Abstract 155). Investigators analyzed 37,730 reports of hospitalization due to nausea and vomiting that occurred during 2014. According to the data, on average the hospital charged the insurance company $26,603. With adjustments, the average amount paid out was $11,232. After the additional costs of physicians' professional fees, the total average cost was $14,197, which, when considering inflation, ends up being $15,120 in 2016. “Hospitalization for nausea and vomiting is common and costly, study authors concluded. “This economic impact, in addition to the consequences for patients' quality of life, suggests the need for continued advances in preventing [chemotherapy-induced nausea and vomiting] and optimizing compliance with national antiemetic guidelines, particularly for chemotherapy with high emetogenic potential.” Catlin Nalley is associate editor.