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Pediatric Chemotherapy-Induced Nausea and Vomiting Medication

  • Author: Reuven J Schore, MD; Chief Editor: Max J Coppes, MD, PhD, MBA  more...
 
Updated: Sep 16, 2015
 

Medication Summary

Various prevention and treatment options are available and contribute to the overall successful treatment of cancer.[2, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24] For guidance regarding selection of antiemetic regimen, see the table above. For treatment of anticipatory, breakthrough, or refractory emesis, see the recommendations above.

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Antiemetic, serotonin antagonists

Class Summary

These agents bind serotonin receptors to prevent chemotherapy-induced nausea and vomiting.

QT prolongation may occur with use of 5-HT3 antagonists (eg, ondansetron, dolasetron, granisetron). Avoid use in patients with long QT syndrome. Correct hypokalemia and hypomagnesemia before initiating. EKG monitoring may be warranted when coadministered with other drugs that may prolong QT interval, bradyarrhythmias, or congestive heart failure.

IV dolasetron is no longer indicated for CINV because of risk for QT prolongation. Palonosetron has been studied for its effect on QT interval, and results showed no significant effect at doses of as much as 2.25 mg. Although the increased QT interval warning with palonosetron use has been removed by the manufacturer, monitoring patients receiving other drugs known to cause QT interval prolongation may still be wise.

In June 2012, the 32 mg IV dose of ondansetron was removed from the prescribing information because of dose-related QT prolongation. The recommended dose for ondansetron IV for chemotherapy-induced nausea and vomiting is 3 doses of 0.15 mg/kg (not to exceed 16 mg/dose) IV 30 minutes before chemotherapy and repeated 4 and 8 hr after the first dose.[25]

In May 2014, palonosetron was approved by the US Food and Drug Administration (FDA) for prevention of CINV in children as young as 1 month. Approval was based on a randomized, double-blind, noninferiority, pivotal trial that compared single-dose IV palonosetron (20 mcg/kg given 30 min prior to chemotherapy) with the current standard of care, IV ondansetron regimen (0.15 mg/kg given 30 min prior to chemotherapy), followed by infusions 4 hours and 8 hours after the first dose of ondansetron. Within the first 24 hours after chemotherapy, complete response, defined as no vomiting, no retching, and no antiemesis rescue medication, was achieved in 59.4% of patients who received palonosetron compared with 58.6% of those who received the ondansetron regimen.[26]

Dolasetron (Anzemet)

 

Prevents nausea and vomiting by binding to 5-HT3 receptors located on chemotherapy trigger zone (CTZ) and vagal neurons in GI tract. Prophylaxis with antiemetic agents prior to and following cancer treatment is often essential to ensure administration of the entire chemotherapy regimen.

Granisetron (Sancuso)

 

Used for prevention of chemotherapy-induced nausea and vomiting. At CTZ, peripherally and centrally blocks serotonin on vagal nerve terminals.

Ondansetron (Zofran, Zuplenz)

 

Selective 5-HT3 -receptor antagonist that blocks serotonin both peripherally and centrally. Prevents nausea and vomiting associated with emetogenic cancer chemotherapy (eg, high-dose cisplatin) and complete body radiotherapy.

Palonosetron (Aloxi)

 

Selective 5-HT3 -receptor antagonist with long half-life (40 h). Indicated for prevention and treatment of chemotherapy-induced nausea and vomiting. Peripherally and centrally blocks 5-HT3 receptors in CTZ.

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Corticosteroids

Class Summary

These agents are used to prevent nausea and vomiting caused by chemotherapy regimens with level 3 and level 4 agents. The antiemetic mechanism for corticosteroids is unknown, but inhibition of prostaglandin synthesis and cell membrane permeability are thought to be involved.

Dexamethasone

 

Antiemetic mechanism for corticosteroids is unknown. Used in combination with other agents as part of an antiemetic regimen.

Methylprednisolone (Depo-Medrol)

 

Antiemetic mechanism for corticosteroids is unknown. Used in combination with other agents as part of an antiemetic regimen.

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NK1 Receptor Antagonists

Class Summary

NK-1 receptors are highly concentrated in the vomiting center of the brain and bind a neurokinin termed substance P; Activation of NK-1 receptors by substance P plays a central role in eliciting chemotherapy-induced nausea and vomiting.

Aprepitant (Emend)

 

Neurokinin receptor (NK)-1 antagonist. NK-1 receptors are highly concentrated in the vomiting center of the brain and bind a neurokinin termed substance P. Blocking the interaction of substance P at the NK-1 receptor improve the management of nausea and vomiting.

It is approved in the United States for adults and children aged ≥6 months. It is indicated in combination with other antiemetic agents for prevention of acute and delayed nausea and vomiting associated with initial and repeat courses of highly emetogenic cancer chemotherapy (including high-dose cisplatin). It is also indicated for nausea and vomiting associated with initial and repeat courses of moderately emetogenic cancer chemotherapy.

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Benzodiazepines

Class Summary

These agents decrease anxiety associated with chemotherapy-induced nausea and vomiting.

Lorazepam (Ativan)

 

Sedative hypnotic with short onset of effects and relatively long half-life. By increasing the action of GABA, which is a major inhibitory neurotransmitter in the brain, may depress all levels of CNS, including limbic and reticular formation.

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Dopamine receptor antagonist

Class Summary

Consider adding these agents in patients with breakthrough or resistant nausea and vomiting.

Metoclopramide (Reglan, Metozolv ODT)

 

Dopamine antagonist that stimulates acetylcholine release in the myenteric plexus. Acts centrally on chemoreceptor triggers in the floor of the fourth ventricle, which provides important antiemetic activity.

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Phenothiazines

Class Summary

Consider adding these agents in patients with breakthrough or resistant nausea and vomiting.

Promethazine (Phenergan, Phenadoz, Promethegan)

 

For symptomatic treatment of nausea in vestibular dysfunction. Antidopaminergic agent effective in treating emesis. Blocks postsynaptic mesolimbic dopaminergic receptors in brain and reduces stimuli to brainstem reticular system.

Prochlorperazine (Compazine, Compro)

 

May relieve nausea and vomiting by blocking postsynaptic mesolimbic dopamine receptors through anticholinergic effects and depressing reticular activating system. In addition to antiemetic effects, has the advantage of augmenting hypoxic ventilatory response, acting as a respiratory stimulant at high altitude.

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Antiemetic, Cannabinoid

Class Summary

Consider adding these agents in patients with breakthrough or resistant nausea and vomiting.

Dronabinol (Marinol)

 

Synthetic cannabinoid for PO administration. Antiemetic effect attributed to action within cannabinoid receptor system (ie, CB1 receptor) located in neural tissues.

Indicated for nausea and vomiting associated with cancer chemotherapy in patients who have inadequate response to conventional antiemetic treatments. This restriction is required because a substantial proportion of patients treated with dronabinol experience disturbing psychotomimetic reactions not observed with other antiemetic agents.

Nabilone (Cesamet)

 

Synthetic cannabinoid for PO administration. Antiemetic effect thought to be due to action within cannabinoid receptor system (ie, CB1 receptor) located in neural tissues. Indicated for nausea and vomiting associated with cancer chemotherapy in patients who have inadequate response to conventional antiemetic treatments. This restriction is required because a substantial proportion of patients treated with nabilone will experience disturbing psychotomimetic reactions not observed with other antiemetic agents.

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Contributor Information and Disclosures
Author

Reuven J Schore, MD Assistant Professor of Pediatrics, George Washington University School of Medicine and Health Sciences; Attending Physician, Center for Cancer and Blood Disorders, Leukemia and Lymphoma Program, Division of Oncology, Children's National Medical Center

Reuven J Schore, MD is a member of the following medical societies: American Academy of Pediatrics, American Society of Hematology, American Society of Pediatric Hematology/Oncology

Disclosure: Received research grant from: Millennium Pharmaceuticals, Inc; Onyx Pharmaceuticals, Inc; Merck Inc<br/>Received income in an amount equal to or greater than $250 from: Baxalta Pharmaceuticals, Inc.

Coauthor(s)

Devona Williams, PharmD Pharmacy Clinical Specialist, Children's National Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Max J Coppes, MD, PhD, MBA Executive Vice President, Chief Medical and Academic Officer, Renown Heath

Max J Coppes, MD, PhD, MBA is a member of the following medical societies: American College of Healthcare Executives, American Society of Pediatric Hematology/Oncology, Society for Pediatric Research

Disclosure: Nothing to disclose.

References
  1. Piko B, Bassam A. [Treatment of tumor therapy-induced nausea and vomiting.]. Magy Onkol. 2009 Mar. 53(1):39-45. [Medline].

  2. Kris MG, Hesketh PJ, Somerfield MR, et al. American Society of Clinical Oncology guideline for antiemetics in oncology: update 2006. J Clin Oncol. 2006 Jun 20. 24(18):2932-47. [Medline]. [Full Text].

  3. Czarnetzki C, Elia N, Lysakowski C, et al. Dexamethasone and risk of nausea and vomiting and postoperative bleeding after tonsillectomy in children: a randomized trial. JAMA. 2008 Dec 10. 300(22):2621-30. [Medline].

  4. Navari RM. Pharmacological management of chemotherapy-induced nausea and vomiting: focus on recent developments. Drugs. 2009. 69(5):515-33. [Medline].

  5. Kang HJ, Loftus S, Taylor A, DiCristina C, Green S, Zwaan CM. Aprepitant for the prevention of chemotherapy-induced nausea and vomiting in children: a randomised, double-blind, phase 3 trial. Lancet Oncol. 2015 Apr. 16 (4):385-94. [Medline].

  6. Hesketh PJ, Kris MG, Grunberg SM, et al. Proposal for classifying the acute emetogenicity of cancer chemotherapy. J Clin Oncol. 1997 Jan. 15(1):103-9. [Medline].

  7. Dupuis LL, Nathan PC. Options for the prevention and management of acute chemotherapy-induced nausea and vomiting in children. Paediatr Drugs. 2003. 5(9):597-613. [Medline].

  8. Zeltzer LK, Dolgin MJ, LeBaron S, LeBaron C. A randomized, controlled study of behavioral intervention for chemotherapy distress in children with cancer. Pediatrics. 1991 Jul. 88(1):34-42. [Medline].

  9. Kelly KM. Complementary and alternative medical therapies for children with cancer. Eur J Cancer. 2004 Sep. 40(14):2041-6. [Medline].

  10. American Cancer Society. Nutrition for Cancer Patients; Nausea and Vomiting. American Cancer Society Web Page. Available at http://www.cancer.org/Treatment/SurvivorshipDuringandAfterTreatment/NutritionforPeoplewithCancer/index?sitearea=MBC. Accessed: September 9, 2007.

  11. Grunberg SM. Antiemetic activity of corticosteroids in patients receiving cancer chemotherapy: dosing, efficacy, and tolerability analysis. Ann Oncol. 2007 Feb. 18(2):233-40. [Medline]. [Full Text].

  12. Hirota T, Honjo T, Kuroda R, et al. [Antiemetic efficacy of granisetron in pediatric cancer treatment--(2).Comparison of granisetron and granisetron plus methylprednisolone as antiemetic prophylaxis]. Gan To Kagaku Ryoho. 1993 Dec. 20(15):2369-73. [Medline].

  13. Holdsworth MT, Raisch DW, Frost J. Acute and delayed nausea and emesis control in pediatric oncology patients. Cancer. 2006 Feb 15. 106(4):931-40. [Medline]. [Full Text].

  14. Luisi FA, Petrilli AS, Tanaka C, Caran EM. Contribution to the treatment of nausea and emesis induced by chemotherapy in children and adolescents with osteosarcoma. Sao Paulo Med J. 2006 Mar 2. 124(2):61-5. [Medline].

  15. Osoba D, Erlichman C, Willan AR, Levitt M, Pater JL. Superiority of methylprednisolone sodium succinate over low dose metoclopramide hydrochloride in the prevention of nausea and vomiting produced by cancer chemotherapy. Clin Invest Med. 1986 Nov. 9(4):225-31. [Medline].

  16. Small BE, Holdsworth MT, Raisch DW, Winter SS. Survey ranking of emetogenic control in children receiving chemotherapy. J Pediatr Hematol Oncol. 2000 Mar-Apr. 22(2):125-32. [Medline].

  17. Smith AR, Repka TL, Weigel BJ. Aprepitant for the control of chemotherapy induced nausea and vomiting in adolescents. Pediatr Blood Cancer. 2005 Nov. 45(6):857-60. [Medline].

  18. Herrstedt J. Antiemetics: an update and the MASCC guidelines applied in clinical practice. Nat Clin Pract Oncol. 2008 Jan. 5(1):32-43. [Medline].

  19. Dalzell AM, Bartlett H, Lilleyman JS. Nabilone: an alternative antiemetic for cancer chemotherapy. Arch Dis Child. 1986 May. 61(5):502-5. [Medline].

  20. Chan HS, Correia JA, MacLeod SM. Nabilone versus prochlorperazine for control of cancer chemotherapy-induced emesis in children: a double-blind, crossover trial. Pediatrics. 1987 Jun. 79(6):946-52. [Medline].

  21. Jones E, Koyama T, Ho RH, et al. Safety and efficacy of a continuous infusion, patient-controlled antiemetic pump for children receiving emetogenic chemotherapy. Pediatr Blood Cancer. 2007 Mar. 48(3):330-2. [Medline].

  22. Sepúlveda-Vildósola AC, Betanzos-Cabrera Y, Lastiri GG, Rivera-Márquez H, Villasis-Keever MA, Del Angel VW, et al. Palonosetron hydrochloride is an effective and safe option to prevent chemotherapy-induced nausea and vomiting in children. Arch Med Res. 2008 Aug. 39(6):601-6. [Medline].

  23. Jordan K, Roila F, Molassiotis A, Maranzano E, Clark-Snow RA, Feyer P. Antiemetics in children receiving chemotherapy. MASCC/ESMO guideline update 2009. Support Care Cancer. 2011 Mar. 19 Suppl 1:S37-42. [Medline].

  24. R. Kadota, V. Shen and Y. Messinger. Safety, pharmacokinetics, and efficacy of palonosetron in pediatric patients: A multicenter, stratified, double-blind, phase 3, randomized study. Journal of Clinical Oncology. June 2007. 25:9570. [Full Text].

  25. US Food and Drug Administration (FDA) MedWatch Safety Alert. Ondansetron (Zofran) IV: Drug safety communication – QT prolongation. June 29, 2012. Available at http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm310219.htm.

  26. Helsinn Healthcare SA. Efficacy and Safety of Palonosetron Intravenous in Prevention of Chemotherapy Induced Nausea and Vomiting in Pediatric Patients. Clinicaltrials.gov. Available at http://clinicaltrials.gov/ct2/show/NCT01442376.

  27. Association of Comprehensive Cancer Centres (ACCC). Nausea and vomiting. Practice Guidelines. Utrecht, The Netherlands: Association of Comprehensive Cancer Centres (ACCC); 2006.

  28. Ladas EJ, Post-White J, Hawks R, Taromina K. Evidence for symptom management in the child with cancer. J Pediatr Hematol Oncol. 2006 Sep. 28(9):601-15. [Medline].

  29. Reindl TK, Geilen W, Hartmann R, et al. Acupuncture against chemotherapy-induced nausea and vomiting in pediatric oncology. Interim results of a multicenter crossover study. Support Care Cancer. 2006 Feb. 14(2):172-6. [Medline].

 
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Vomiting reflex.
Table. Emetogenic Risk of Intravenously Administered Antineoplastic Agents [2, 6]
Emetogenic Risk level Antineoplastic Agents Antiemetic Regimen
level 4 (High): More than 90% of patients who receive these agents experience nausea and vomiting. Carmustine, cisplatin, cyclophosphamide (>1500 mg/m2), dacarbazine, dactinomycin, mechlorethamine, streptozotocin Serotonin-receptor antagonist,



dexamethasone, and aprepitant



level 3 (Moderate): Nausea and vomiting occurs in 30-90% of patients who receive these agents. Carboplatin, cyclophosphamide (< 1500 mg/m2), cytarabine (>1 g/m2), daunorubicin, doxorubicin, epirubicin, idarubicin, ifosfamide, irinotecan, oxaliplatin Serotonin-receptor antagonist and dexamethasone
level 2 (Low): Nausea and vomiting occurs in 10-30% of patients who receive these agents. Bortezomib, cetuximab, cytarabine (< 1 g/m2), docetaxel, etoposide, fluorouracil, gemcitabine, methotrexate, mitomycin, mitoxantrone, paclitaxel, pemetrexed, topotecan, trastuzumab Serotonin-receptor antagonist
level 1 (Minimal): Less than 10% of patients who receive these agents experience nausea and vomiting. Bevacizumab, bleomycin, busulfan, 2-chlorodeoxyadenosine, fludarabine, rituximab, vinblastine, vincristine, vinorelbine No antiemetic routinely administered*
*If antiemetic required for individual patients, may use a single dose of serotonin-receptor antagonist
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