Nausea and vomiting - chemotherapy and radiotherapy induced: prevention and treatment

Shared care information

Different shared care centres will have different roles in the administration of chemotherapy to paediatric oncology children. In centres where little or no chemotherapy is administered, patients may still present with delayed emesis.

In centres where more chemotherapy is administered, all patients should have antiemetic medication prophylactically prescribed as per the guidelines. Check to see what antiemetics the patient has previously required to determine which level of antiemesis to start at.

Introduction

It is essential during chemotherapy, and for 24 - 48 hours following chemotherapy, to ensure that children receive adequate prophylactic antiemetic therapy. Appropriate management of chemotherapy induced nausea and vomiting decreases anxiety and improves the overall compliance with therapy.

Chemotherapy-induced nausea and vomiting may be:

• Acute - occurs within a few minutes to several hours after chemotherapy administration and resolves within 24 hours.

• Delayed - occurs within 24 hours to 5 - 7 days from the administration of chemotherapy. Commonly associated with platinum agents (cisplatin and carboplatin) and anthracyclines. 

• Anticipatory - conditioned response that leads to nausea and vomiting before chemotherapy administration due to anxiety and previous experiences.

• Breakthrough - vomiting that occurs despite prophylactic treatments and/or requires "rescue" with antiemetic agents.

Radiation induced nausea and vomiting

This is common in children receiving abdominal radiation but also occurs with radiotherapy for brain tumours and total body irradiation. Radiation-induced vomiting responds to prophylaxis with 5HT₃ antagonists such as ondansetron.

Other causes of nausea and vomiting

• Children with advanced disease with metastases have high rates of nausea and vomiting which can be due to disease or medications being given for symptom control eg morphine.

• Raised intracranial pressure. Due to tumours or medications

• Gastrointestinal - gastritis, constipation, abdominal tumours

• Infections

• Metabolic abnormalities

• Medications

Principles of preventing and treating chemotherapy-induced nausea and vomiting

• Antiemetics should be prescribed and administered regularly during chemotherapy.

• Antiemetics appropriate for the emetogenic class of the chemotherapy should be administered for each day of chemotherapy and for 2 days after if appropriate (longer for agents that cause delayed emesis).

• Choice of antiemetics should take into account the emetogenicity of the chemotherapy regimen and the patient's history

• If a patient required an increase in antiemetic therapy for the last cycle of similar chemotherapy they should start a next cycle on this higher regimen.

• To minimise the risk of nausea and vomiting, the first dose of antiemetics should be given prior to starting chemotherapy

  • Oral - 60 minutes prior to chemotherapy

  • Intravenous - 30 minutes prior to chemotherapy

• Antiemetics should be charted on the regular chart at the time of admission with a start and end date.

• Scheduled doses of antiemetics must be given on time regardless of whether the patient is experiencing nausea/vomiting or not.

• Dexamethasone and 5-HT antagonists have been shown to have synergistic action.

Recording nausea and vomiting

Nausea and vomiting should be assessed and recorded in children > 7 years using the "Baxter Barf Scale". In younger children, parental reports should be sought and recorded.

Amy Baxter; Paediatrics 127(6) 2011

Emetogenicity of chemotherapy

Antiemetic prophylaxis charts

1. CINV no restrictions

2. CINV no steroids

3. CINV no aprepitant

4. CINV refractory

Patients with delayed emesis and all patient receiving Cisplatin

Delayed emesis occurs within 24 hours to 5 - 7 days from the administration of chemotherapy. Delayed emesis is most common with cisplatin but also seen with high dose cyclophosphamide, doxorubicin, carboplatin and Ifosfomide. It is more likely when these drugs are used in combination.

To decrease the incidence and severity of delayed chemotherapy induced nausea and vomiting (CINV) the first step is pre-emptive management of the acute phase of CINV -see Prophylaxis and Treatment table above.

Oral dexamethasone is very effective but the total dose given over the cycle(s) and steroid side effects need to be considered. If the dexamethasone dose was halved due to interaction with aprepitant this can be increased 48 hours after the last dose of aprepitant.

If delayed nausea and vomiting then occur treatment with ondansetron +/- dexamethasone +/- metoclopramide or cyclizine should be restarted and again given regularly to prevent breakthrough until symptoms subside.

If symptoms persist 5-7 days after chemotherapy further investigation for other possible causes should be undertaken.

Managing anticipatory nausea and vomiting (ANV) in paediatric cancer patients

Antiemetic therapy should be optimised from the first cycle to prevent the development of anticipatory nausea and vomiting - see antiemetic prophylaxis for acute chemotherapy induced nausea and vomiting in paediatric cancer patients

Psychological interventions, where available, should be utilised to help manage ANV.

Lorazepam (0.04-0.08mg/kg/dose max 2mg) may be used the night before day 1 of the chemotherapy cycle and a second dose 12 hours later the morning of chemotherapy if required. Regular use of multiple days of Lorazepam for multiday chemotherapy cycles is discouraged due to the risk of benzodiazepine tolerance.