Seminar in Palliative CareSeptember 26 – October 02, 2010

Salzburg, Austria

in Collaboration with

The EPEC-O Curriculum is produced by the EPECTM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

Education in Palliative and End-of-life Care - Oncology

The

ProjectEPEC-O

TM

Nausea / Nausea / VomitingVomiting

Jamie H. Von Roenn, Jamie H. Von Roenn, MDMD

Northwestern University,Northwestern University,Feinberg School of Medicine, Feinberg School of Medicine,

Chicago, Illinois, USAChicago, Illinois, USA

Nausea / vomiting . . .Nausea / vomiting . . .

• DefinitionDefinition

Nausea is an unpleasant subjective Nausea is an unpleasant subjective sensation of being about to vomitsensation of being about to vomit

Vomiting is the reflex expulsion of gastric Vomiting is the reflex expulsion of gastric contents through the mouthcontents through the mouth

. . . Nausea / vomiting. . . Nausea / vomiting

• Impact very distressing:Impact very distressing:

Awareness of nauseaAwareness of nausea

Inability to keep food or fluids downInability to keep food or fluids down

Acid and bitter tastesAcid and bitter tastes

Unpleasant smells of vomitusUnpleasant smells of vomitus

Key pointsKey points

1.1. PathophysiologyPathophysiology

2.2. AssessmentAssessment

3.3. ManagementManagement

PathophysiologyPathophysiology

• Nausea Nausea

Subjective sensation (easily learned)Subjective sensation (easily learned)

Stimulation Stimulation

Gastrointestinal lining, CTZ, vestibular Gastrointestinal lining, CTZ, vestibular apparatus, cerebral cortexapparatus, cerebral cortex

• VomitingVomiting

Neuromuscular reflexNeuromuscular reflex

PathophysiologyPathophysiology

CortexCortexCortexCortex

Vestibular Vestibular apparatusapparatusVestibular Vestibular apparatusapparatus

GI tractGI tractGI tractGI tract

ChemoreceptorChemoreceptorTrigger Zone (CTZ)Trigger Zone (CTZ)

ChemoreceptorChemoreceptorTrigger Zone (CTZ)Trigger Zone (CTZ)

NeurotransmittersNeurotransmitters AcetylcholineAcetylcholine DopamineDopamine HistamineHistamine Neurokinin Neurokinin SerotoninSerotonin

NeurotransmittersNeurotransmitters AcetylcholineAcetylcholine DopamineDopamine HistamineHistamine Neurokinin Neurokinin SerotoninSerotonin

Vomiting centerVomiting center

CausesCauses

MMetastasesetastases

MMeningeal irritationeningeal irritation

MMovementovement

MMental anxietyental anxiety

MMedicationsedications

MMucosal irritationucosal irritation

MMechanical echanical

obstructionobstruction

MMotilityotility

MMetabolicetabolic

MMicrobesicrobes

MMyocardialyocardial

AssessmentAssessment• WhenWhen• Acute versus chronicAcute versus chronic• Intermittent or constantIntermittent or constant• Associated with sights or smellsAssociated with sights or smells• Eating patternsEating patterns• Bowel patternsBowel patterns• MedicationsMedications

ManagementManagement

• Dopamine Dopamine

antagonistsantagonists

• AntihistaminesAntihistamines

• AnticholinergicsAnticholinergics

• Serotonin Serotonin

antagonistsantagonists

• Neurokinin Neurokinin

antagonistsantagonists

• Prokinetic Prokinetic

agentsagents

• AntacidsAntacids

• Cytoprotective Cytoprotective

agentsagents

• Other Other

medicationsmedications

Gralla R, et al. J Clin Oncol, 1999.

Chemotherapy nauseaChemotherapy nausea

• AcuteAcute

< 24 hr< 24 hr

Chemoreceptor trigger zoneChemoreceptor trigger zone

Serotonin release in the gutSerotonin release in the gut

• DelayedDelayed

24 hr (may be days)24 hr (may be days)

Unclear mechanismUnclear mechanism

Chemotherapy Chemotherapy emetogenicityemetogenicity

Emetogenic Emetogenic ClassClass

Incidence acute Incidence acute vomitingvomiting

II Minimal < 10 %Minimal < 10 %

IIII Low 10 – 30 %Low 10 – 30 %

IIIIII Mild 30 – 60 %Mild 30 – 60 %

IVIV Moderate 80 – 90 %Moderate 80 – 90 %

VV High > 90 %High > 90 %

Dopamine antagonistsDopamine antagonists

• HaloperidolHaloperidol

• ProchlorperazineProchlorperazine

• Droperidol Droperidol

• ThiethylperazineThiethylperazine

• Promethazine Promethazine

• TrimethobenzamideTrimethobenzamide

• MetoclopramideMetoclopramide

• OlanzapineOlanzapine

• PerphenazinePerphenazine

Histamine antagonists Histamine antagonists (antihistamines)(antihistamines)

• DiphenhydramineDiphenhydramine

• MeclizineMeclizine

• HydroxyzineHydroxyzine

Acetylcholine antagonistsAcetylcholine antagonists(anticholinergics)(anticholinergics)

• ScopolamineScopolamine

Serotonin antagonistsSerotonin antagonists

• OndansetronOndansetron

• GranisetronGranisetron

• DolasetronDolasetron

• PalonosetronPalonosetron

Neurokinin-1 antagonistsNeurokinin-1 antagonists

• AprepitantAprepitant

Prokinetic agentsProkinetic agents

• MetoclopramideMetoclopramide

• DomperidoneDomperidone

• Macrolide antibiotics, Macrolide antibiotics, eg, erythromycineg, erythromycin

AntacidsAntacids

• AntacidsAntacids

• HH22 receptor antagonists receptor antagonistsCimetidineCimetidineFamotidineFamotidineRanitidineRanitidine

• Proton pump inhibitorsProton pump inhibitorsOmeprazoleOmeprazoleLansoprazoleLansoprazole

Other medicationsOther medications

• Dexamethasone 6 – 20 mg PO dailyDexamethasone 6 – 20 mg PO daily

• Tetrahydrocannabinol 2.5 – 5 mg PO tidTetrahydrocannabinol 2.5 – 5 mg PO tid

• Lorazepam 0.5 – 2 mg PO q 4 – 6 hLorazepam 0.5 – 2 mg PO q 4 – 6 h

• Octreotide 10 Octreotide 10 g / hr IV / SC infusiong / hr IV / SC infusion

or 100 or 100 g SC q 8 h for bowel obstructiong SC q 8 h for bowel obstruction

SummarySummary

Use comprehensive assessment and Use comprehensive assessment and

pathophysiology-based therapy pathophysiology-based therapy

to treat the cause and improve the to treat the cause and improve the

cancer experiencecancer experience