Vomiting In Patients Research Articles

Abstract PO3-27-12: Dexamethasone is necessary for preventing acute emesis induced by anthracycline/cyclophosphamide chemotherapy (HELEN-009) : a multicenter, randomized, open-labeled phase 3 trial

Abstract Background Olanzapine, in combination with NK1 receptor antagonist (RA), 5-hydroxytryptamine-3 (5-HT3) RA, and dexamethasone, is now the standard approach to prevent chemotherapy-induced nausea and vomiting (CINV). In this study, we assessed the preventive effect of removing dexamethasone from the quadruple standard antiemetic regimen on CINV caused by anthracycline/cyclophosphamide chemotherapy. Methods The HELEN-009 was a multicenter, randomized, open-labeled phase 3 trial to evaluate the efficacy of NK1RA,5-HT3RA and Olanzapine triplet-combination antiemetic therapy done in 3 hospitals in China.Key inclusion criteria were patients with early breast cancer who were scheduled to be treated with epirubicin plus cyclophosphamide chemotherapy for the first time, age between 18 and 75 years, and with Eastern Cooperative Oncology Group performance status of 0–1. Eligible patients were randomly assigned (1:1) to receive either fosaprepitant, tropisetron, dexamethasone and olanzapine(quadruple group)or fosaprepitant, tropisetron and olanzapine without dexamethasone(triple group). Patients were randomly assigned to interventions by use of a web entry system and the minimization method with a random component, with age as factors of allocation adjustment. The primary endpoint was the proportion of patients who achieved a complete response, defined as absence of vomiting and no use of rescue medications in the overall phase (days 1–5) after starting chemotherapy. All randomly assigned patients who satisfied eligibility criteria received epirubicin plus cyclophosphamide chemotherapy were included in efficacy analysis. All patients who received any treatment in this study were assessed for safety. This study is registered at Clinical Trials Registry, number NCT05242874. Findings Between January 2022 and July 2023, 439 patients with breast cancer were enrolled in the study, with 218 participants randomly assigned to quadruple group and 221 participants assigned to triple group. All eligible patients were observed 120 h after epirubicin plus cyclophosphamide chemotherapy initiation. One patient in the quadruple group withdrew consent. One patient in the quadruple group and one in triple group discontinued treatment on day 1 and was excluded from the efficacy analysis. In the overall phase, the proportion of patients who achieved a complete response was 180 (83.3% [95% CI 78.3–88.3] of 216 patients in the quadruple group and 137 (62.4% [55.8–68.7] of 220 patients in the triple group (p< 0·0001). No grade 3 or higher treatment-related adverse events occurred in either of the groups. Interpretation Dexamethasone remains essential in preventing acute emesis in patients receiving epirubicin plus cyclophosphamide chemotherapy. Table. Proportion of patients in the efficacy analysis set achieving a complete response Table. Treatment-related adverse events with an incidence ≥ 2% Citation Format: Xiuchun Chen, Jiao Dechuang, Chongjian Zhang, Xianfu Sun, Zhenduo Lu, Lianfang Li, Jianghua Qiao, Chengzheng Wang, Min Yan, Yueqing Feng, Ya Wei, Zhenzhen Liu. Dexamethasone is necessary for preventing acute emesis induced by anthracycline/cyclophosphamide chemotherapy (HELEN-009) : a multicenter, randomized, open-labeled phase 3 trial [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-27-12.

Olanzapine for Non-Chemotherapy Related Nausea and Emesis in Patients with a Palliative Care Consult.

Current palliative care guidelines lack a specific treatment algorithm for nausea and emesis. Olanzapine is an atypical antipsychotic with antiemetic activity that's recommended in the guidelines for the treatment of chemotherapy induced nausea and vomiting, but outside of oncologic indications there is a lack of research. To describe the safety and efficacy of olanzapine for nausea and emesis in the palliative care domain, excluding patients actively undergoing chemotherapy or radiation. This retrospective chart review encompassed hospitalized adult patients from six hospitals across a large health system admitted from August 2020 through August 2021, with a palliative care consult, and being treated with olanzapine for nausea or emesis. Data was collected on antiemetic therapy affordability, the ability for patients to tolerate medications by mouth, and safety outcomes such as QTc prolongation and increased liver function tests. A total of 78 patients were included in the study. Olanzapine decreased the number of doses required of antiemetic medications, the median doses of antiemetic medications pre-olanzapine was 1.6 (IQR 0.8-2.8) and post-olanzapine was 0.6 (IQR 0-2.4) (P=0.0006). After olanzapine was initiated, appetite was improved (P < 0.001), cost of antiemetic therapy was reduced by 65 cents per day (P=0.059) and olanzapine was prescribed at discharge in 69% of patients. QTc prolongation was observed in 19% of patients, and increased ALT and AST were observed in 4.3% and 0%, respectively. This retrospective review demonstrated benefit to utilizing olanzapine for nausea and emesis in palliative care patients and should be considered to aid in symptom management.

Clinical impact of human parainfluenza virus infections before and during the COVID-19 pandemic in Southern China

Human parainfluenza viruses (HPIVs) are a leading cause of acute respiratory tract infections (ARTIs). Non-pharmaceutical interventions (NPIs) were widely administered to combat the pandemic of the coronavirus disease 2019 (COVID-19). Respiratory specimens were obtained from 10,454 hospitalized children with ARTIs to detect HPIV. We investigated differences in epidemiological and clinical characteristics of HPIV infections before (2017–2019) and during the COVID-19 pandemic (2020–2022). HPIVs were detected in 392 (3.75%, 392/10,454) patients, of whom 70 (17.86%), 48 (12.24%), and 274 (69.90%) were positive for HPIV1, HPIV2, and HPIV3, respectively. Detection rates of HPIV3 were higher in 2020–2022 than in 2017–2019 (3.38% vs. 2.24%). The seasonal distribution of HPIV1 showed no difference, but HPIV3 peaked between September and December during the COVID-19 pandemic, which differed from previous epidemiological patterns. Compared to the period before the COVID-19 pandemic, there has been a noticeable decrease in the incidence of asthma, moist rales, and emesis in patients infected with HPIV1 and in asthma, expectoration, and severe pneumonia in patients infected with HPIV3 during 2020–2022. The detection rates of HPIV increased in Southern China during the COVID-19 outbreak, which underlines the importance of continuous surveillance of HPIV in the next epidemic season.

The effects of two different doses of intravenous dexamethasone on blood glucose concentration intra-operatively and on postoperative pain and emesis in patients undergoing surgery under spinal anesthesia: A double-blind randomized clinical study

Background: Spinal anesthetic techniques are relatively safe and associated with quick and uneventful recovery, but post-operative pain and postoperative nausea and vomiting (PONV) are major concerns after the effect weans off. Steroids by virtue of their anti-inflammatory effect are expected to reduce pain as well as PONV. Aims and Objectives: The study was conducted to evaluate the efficacy of two different doses of intravenous dexamethasone on blood glucose concentration intra-operatively and on post-operative analgesia and emesis for different surgeries under spinal anesthesia. Materials and Methods: This double-blind randomized clinical study was performed on 120 patients aged 20–60 year posted for surgery under spinal anesthesia who were randomly allocated into three groups to receive either normal saline (Group A: 40 pts), intravenous 4 mg dexamethasone (Group B: 40 pts), or iv 8 mg dexamethasone (Group C: 40 pts) immediately after spinal anesthesia. Hemodynamic parameters, respiratory rate, intraoperative blood glucose concentration., severity of post-operative pain, and incidence of PONV was compared among the groups. Results: Patients in Group C had significantly less severe post-operative pain and incidence of PONV (P&lt;0.05). Furthermore, less post-operative rescue analgesia was required in Group C (P&lt;0.05). There was a highly significant rise in intraoperative blood glucose level in Group C as compared to other groups, but it was well below the recommended guidelines (&lt;180 mg/dL). Conclusion: Our study concluded that i.v. dexamethasone 8 mg was more effective, although it caused raised blood glucose concentration intraoperatively, but it also provided prolonged post-operative analgesia, increased time of first rescue analgesic, less incident of post-operative nausea and vomiting, and better patient satisfaction.

Prodromal emesis in MOG-antibody associated disorder

BackgroundExclusive emesis has been observed in few patients of MOG-associated disorder (MOGAD). ObjectivesTo study the occurrence of emesis in patients of Demyelinating disorders and determine their clinical and radiological features. Methods and ResultsMedical records of 551 patients of CNS demyelinating disorders were reviewed. Exclusive emesis without hiccups was observed in 1 (0.1%) patient of MS, 17 (6.5%) patients of MOGAD while none were observed in patients of AQP4-ab associated disorders (p < 0.001). There were 17(M:F-8:9) patients with exclusive emesis in MOGAD in 58.8% pediatric age group, adults (35.3%) and late-onset (5.9%). ADEMON (acute demyelinating encephalomyelitis -ADEM followed by optic neuritis) was observed in 7 patients. Preceding clinical syndrome was ON (41.2%), brainstem syndrome (BS) (23.5%), involvement of both ON and BS in 23.5%, myelopathy (11.8%). MRI analysis showed combination of lesions affecting the brainstem (11), optic nerve (10), juxtacortical white matter (10) and periventricular lesions (3). Odds ratio for the presence of ADEM, lesions in medulla, pons, MCP or any of the three areas was found to be significant. ConclusionsExclusive emesis without hiccups appears to be common in MOG-antibody associated disorder and may occur as a prodromal illness or exclusive clinical episode. It is known to occur most commonly in association with ADEM and/or Optic neuritis.

Review the Contributing Factors Associated With Emesis and Enteral Nutrition Intolerance in Patients With Disorders of Consciousness

<h3>Research Objectives</h3> Review the presence of the risk factors for emesis in patients with DOC. <h3>Design</h3> Retrospective review of factors of emesis via chart review. Data collection included patient onset of injury, age, gender, brain injury diagnosis, CRS-R diagnostic category, opioids, enteral nutrition (EN) administration, pharmacological agents and the diagnosis of diabetes or hydrocephalus. <h3>Setting</h3> Inpatient rehabilitation hospital. <h3>Participants</h3> All patients admitted to the disorders of consciousness (DOC) program between 2017 and 2019 that received scheduled metoclopramide or ondansetron. Patients with DOC exhibit altered gastric emptying which contribute to the presence of emesis and enteral nutrition (EN) intolerance. Previously identified risk factors include diabetes, hydrocephalus, vestibular dysfunction, hyperglycemia, opioid use, pharmacological agents and bolus vs continuous nutrition administration. <h3>Interventions</h3> None. <h3>Main Outcome Measures</h3> Incidence of different risk factors. <h3>Results</h3> 28 patient admissions were included, 54% with traumatic brain injury (TBI) and 46% with non-TBI. Increased risk of emesis was associated with the diagnosis of hydrocephalus (54%) and opioid use (25%). Pharmacological agents with highest incidence were levetiracetam (57%) and intrathecal baclofen (ITB) (50%). 70% patients received continuous EN. <h3>Conclusions</h3> The presence of emesis may place the patient at increased risk for infections, malnutrition and prolonged hospital stay. Understanding the etiology of emesis will aid in the approach to treatment, though our findings indicate this is a multifactorial issue. The presence of hydrocephalus, opioids, ITB and levetiracetam were the most common contributing factors, though no modifiable factors were identified. Future research will focus on effectiveness of treatment with the goal of improving patient outcomes. <h3>Author(s) Disclosures</h3> The authors have nothing to disclose.

Efficacy of ondansetron against emesis induced by a multiple-day cisplatin-based chemotherapy regimen for malignant lymphoma

ABSTRACT Objectives This study aimed to evaluate the antiemetic efficacy of a 5-hydroxytryptamine-3 receptor antagonist (5-HT3RA), ondansetron, in patients with malignant lymphoma receiving multi-day cisplatin-based combination chemotherapy. Methods We conducted a single-institution retrospective analysis of patients receiving the first course of an ESHAP (etoposide, cisplatin, methylprednisolone, cytarabine) regimen including 4-day continuous infusion of cisplatin (25 mg/m2/day). All patients received ondansetron 4 mg intravenously during 5-day administration of ESHAP. The primary endpoint was complete response (CR) for emesis, which was defined as absence of both emesis and rescue medications. Total control (TC) was defined as an absence of emetic episodes, including nausea and emesis, and complete protection (CP) was defined as an absence of emesis with addition of rescue antiemetics. Nausea and vomiting were assessed and graded daily by medical staff. Results Eighty-two patients were analyzed. Nausea and vomiting were generally well controlled, with the CR rates of emesis being 79% in the overall phase, 82% in the early phase (days 1–6), and 89% in the delayed phase (days 7–10). TC and CP were achieved in 51 patients (62%) and 77 patients (94%) in the overall phase. Discussion Most of the chemotherapy regimens for lymphoid malignancies include high-dose corticosteroid which may be also effective as antiemetics. Although NK1 receptor antagonist (NK1RA) is generally recommended for cisplatin-containing chemotherapy, it can interact with variety drugs. Conclusion Although NK1RA is generally recommended for cisplatin-containing regimen, our results suggest that ondansetron effectively controlled emesis in patients receiving ESHAP therapy which includes high-dose corticosteroid.

Real-world evidence evaluating the use of an NK-1 antiemetic in the systemic chemotherapy treatment of metastatic breast cancer.

e12599 Background: Severe and persistent nausea and vomiting (n/v) impacts quality of life and may lead to treatment discontinuation. While antiemetics assist with minimizing these effects, newer drugs can be expensive and carry their own side effect profile. Prior research has suggested that neurokinin 1 receptor inhibitor(NK-1) antiemetics are overly prescribed. Using the package insert recommendations for aprepitant, an NK-1, we evaluated the frequency of its prophylactic use to prevent emesis in patients receiving systemic chemotherapy(chemo) with moderate to high emetogenic risk. Methods: Patients were identified from a third-party, administrative claims database. Using medical and pharmacy claims, any female with ICD-9/10 codes for both breast cancer and metastases diagnosed between Jan-2013 and Dec-2017, who initiated systemic chemo and received aprepitant prophylactically were selected. Chemo regimen emetogenic potential was scored using the Hesketh scale and aggregated into two cohorts: low risk (grade 1-2 = none- &lt; 30%), and moderate-high risk (grade 3-5: &gt; 30- &gt; 60%). If patients received combination chemo, the assigned risk level was the highest risk of any individual agent. The frequency of NK-1 use for each risk cohort was calculated per line of therapy independent of the previous treatment. Results: 10,342 patients met the selection criteria with 2,868 patients administered moderate-high emetogenic risk chemotherapy regimens. Mean age at initiation of treatment was 61.7 years (SD = 12.12). By line, the aprepitant utilization rate was: 1 line(L) 43% ,2L 27%, 3L 18%, 4L 16%, 5L 11% and 6L 12%. Across all lines of therapy, aprepitant was used prophylactically in 23% of patients treated with high risk chemo regimens and in 2% of patients who had received low risk regimens. Conclusions: Prophylactic use of the NK-1 inhibitor aprepitant was less than 50% in 1L moderate-high emetogenic risk chemotherapy and declined with consecutive lines of treatment. NK-1 use with low risk regimens was minimal. Further research is needed to understand the pattern of use and clinical outcomes between moderate-high emetogenic risk patients who do and don't receive NK-1 antiemetic supportive care.

Quick Consult

marijuana, cannabinoid hyperemesis syndrome: marijuana, cannabinoid hyperemesis syndromeFigureFigureFigureA 28-year-old man presented to the ED with diffuse abdominal pain, nausea, and more than 15 episodes of non-bilious, non-bloody emesis over the previous 48 hours. His pain was worst in the morning, but improved after a hot shower. Of note, the patient had used products similar to this on a daily basis. (Photo.) This was his fourth visit to the ED for abdominal pain over the past year. Previous visits have included an extensive workup, including unremarkable abdominal CTs, labs, and upper endoscopy. What is the most appropriate diagnosis, and what are the treatment options? Find the diagnosis and case discussion on p. 16. Diagnosis: Cannabinoid Hyperemesis Syndrome Cannabinoid hyperemesis syndrome (CHS) is characterized by cyclic episodes of moderate to severe diffuse abdominal pain, nausea, and emesis in patients endorsing frequent marijuana use. Many patients present repeatedly, and undergo multiple rounds of costly, nondiagnostic tests. The diagnosis of CHS is becoming increasingly common, and is likely due to an increase in the THC content of marijuana, the prevalence of marijuana use, and the availability of commercial marijuana. Shifts in laws and stigma about marijuana use may also be influencing the frequency with which patients report marijuana use to physicians. CHS can be separated into three phases: prodromal, hyperemetic, and recovery. The prodromal phase may last months to years, and involves low-level abdominal discomfort from frequent marijuana use. The hyperemetic phase typically lasts up to 48 hours, and involves intense episodes of non-bilious, non-bloody emesis, sometimes more than five times per hour. Episodes occur cyclically at an interval of weeks to months, and asymptomatic periods may or may not involve marijuana use. (Curr Drug Abuse Rev 2011;4[4]:241.) The pathophysiology of CHS is still an active area of investigation, but may involve CB1 receptors in the gastrointestinal tract and central nervous system. (Pharmaceuticals [Basel] 2010;3[7]:2163.) Initial use of marijuana may provide a therapeutic effect to the patient with decreased nausea and abdominal pain, while chronic use eventually tips the scale toward nausea, pain, and emesis. The recovery phase, which almost invariably coincides with marijuana cessation, is characterized chiefly by a lack of hyperemetic episodes. Confidently diagnosing CHS can be challenging. Excluding the diagnosis of cyclic vomiting syndrome is difficult because both conditions involve cyclic episodes of abdominal pain, nausea, and emesis. Some studies indicated that the only way to discriminate between the syndromes is whether marijuana cessation causes remission. (Ger Med Sci 2017;15:Doc06.) CHS is also more often associated with frequent marijuana use and symptomatic relief via hot showers. (Curr Drug Abuse Rev 2011;4[4]:241.) Up to 92 percent of patients diagnosed with CHS endorse symptomatic relief when taking hot showers. (J Med Toxicol 2017;13[1]:71.) It is important in the ED to exclude acute diagnoses such as pancreatitis, bowel obstruction, or cholecystitis while not repeating prior negative workups. Chronic diagnoses, such as irritable bowel syndrome, Crohn's, or celiac should be investigated by the primary care physician. Treatment in the ED consists primarily of IV fluids and antiemetic medications. Haloperidol (5-10 mg IV) may be beneficial because of the dopamine antagonism and interactions between CB1 and dopamine pathways. (Am J Ther 2017;24[1]:e64.) Recent research suggests that capsaicin creams applied in the ED can also provide quick symptomatic relief. A suggested mechanism of action involves TRPV1 receptors in nociceptive pathways. (Clin Toxicol [Phila] 2017;55[8]:908.) No long-term pharmacologic interventions have been shown to reduce the intensity or frequency of episodes, and cessation of marijuana use is the only intervention that has consistently demonstrated efficacy. (J Med Toxicol 2017;13[1]:71.) Broaching the topic of marijuana as a causative agent while the patient is in the ED is challenging. Many patients resist the idea that marijuana use may be causing their symptoms. Discussion of CHS should be reserved for the end of the visit when symptoms have significantly resolved. It is useful to engage the patient in a conversation on the paradoxical causative role of marijuana. Admitting that cannabis can provide nausea relief in many situations and elaborating on CHS may help reduce resistance to the diagnosis. Engaging patients in the idea that marijuana, like many other medications and remedies, may have side effects is also useful. These conversations help reduce return visits, which are common for CHS patients. This patient received treatment in the ED with IV normal saline and haloperidol with significant improvement. After engaging him in a thoughtful discussion about his cannabis use, he acknowledged that cannabis may have side effects in some patients and agreed to a trial of cannabis cessation to see if his symptoms would resolve.

Emesis in patients receiving acupuncture, sham acupuncture or standard care during chemo-radiation: A randomized controlled study

ObjectiveTo study nausea, vomiting and need for rescue antiemetics in patients receiving antiemetic acupuncture, sham acupuncture or standard care during concomitant chemotherapy during pelvic radiotherapy. MethodsIn total, 68 patients participated (75% women, mean age 56 years, 53% had gynecological, 43% colorectal, and 4% other cancer types). Fifty-seven of them were blinded randomized to verum (n=28) or sham (n=29) acupuncture, median 10 sessions. During the study period of four weeks, the patients daily registered their nausea, vomiting and consumption of antiemetics. They were compared to a reference group (n=11) receiving standard care only, who delivered these data once (after receiving mean 27Gy radiotherapy dose). ResultsMore patients in the sham acupuncture group (17 of 20; 85%, p=0.019, RR 1.81, CI 1.06–3.09) consumed antiemetics, compared to the verum acupuncture group (8 of 17; 47%). In the standard care group, 7 of 11 (63%) consumed antiemetics. The verum acupuncture treated patients experienced lower intensity of nausea than the other patients (p=0.049). There was a non-significant tendency that more patients receiving either sham acupuncture or standard care experienced nausea (21 of 31; 68%) than patients receiving verum acupuncture (9 of 17; 53%: p=0.074, RR 1.58, CI 0.91–2.74). ConclusionPatients treated with verum acupuncture needed less antiemetics and experienced milder nausea than other patients. Our study was small and many analyses lacked statistical power to detect differences; we welcome further sham-controlled efficacy studies and studies regarding the role of non-specific treatment components for experiencing antiemetic effects of acupuncture.

A randomized, double-blind, placebo-controlled study of the safety and efficacy of olanzapine for the prevention of chemotherapy-induced nausea and vomiting in patients receiving moderately emetogenic chemotherapy.

e21699 Background: Olanzapine was found to be effective for preventing acute and delayed emesis in patients receiving highly emetogenic chemotherapy by randomized phase 3 study. However, there is limited data for the efficacy of olanzapine combined with palonosetron and dexamethasone in patients receiving moderately emetogenic chemotherapy (MEC). Methods: We conducted randomized, double-blind, placebo-controlled study to determine whether olanzapine could reduce the frequency of CINV and improve quality of life (QOL) in patients receiving palonosetron and dexamethasone for the prophylaxis of MEC induced nausea and vomiting. Two groups received either 10 mg of olanzapine orally or matching placebo daily on days 1 through 4. The primary end point was the complete response (no emesis and no use of rescue medication) for the acute phase (0-24 hours after chemotherapy). Secondary end points included the complete responses for the delayed (24-120 hours) and overall phase (0-120 hours), proportion of significant emesis (VAS ≥ 25 mm) for overall phase, use of rescue medications, and effect on QOL by Functional Living Index-Emesis (FLIE) questionnaire. Results: Fifty-six patients were randomized and fifty-four patients were evaluable (29 assigned to olanzapine, and 25 to placebo). The complete response rate was not significant between olanzapine and placebo group in the acute (96.5% vs. 88.0%, P = 0.326), delayed (69.0% vs. 48.0%, P = 0.118), and overall phase (69.0% vs. 48.0%, P = 0.118). However, the percentage of patients with significant emesis (17.2% vs. 44.0%, P = 0.032) and the use of rescue medications (0.03±0.19 vs. 1.88±2.88, P = 0.002) were significantly lower with olanzapine than with placebo in the overall phase. Furthermore, olanzapine group experienced a better QOL than the placebo group, as reported on the FLIE questionnaire (P = 0.015). Conclusions: Olanzapine in addition to palonosetron and dexamethasone significantly improved the management of emesis and QOL among previously untreated patients receiving MEC, although the efficacy was limited to reduce the frequency of CINV. Clinical trial information: NCT02400866.

The Efficacy of Palonosetron Plus Dexamethasone in Preventing Chemoradiotherapy-induced Nausea and Emesis in Patients Receiving Daily Low-dose Cisplatin-based Concurrent Chemoradiotherapy for Uterine Cervical Cancer

The prevention of chemotherapy-induced and radiotherapy-induced emesis is recommended by several guidelines; however, there are no evidence-based recommendations for the use of antiemetics in concurrent chemoradiotherapy (CCRT). The aim of the present study was to evaluate the efficacy and safety of antiemetic therapy comprising palonosetron and dexamethasone during CCRT. This is a nonrandomized, prospective, single-center, open phase II study.Twenty-six consecutive patients with cervical carcinoma were treated with daily low-dose cisplatin (8 mg/m/d)-based CCRT (2 Gy/d, 25 fractions, 5 times a week). All patients received 0.75 mg of palonosetron on day 1 of each week and 4 mg of oral dexamethasone daily. The primary endpoint was the percentage of patients achieving a complete response, which was defined as no emetic episodes and no antiemetic rescue medication during treatment. Planned daily low-dose cisplatin-based CCRT was successful without delay or interruption in 46% (12/26) of the patients. The mean dose of total cisplatin was 184 (range, 136 to 200) mg/m.No patient vomited during the treatment period. The complete response rate during CCRT was 100%. A total of 81% patients were completely free from nausea. All patients tolerated the combination of palonosetron and dexamethasone and completed the scheduled regimen. Five patients exhibited grade 1 Cushingoid features that resolved after treatment. Antiemetic therapy comprising palonosetron and dexamethasone provided complete protection from nausea and vomiting in patients with cervical cancer receiving daily low-dose cisplatin-based CCRT.

Amelioration of Pain on Injection of Propofol: A Comparison of Pretreatment with Granisetron Vs Lignocaine.

Pain during propofol injection is a very commonly and frequently encountered event during induction of anaesthesia. A 5HT3 antagonists like granisetron are commonly used just prior to intravenous propofol as pre anaesthetic medication to prevent emesis in patients. Comparison of pre treatment with granisetron versus lignocaine with respect to amelioration of pain induced by injection of propofol, in patient admitted for elective surgery with general anaesthesia. A randomized double blinded controlled study was conducted with patients divided into three groups with (n=30) in each group. Group I (the placebo group) received 2 ml of 0.9% normal saline, Group II received 2 ml of 1% lignocaine and Group III received 2 ml of granisetron (1 mg/ml) as pre treatment medication respectively. The patient's complain regarding pain on intravenous propofol administration was recorded using the Verbal Rating Score. Pulse, BP, SpO2 were noted meticulously on three occasions-immediately after pre-treatment, injecting full dose of propofol (not for pain assessment) and after 10 minutes. The results were analysed using the null hypothesis and two sample t-tests. It was observed and obvious that the relief of pain was significant (p<0.05) when granisetron or lignocaine was compared with the placebo group. But there was insignificant difference (p>0.05) when granisetron was compared with lignocaine in terms of relieve of pain induced by propofol. It was concluded that parenteral administration of granisetron can be considered to be superior to lignocaine as pre treatment medication for pain relief after propofol injection along with the advantage of its anti-emetic effect.

S54 - Transdermal granisetron is effective in prevention of acute-delayed emesis in patients with glioblastoma multiforme (gbm) treated with temozolomide (tmz): results from a monocentric experience

S54 - Transdermal granisetron is effective in prevention of acute-delayed emesis in patients with glioblastoma multiforme (gbm) treated with temozolomide (tmz): results from a monocentric experience

Palonosetron: an evidence-based choice in prevention of nausea and vomiting induced by moderately emetogenic chemotherapy.

In 2003, the second-generation, 5-HT(3) receptor antagonist (5-HT(3) RA) palonosetron was approved by the FDA for the prevention of nausea and vomiting associated with highly and moderately emetogenic chemotherapy. We reviewed the current knowledge on the role of palonosetron against acute and delayed emesis in patients with solid tumors undergoing single-day moderately emetogenic chemotherapy regimens. A literature review in PubMed was performed to update currently available preclinical and clinical evidence on palonosetron, prioritizing randomized clinical trials. The distinct pharmacology of palonosetron provides a rationale behind the improved efficacy observed with the drug in prevention of delayed symptoms. This may be explained by allosteric binding properties and by palonosetron-triggered receptor internalization, which result in prolonged inhibition of the 5-HT(3) receptor function. Very recent pharmacology experiments have also suggested that palonosetron would be able to differentially inhibit 5-HT(3)/neurokinin 1 (NK-1) receptor signaling cross-talk. In two recent meta-analyses, palonosetron was shown to be more effective than other available 5-HT(3) RAs in preventing acute and delayed nausea and vomiting for both HEC and MEC. Recent findings also suggest that a single-day regimen of palonosetron plus dexamethasone (both drugs administered intravenously) may provide a reasonable therapeutic alternative to reduce the total dexamethasone dose administered in patients undergoing moderately emetogenic chemotherapy. On the basis of accumulating data, the evidence-based international guidelines devised from the major organizations have been recently updated to recommend the use of palonosetron plus 3-day dexamethasone for the optimal prevention of nausea and vomiting due to moderately emetogenic chemotherapy. There is still a need to investigate the efficacy of palonosetron in combination with an NK-1 receptor antagonist and dexamethasone in well-designed randomized trials.

Clinical predictors of anticipatory emesis in patients treated with chemotherapy at a tertiary care cancer hospital.

Objective:To determine the clinical predictors of anticipatory emesis in patients treated with chemotherapy at a tertiary care cancer hospital.Methods:This was a cross-sectional study conducted on 200 patients undergoing first line chemotherapy with minimum of two cycles at inpatient department and chemotherapy bay of Shaukat Khanum Memorial Cancer Hospital and Research Centre Pakistan. Anticipatory nausea and vomiting develops before administration of chemotherapy. Clinical signs and symptoms in patients with or without anticipatory emesis were compared using chi square test statistics.Results:The mean age of the study participants was 36.68 years (SD±12.23). The mean numbers of chemotherapy cycles administered were 3.23 (SD±1.2). Chemotherapy related nausea and vomiting was experienced by 188 (94%) patients and anticipatory nausea vomiting was reported in 90 (45%) of patients. Greater proportions of patients with anticipatory emesis were females. Fourteen (15.5%) p-value=0.031 patients with anticipatory emesis had history of anxiety and depression. Fifty nine (65.5%) p-value =< 0.0001 patients with anticipatory emesis had severe nausea after last chemotherapy cycle. Forty six (51.11%) p=<0.0001 patients had motion sickness.Conclusion:Female gender, history of motion sickness, anxiety and depression, severe nausea and vomiting experienced in pervious cycle of chemotherapy were clinical predictors of anticipatory nausea and vomiting.

Weekly cisplatin (30-40 mg/m2) as radiosensitizer: Is it high or moderate emetic agent?

The American Society of Clinical Oncology (ASCO) guideline recommends a high antiemetic prophylaxis for any dose of cisplatin. This hypothesis was tested by us in this analysis of solid tumor patients who received weekly cisplatin as a radiosensitizer in a dose range of 30-40 mg/m2. This was a retrospective analysis of 181 solid tumor patients who received weekly cisplatin (in the dose range of 30-40 mg/m2) as a radiosensitizer between July 2015 and August 2015. The antiemetic prophylaxis schedule provided was classified as optimal (if a high antiemetic prophylaxis was provided) or suboptimal (if a nonhigh antiemetic prophylaxis was provided). The incidence of acute, delayed and breakthrough vomiting after chemotherapy was noted. SPSS version 20 was used for analysis. Fisher's exact test was used to determine the association between antiemetic schedule (suboptimal vs. optimal) and postchemotherapy emesis. In the present study, of 181 patients, only 25 patients (13.8%) received optimal antiemetic prophylaxis while the remaining 156 (86.2%) received suboptimal prophylaxis. In the cohort of patients with suboptimal prophylaxis, dexamethasone was omitted in all patients (100%) while NK receptor antagonist was omitted in 76 patients (48.7%). The rate of vomiting was lower in patients receiving optimal prophylaxis as compared to that in patients receiving suboptimal prophylaxis (12% vs. 39.75%; P - 0.005). Omission of dexamethasone followed by aprepitant was the main reason for suboptimal prophylaxis. High antiemetic prophylaxis in accordance with ASCO guidelines overall decreased the risk of emesis in patients receiving CTRT with weekly cisplatin in the dose range of 30-40 mg/m2.

Aprepitant for the Management of Refractory Emesis in a Patient With a Small Bowel Carcinoid Tumor

ABSTRACTNausea and vomiting are common distressing symptoms with multiple etiologies. Serotonin and substance P can induce nausea and vomiting by binding to specific receptors (5-hydroxytryptamine3 [5HT3] and neurokinin-1 [NK-1] receptors respectively). Carcinoid tumors, which originate from enterochromaffin cells of the neuroendocrine system, secrete several biologically active amines and peptides, including serotonin and substance P, that are responsible for the distant effects of this tumor. The authors present an 88-year-old lady with metastatic carcinoid tumor, with evidence of carcinoid syndrome. She had nausea and vomiting that became unresponsive to 5HT3 receptor antagonists and other antiemetics. As substance P is released from carcinoid tumors and has a role in the pathogenesis of emesis, the NK-1 receptor antagonist aprepitant was trialed. This provided complete and sustained improvement of the nausea and vomiting until her death 2 months later. This case demonstrates the potential role and rationale of NK-1 receptor antagonists in the management of resistant emesis in patients with carcinoid tumors. Clinical trials are needed to evaluate the efficacy and toxicity of these drugs in the management of emesis in patients with carcinoid syndrome.

Antiemetic Role of Thalidomide in a Rat Model of Cisplatin-Induced Emesis

The efficacy of thalidomide to attenuate cisplatin-induced emesis was evaluated in a rat model. Four groups were utilized: control group (peritoneal injection and gastric lavage with normal saline), cisplatin group (peritoneal injection of cisplatin at 10 mg/kg and gastric lavage with normal saline), thalidomide group (cisplatin as above and gastric lavage with thalidomide at 10 mg/kg), and granisetron group (positive control for antiemetic effects; cisplatin given as above and gastric lavage done with granisetron at 0.5 mg/kg). The cisplatin-induced kaolin consumption (pica behavior) was used as a model of emesis in patients. The animals' kaolin and food intakes were measured. Further, medulla and gastric tissues were obtained 5 and 33 h after peritoneal injections to quantify the levels of Substance P and Neurokinin-1 receptor (NK-1R). The cisplatin-induced kaolin consumption was significantly (p < 0.05 vs. cisplatin group) attenuated by thalidomide 72 h after the injection. The levels of Substance P in the medulla and gastric tissue were increased 5 h after the injection in both cisplatin and thalidomide groups, however, returned faster to normal levels in the thalidomide group (p < 0.05 vs. cisplatin group). Further, levels of NK-1R in the cisplatin, thalidomide, and granisetron group were significantly increased at both 5 and 33 h (p < 0.05 vs. control group), with no obvious difference among these three groups. In conclusion, thalidomide attenuates animal equivalent of cisplatin-induced emesis, and this beneficial effect is associated with decreased levels of Substance P levels in the medulla and gastric tissue.

Tranexamic acid induces kaolin intake stimulating a pathway involving tachykinin neurokinin 1 receptors in rats

Tranexamic acid suppresses post-partum haemorrhage and idiopathic menorrhagia through its anti-fibrinolytic action. Although it is clinically useful, it is associated with high risks of side effects such as emesis. Understanding the mechanisms underlying tranexamic acid-induced emesis is very important to explore appropriate anti-emetic drugs for the prevention and/or suppression of emesis. In this study, we examined the receptors involved in tranexamic acid-induced kaolin intake in rats, which reflects the drug's clinical emetogenic potential in humans. Further, we examined the brain regions activated by administration of tranexamic acid and elucidated pivotal pathways of tranexamic acid-induced kaolin intake. We examined the effects of ondansetron, a 5-hydroxytryptamine 3 receptor antagonist, domperidone, a dopamine 2 receptor antagonist, and aprepitant, a tachykinin neurokinin 1 (NK1) receptor antagonist, on tranexamic acid-induced kaolin intake in rats. Then, we determined the brain regions that showed increased numbers of c-Fos immunoreactive cells. Finally, we examined the effects of an antagonist(s) that reduced tranexamic acid-induced kaolin intake on the increase in c-Fos immunoreactive cells. Aprepitant significantly decreased tranexamic acid-induced kaolin intake. However, neither ondansetron nor domperidone decreased kaolin intake. Tranexamic acid significantly increased c-Fos immunoreactive cells by approximately 5.5-fold and 22-fold in the area postrema and nucleus of solitary tract, respectively. Aprepitant decreased the number of c-Fos immunoreactive cells in both areas. Tranexamic acid induced kaolin intake possibly via stimulation of tachykinin NK1 receptors in rats. The tachykinin NK1 receptor could be targeted to prevent and/or suppress emesis in patients receiving tranexamic acid.