Standard Antiemetics Research Articles

Efficacy and Safety of Ginger on Chemotherapy-Induced Nausea and Vomiting: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

Chemotherapy-induced nausea and vomiting (CINV) is a prevalent and distressing side effect. Historically, ginger has been explored as a potential remedy for various ailments, including its potential efficacy against CINV. The aim of this study was to determine whether taking ginger supplements can relieve CINV. A comprehensive search was conducted across PubMed, EMBASE, Cochrane Library, and the Wanfang database. Randomized controlled trials meeting our inclusion criteria were analyzed. The primary outcomes were the incidence and severity of CINV. The protocol was registered on PROSPERO, and the number is CRD4202232104. Of the 35 randomized controlled trials analyzed, 22 trials employed ginger capsules as the primary intervention, whereas 13 studies evaluated the prophylactic effects of ginger-partitioned moxibustion. The outcomes indicated that combining ginger capsules with standard antiemetic agents can significantly reduce the incidence of grade 3 acute nausea (Risk Ratio [RR], 0.19; P < .001) and the incidence of high-grade overall vomiting (RR, 0.47; P = .01). Moreover, ginger-partitioned moxibustion can significantly alleviate the incidence of both mild (RR, 0.56; P = .001) and severe (RR, 0.39; P < .00001) vomiting. Only 2.8% of patients experienced dizziness after ginger-partitioned moxibustion. Our findings indicate that ginger capsules, when used alongside antiemetic drugs, enhance the management of severe CINV, particularly in highly emetogenic chemotherapy regimens. Based on our findings, we recommend initiating ginger supplements before chemotherapy, in conjunction with standard antiemetics, to reduce the severity of CINV. The promising results warrant more rigorous clinical trials to firmly establish the role of ginger in CINV management.

Efficacy and safety of bevacizumab, irinotecan, and temozolomide combination for relapsed or refractory pediatric central nervous system embryonal tumor: a single-institution study.

This study aimed to evaluate the efficacy and safety of combination therapy with bevacizumab (Bev), irinotecan (CPT-11), and temozolomide (TMZ) in children with central nervous system (CNS) embryonal tumor relapse. The authors retrospectively examined 13 consecutive pediatric patients with relapsed or refractory CNS embryonal tumors who received combination therapy comprising Bev, CPT-11, and TMZ. Specifically, 9 patients had medulloblastoma, 3 had atypical teratoid/rhabdoid tumor (AT/RT), and 1 had CNS embryonal tumor with rhabdoid features. Of the 9 medulloblastoma cases, 2 were categorized in the Sonic hedgehog subgroup and 6 in molecular subgroup 3 for medulloblastoma. The complete and partial objective response rates were 66.6% in patients with medulloblastoma and 75.0% in patients with AT/RT or CNS embryonal tumors with rhabdoid features. Furthermore, the 12- and 24-month progression-free survival rates were 69.2% and 51.9% for all patients with recurrent or refractory CNS embryonal tumors, respectively. In contrast, the 12- and 24-month overall survival rates were 67.1% and 58.7%, respectively, for all patients with relapsed or refractory CNS embryonal tumors. The authors observed grade 3 neutropenia, thrombocytopenia, proteinuria, hypertension, diarrhea, and constipation in 23.1%, 7.7%, 23.1%, 7.7%, 7.7%, and 7.7% of patients, respectively. Furthermore, grade 4 neutropenia was observed in 7.1% of patients. Nonhematological adverse effects, such as nausea and constipation, were mild and controlled with standard antiemetics. This study demonstrated favorable survival outcomes in patients with relapsed or refractory pediatric CNS embryonal tumors and thus helped to investigate the efficacy of combination therapy comprising Bev, CPT-11, and TMZ. Moreover, combination chemotherapy had high objective response rates, and all adverse events were tolerable. To date, data supporting the efficacy and safety of this regimen in the relapsed or refractory AT/RT population are limited. These findings suggest the potential efficacy and safety of combination chemotherapy in patients with relapsed or refractory pediatric CNS embryonal tumors.

32 Droperidol on Prevention of Emesis from Cannabinoid Hyperemesis Syndrome (DOPE Study)

Cannabis Hyperemesis Syndrome (CHS) is characterized by persistent nausea, vomiting and abdominal pain with episodes of cyclic vomiting associated with chronic cannabis use. CHS symptoms are difficult to manage and are often refractory to standard first-line antiemetics and analgesics. Recent prospective studies have demonstrated the superiority of haloperidol, a dopamine antagonist, over ondansetron for the treatment of CHS. Interim analysis of our study has determined that droperidol, also a dopamine antagonist, has equal or better efficacy to haloperidol.

Effect of Acupuncture on Delayed Emesis for the Patients Who Received High-Emetogenic Chemotherapy with Standard Antiemetic Prophylaxis (KHMC-HO-01): An Open-Label, Randomized Study.

Background Chemotherapy-induced nausea and vomiting (CINV) is one of the most important issues associated with chemotherapy. The additional or synergistic effect of acupuncture on CINV remains controversial. Methods Patients were randomized into either the group that received standard antiemetics with acupuncture (Arm A) or standard antiemetics only (Arm C). Acupuncture with manual stimulation was applied at eight predefined points and was started before the first cycle of chemotherapy on the first day and two additional sessions were administered on the second day of chemotherapy. Acute and delayed CINV was assessed using the Rhodes Index of Nausea, Vomiting, and Retching (RINVR) and the MASCC Antiemesis Tool (MAT). The primary outcome was the delayed nausea score assessed using the RINVR. Results Overall, 42 patients were included. In the delay phase, the severity of delayed nausea was slightly lower without significance in Arm A than in Arm C (5.35 vs. 5.98, p = 0.3011). Similarly, patients in Arm A reported less severe vomiting than those in Arm C (0.75 vs. 1.25, p = 0.3064). Delayed nausea and vomiting assessed by the MAT showed significant relief with acupuncture compared to standard antiemesis alone. In terms of acute emesis, there was no significant difference between the two arms according to either scoring method. Conclusions Delayed nausea after HEC tended to decrease with acupuncture using the RINVR score, though it was also not significant. With the MAT assessment, delayed emesis (nausea and vomiting) was significantly improved with acupuncture, suggesting a promising effect of acupuncture. This trial is registered with KCT0006477.

A Smartphone-Based Decision Support Tool for Predicting Patients at Risk of Chemotherapy-Induced Nausea and Vomiting: Retrospective Study on App Development Using Decision Tree Induction.

BackgroundChemotherapy-induced nausea and vomiting (CINV) are the two most frightful and unpleasant side effects of chemotherapy. CINV is accountable for poor treatment outcomes, treatment failure, or even death. It can affect patients' overall quality of life, leading to many social, economic, and clinical consequences.ObjectiveThis study compared the performances of different data mining models for predicting the risk of CINV among the patients and developed a smartphone app for clinical decision support to recommend the risk of CINV at the point of care.MethodsData were collected by retrospective record review from the electronic medical records used at the University of Missouri Ellis Fischel Cancer Center. Patients who received chemotherapy and standard antiemetics at the oncology outpatient service from June 1, 2010, to July 31, 2012, were included in the study. There were six independent data sets of patients based on emetogenicity (low, moderate, and high) and two phases of CINV (acute and delayed). A total of 14 risk factors of CINV were chosen for data mining. For our study, we used five popular data mining algorithms: (1) naive Bayes algorithm, (2) logistic regression classifier, (3) neural network, (4) support vector machine (using sequential minimal optimization), and (5) decision tree. Performance measures, such as accuracy, sensitivity, and specificity with 10-fold cross-validation, were used for model comparisons. A smartphone app called CINV Risk Prediction Application was developed using the ResearchKit in iOS utilizing the decision tree algorithm, which conforms to the criteria of explainable, usable, and actionable artificial intelligence. The app was created using both the bulk questionnaire approach and the adaptive approach.ResultsThe decision tree performed well in both phases of high emetogenic chemotherapies, with a significant margin compared to the other algorithms. The accuracy measure for the six patient groups ranged from 79.3% to 94.8%. The app was developed using the results from the decision tree because of its consistent performance and simple, explainable nature. The bulk questionnaire approach asks 14 questions in the smartphone app, while the adaptive approach can determine questions based on the previous questions' answers. The adaptive approach saves time and can be beneficial when used at the point of care.ConclusionsThis study solved a real clinical problem, and the solution can be used for personalized and precise evidence-based CINV management, leading to a better life quality for patients and reduced health care costs.

Drug repositioning of antipsychotic drugs for cisplatin-induced pica behavior in mice.

We aimed to clarify whether various antipsychotics ameliorate cisplatin-induced pica behavior in mice using a drug repositioning approach. Mice were administered cisplatin (12.5 mg/kg, i.p.) with or without olanzapine (1 mg/kg, i.p.), asenapine (4 mg/kg, i.p.), mirtazapine (5 mg/kg, i.p.) or standard three-drug antiemetics (granisetron [0.5 mg/kg, i.p.], fosaprepitant [25 mg/kg, i.p.], and dexamethasone [3 mg/kg, i.p.]). Kaolin, food, and water intake, and spontaneous motor activity on the day before and seven consecutive days after the cisplatin administration were measured using a telemetry system. At the primary endpoint, kaolin intake was significantly higher at day three in the cisplatin group than in the pre-treatment and saline groups ( p < 0.05). Additionally, kaolin intake was not significantly higher in cisplatin with olanzapine, asenapine, and mirtazapine groups for seven days than in the pre-treatment group. At the secondary endpoint, cisplatin decreased the food and water intake, and spontaneous motor activity in a time-dependent manner. Three antipsychotics failed to improve the cisplatin-induced decrease in food and water intake, and spontaneous motor activity. The findings suggest that prophylactic administration of antipsychotics besides olanzapine may improve cisplatin-induced nausea and vomiting in a delayed phase and de-escalate standard 3-drug antiemetics.

Aromatherapy to The Rescue for Postoperative Nausea and Vomiting

<h3>Introduction</h3> Post- operative nausea and vomiting (PONV) occurs in in approximately 30 to 37 % of patients. It is one of the most common complaints after surgery. A modality of pre-and post- operative antiemetics are routinely used, however PONV persists. The literature indicates that patients have reported significantly lower levels of PONV with aromatherapy. Inhaled aromatherapy that consists of a blend of essential oils such as spearmint, peppermint, lavender and ginger have been shown to decrease and eliminate PONV. Aromatherapy can be initiated as a nursing measure immediately upon patient complaint of symptoms. The patients can be instructed to self-administer the product upon discharge. <h3>Identification of the problem</h3> PONV can lead to delays in discharge, increased healthcare cost, undue stress, pain and discomfort at the surgical site, and electrolyte imbalance. All these lead to patient dissatisfaction with the surgical experience. <h3>EBP Question/Purpose</h3> For the adult ambulatory surgery patient, is the use of an inhaled aromatherapy product effective for the relief of PONV in the Phase I and Phase II PACU setting prior to discharge? Data bases utilized for the project include, PubMed, Ovid and CINAHL. <h3>Methods/Evidence</h3> Patients were assessed for risk factors of PONV in the pre-operative area and received preliminary education regarding use of the product. The aromatherapy was used as a first line defense against PONV. Patients were not denied refusal or use of standard antiemetics. Nurses assessed the effectiveness of the product prior to patient discharge by completing the data collection sheet. Follow up phone calls inquired about the use of the product at home as well as overall satisfaction. <h3>Significance of Findings/Outcomes</h3> 38 patients used the product, with 81% reporting improved or total relief of PONV. A total of 47.4% had total relief. Only 7.89% stated they had minor or no relief. Nurses expressed 100% satisfaction with ease and use. <h3>Implications for perianesthesia nurses and future research</h3> Use of aromatherapy provides the perianesthesia nurse with greater autonomy and satisfaction. The use of aromatherapy can only increase the patient's overall satisfaction. Further research can be done by comparing actual length of stays for patients with and without the use of aromatherapy.

A protocol for efficacy of rikkunshito on chemotherapy-induced nausea and vomiting in patients with uterine corpus or cervical cancer treated with cisplatin-based regimen -placebo-controlled, double-blind, randomized confirmatory study (efficacy of rikkunshito on chemotherapy-induced nausea and vomiting)

Background: Current standard treatment of chemotherapy-induced nausea and vomiting (CINV) using standard antiemetics is not sufficient. Rikkunshito, a Japanese traditional herbal medicine, has been shown to ameliorate cisplatin-induced anorexia in animal models, and an exploratory study suggested that rikkunshito had an additive beneficial effect on CINV in patients with uterine corpus and cervical cancer during cisplatin-including chemotherapy. Methods: This multicenter, randomized, double-blind, placebo-controlled confirmatory study will evaluate the potential additive beneficial effect of rikkunshito on CINV in patients treated with standard antiemetics. One hundred-eighty patients aged ≥20 years with uterine corpus or cervical cancer who are scheduled for treatment with a cisplatin-based regimen as initial chemotherapy will be enrolled across 17 institutions in Japan. Patients will be randomized with a 1:1 equal allocation ratio to the rikkunshito or the placebo group. The primary endpoint is complete response (CR; no vomiting and no rescue medication) during the delayed phase (24–120 hours after cisplatin treatment). The secondary endpoints include complete control (CC) (CR without significant nausea) and total control (CR without nausea) rates during the overall (0–120 hours), acute (0–24 hours), and delayed phases; CR rate during the overall and acute phases; time to treatment failure, degree of nausea and appetite during the overall phase; and adherence to intervention. Estimated study completion: April 30, 2022. Discussion: This is the first prospective, randomized, double-blinded, placebo-controlled confirmatory study evaluating the additive beneficial effect of rikkunshito on CINV. This study is ongoing and is currently recruiting. Trial registration: Identifier on Japan Registry of Clinical Trials (jRCT): jRCT1011190007, registered December 2, 2019, https://jrct.niph.go.jp/en-latest-detail/jRCT1011190007.

Secondary and cumulative meta-analysis of olanzapine for antiemetic prophylaxis for chemotherapy-induced nausea and vomiting: do we still need to study its effectiveness?

Olanzapine has been found to have antiemetic properties due to its ability to inhibit multiple serotonergic, dopaminergic, alpha-1 adrenergic and histamine receptors. In 2016, a meta-analysis of 10 randomized controlled trials (RCTs) on olanzapine in the prophylactic setting found olanzapine to be more efficacious than other standard antiemetics in the prophylactic setting. However, since the review, many clinical trials using olanzapine for chemotherapy-induced nausea and vomiting (CINV) have been published-in many cases, contending that further trials would further help elucidate the efficacy of olanzapine for CINV given the continued paucity of literature. The primary aim of this study is to conduct a secondary, cumulative meta-analysis to assess the impact of the most recent trials on the published effect estimate of olanzapine and ultimately determine whether trials published since 2016 have significantly changed the summary estimate. As reported previously, a literature search was conducted up until 2015, of Ovid Medline, Embase and the Cochrane Central Register of Controlled Trials; 10 RCTs with a total of over 1,000 patients were included, that compared olanzapine to other antiemetics in the prophylactic setting, which reported on at least one of two endpoints-no emesis and no nausea. The Mantel-Haenszel, random-effects analysis model was used to compute cumulative risk ratios (RR) and their accompanying 95% confidence intervals (CIs). For the endpoint of emetic control, the cumulative meta-analysis shows that the summary effect did not change noticeably with the inclusion of the most recent trials. In the acute phase, the RR shifted from 1.07 before 2011 to 1.10 after 2015, even after the inclusion of 7 trials. Similar small changes were noted in the delayed and overall phases. For the endpoint of nausea control, the cumulative meta-analysis does show a significant visual change in summary effect, except for nausea control in the acute phase. In the delayed phase, the RR shifts from 1.58 before 2011 to 1.50 after 2015. In the overall phase, the RR shifts from 1.642 before 2011 to 1.53 after 2015. Olanzapine's efficacy for the prophylaxis of CINV has been sufficiently documented, with respect to emetic control. There is, however, more limited data supporting its efficacy with respect to nausea control.

Antiemetic medication efficacy during EPOCH and R-EPOCH treatment.

This study aims to determine the adequacy of current institutional standard practice for CINV prophylaxis for EPOCH and R-EPOCH at The Ohio State University James Cancer Hospital. Single-center, retrospective analysis was performed including all patients receiving EPOCH or R-EPOCH chemotherapy for Non-Hodgkin's lymphomas from 1/1/2012 to 6/30/2017. The primary endpoint was rate of CINV events, which included usage of more than 50 percent of available doses of breakthrough antiemetics while inpatient, hospitalization due to CINV or related complications, or adjustments made to the CINV prophylactic or breakthrough regimen during current or subsequent cycles. Secondary endpoints included determining prescriber adherence to institutional standard CINV prophylaxis, characterization of adjustments to the antiemetic regimen following the incidence of CINV, and identification of high-risk patients that may benefit from additional CINV prophylaxis. Of 111 patients, 54 (48.6%) experienced CINV events with any cycle of EPOCH or R-EPOCH chemotherapy. Of those patients, 17 (31.5%) received institutional standard CINV prophylaxis at baseline, 8 (14.8%) received additional scheduled antiemetics, and 26 (48.1%) were prescribed additional breakthrough antiemetics with their first cycle of EPOCH or R-EPOCH. Younger age, diagnosis of anxiety, and previous susceptibility to nausea were significantly associated with CINV events. This study illustrates the inadequacy of current institutional standard for CINV prophylaxis for patients receiving EPOCH and R-EPOCH, highly emetogenic chemotherapy regimens. With nearly half of included patients experiencing CINV events, and most initially receiving more than our standard prophylaxis, changes to our standard antiemetics used with this chemotherapy regimen are needed.

Patient-related Risk Factors for Nausea and Vomiting With Standard Antiemetics in Patients With Cancer Receiving Carboplatin: A Retrospective Study

PurposeThis study aimed to identify patient-related risk factors for chemotherapy-induced nausea and vomiting (CINV) in patients with cancer receiving carboplatin in addition to standard antiemetics, using real-world data. MethodsIn this single-center, observational study, data from electronic medical records of consecutive patients with solid tumors who had received their first cycle of a carboplatin-based regimen and were treated with a 2- or 3-drug combination of antiemetics from January 2014 to January 2019 at Toranomon Hospital were retrospectively analyzed. The primary end point was the occurrence of a complete response (CR) within 5 days after the first cycle, which was defined as no vomiting and no use of rescue medication for CINV. A receiver operating characteristic curve, univariable, and multivariable logistic regression analyses were used. FindingsA total of 314 patients were evaluated in this study. The proportion of patients who had a CR in the overall, acute, and delayed phases was 76.8% (n = 241), 98.7% (n = 310), and 77.4% (n = 243), respectively. Similar to univariable logistic regression analysis, multivariable logistic regression analysis revealed that age ≥70 years and total dexamethasone dose ≥14.6 mg were significantly associated with a non-CR in the overall phase, whereas female sex, history of habitual alcohol intake, and history of smoking were not associated with a non-CR in the overall phase. ImplicationsOur study findings suggest that a patient age of <70 years and a total dexamethasone dose of <14.6 mg are high-risk factors for carboplatin-induced CINV

Results of crossover phase II component of randomized placebo-controlled trial evaluating oral THC/cannabis extract for refractory chemotherapy-induced nausea and vomiting (CINV).

12008 Background: The aim of this multi-centre, randomised, double-blinded, placebo-controlled, phase 2/3 trial is to determine efficacy of addition of oral cannabis in adults with any malignancy of any stage, experiencing CINV during moderate-highly emetogenic intravenous chemotherapy, despite guideline-consistent anti-emetic prophylaxis, requiring ≥ 2 chemotherapy cycles. Here we report the crossover phase 2 component results. Methods: Treatment consisted of 1 cycle of oral THC 2.5mg/CBD 2.5mg (TN-TC11M) capsules tds days -1 to 5 and 1 cycle matching placebo in a crossover design, then blinded patient preference for a 3rd cycle. Primary end-point is difference in proportion of patients with ‘complete response’ (no emesis &amp; no use of rescue medications) during 0-120 hours from chemotherapy between cycles. 80 patients provides 80% power with 2p of 0.1 to detect a 20% difference. Results: 81 patients recruited (2016-9). 72 completing 2 cycles are included in efficacy analyses. 78 not withdrawing consent are included in safety analyses. Median age was 55 years (range 29-80), 78% were female, 42% report historic cannabis use, 55% were treated with curative intent. Most common regimens were AC (26%), FOLFOX (17%). All received steroids &amp; 5-HT3 antagonist, 79% received NK-1 antagonist, 4% received olanzapine. Efficacy is shown in table. 83% preferred cannabis to placebo. Most common bothersome cannabinoid-related adverse events (cannabis, placebo) were sedation (19%,4%), dizziness (10%,1%), disorientation (3%,0%). No SAEs were attributed to THC/CBD. Conclusions: Addition of oral THC/CBD to standard anti-emetics was associated with less nausea &amp; vomiting but additional side effects. Most preferred THC/CBD to placebo. Based on these positive results, the definitive parallel phase 3 trial component continues (additional n=170). Acknowledgements: Trial participants, investigators, research staff. Funding from NSW Government Dept of Health. Clinical trial information: ACTRN12616001036404 . [Table: see text]

Gastrointestinal symptoms are associated with trajectories of chemotherapy-induced nausea

Between 19 and 58% of oncology patients experience chemotherapy-induced nausea (CIN). In a sample of outpatients with breast, gastrointestinal (GI), gynecological, and lung cancer, the study purposes were to evaluate for inter-individual differences in the severity of CIN over two cycles of chemotherapy (CTX) and to determine which demographic and clinical characteristics and GI symptoms were associated with higher initial levels as well as with the trajectories of CIN severity. Patients completed study questionnaires at six time points over two cycles of CTX. These questionnaires provided information on demographic and clinical characteristics, as well as the occurrence of twelve GI symptoms. Hierarchical linear modeling based on full maximum likelihood estimation was performed. Of the 1251 patients, 47.2% reported CIN. Across two cycles of CTX, lower functional status scores and higher levels of comorbidity were associated with higher initial levels of CIN. Younger age and emetogenicity of the CTX regimen were associated with higher initial levels as well as worse trajectories of CIN. The occurrence of five GI symptoms (i.e., vomiting, lack of appetite, constipation, feeling bloated, and difficulty swallowing) was associated with higher initial levels of CIN. The occurrence of mouth sores was associated with higher initial levels as well as with worst trajectories of CIN. This study is the first to identify distinct demographic, clinical, and GI symptom characteristics associated with CIN severity. These findings suggest that the etiology of CIN is complex and may warrant interventions beyond standard antiemetics.

Prospective randomized trial of standard antiemetic therapy with yoga versus standard antiemetic therapy alone for highly emetogenic chemotherapy-induced nausea and vomiting in South Asian population.

Chemotherapy-induced nausea and vomiting (CINV) is one of the most distressing side effects of highly emetogenic chemotherapy regimens. There have been continuous efforts in the direction to control CINV by many investigators. Randomly selected patients were those receiving highly emetogenic chemotherapy regimen grouped into yoga and standard antiemetic therapy (n = 50) just before receiving chemotherapy and continued for the following days and other group (n = 50) received only the standard antiemetic agent. Both the groups were assessed, followed for acute and delayed onset of chemotherapy-induced and anticipatory nausea and vomiting using radiation therapy oncology group grading for the same. We also assessed the quality of life of the patient using the Functional Assessment of Cancer Therapy-General questionnaire. The median age group of the patients was 51 years with male:female ratio 2:1, The Eastern Cooperative Oncology Group (ECOG) performance status was 0/1 in 38% of the selected population, while ECOG 2 in 62% of the patients. In yoga arm, insignificant reduction in chemotherapy-induced nausea (90% vs. 78%, P = 0.35) and but significant reduction in vomiting (42% vs. 22%, P =0.01) was observed as compared to the standard antiemetics only arm. There was a significant reduction in Grade 2 and 3 nausea (84% vs. 38% P < 0.01) and vomiting (14% vs. 0% P < 0.01). Quality of life is also significantly improved in the yoga arm, especially in the ECOG 2 performance status. This study concludes that yoga along with standard antiemetic medication should be a part of the management plan for the cancer patients receiving highly emetogenic chemotherapy.

Patient-related Risk Factors for Nausea and Vomiting with Standard Antiemetics in Patients with Breast Cancer Receiving Anthracycline-based Chemotherapy: A Retrospective Observational Study

PurposeThe aim of this study was to identify a high-risk or low-risk population for chemotherapy-induced nausea and vomiting among patients with breast cancer treated with a current standard 3-drug antiemetic regimen and receiving anthracycline. MethodsWe analyzed data from chemotherapy-naive Japanese patients with breast cancer, who had received the first cycle of anthracycline-based regimen and were treated with a 3-drug combination of aprepitant, palonosetron, and dexamethasone. This study was carried out at Ehime University Hospital (Toon, Japan) using electronic medical records from May 2011 to June 2017. The primary end point was complete response (CR), which was defined as no emesis and no use of rescue medication. FindingsA total of 103 patients were included in this study. The percentages of patients who had a CR in the overall, acute, and delayed phases were 35.0%, 40.8%, and 50.5%, respectively. Multivariate logistic regression analysis revealed that age <55 years and body mass index <27.5 kg/m2 were significantly associated with an increased risk for CR failure in the overall and acute phases. In contrast, a history of alcohol habit was significantly associated with a decreased risk for CR failure in overall phase. ImplicationsThe present findings suggest that, among patients with breast cancer receiving anthracycline and treated with aprepitant, palonosetron, and dexamethasone, patients younger than 55 years and having a body mass index <27.5 kg/m2 are high-risk populations for chemotherapy-induced nausea and vomiting, whereas those with a history of habitual alcohol consumption is a low-risk one.

Aromatherapy for treatment of postoperative nausea and vomiting.

Aromatherapy for treatment of postoperative nausea and vomiting.

Cannabinoid Hyperemesis Syndrome: Pathophysiology and Treatment in the Emergency Department

BackgroundCannabinoid hyperemesis syndrome (CHS) is a challenging clinical disorder. CHS patients frequently present to the emergency department and may require treatment for intractable emesis, dehydration, and electrolyte abnormalities. Thought to be a variant of cyclic vomiting syndrome, CHS has become more prevalent with increasing cannabis potency and use, as enabled by various states having legalized the recreational use of cannabis. ObjectiveThis aim of this review is to investigate the pathophysiology of CHS and evaluate the published literature on pharmacologic treatment in the emergency department. This information may be helpful in providing evidence-based, efficacious antiemetic treatment grounded in knowledge of antiemetic medications’ mechanisms of action, potentially precluding unnecessary tests, and reducing duration of stay. DiscussionThe endocannabinoid system is a complex and important regulator of stress response and allostasis, and it is occasionally overwhelmed from excessive cannabis use. Acute episodes of CHS may be precipitated by stress or fasting in chronic cannabis users who may have pre-existing abnormal hypothalamic–pituitary–adrenal axis feedback and sympathetic nervous system response. The reasons for this may lie in the physiology of the endocannabinoid system, the pathophysiology of CHS, and the pharmacologic properties of specific classes of antiemetics and sedatives. Treatment failure with standard antiemetics is common, necessitating the use of mechanistically logical sedating agents such as benzodiazepines and antipsychotics. ConclusionDespite the increasing prevalence of CHS, there is a limited body of high-quality research. Benzodiazepines and antipsychotics represent logical choices for treatment of CHS because of their powerful sedating effects. Topical capsaicin holds promise based on a totally different pharmacologic mechanism. Discontinuation of cannabis use is the only assured cure for CHS.

Pharmacologic Treatment of Cannabinoid Hyperemesis Syndrome: A Systematic Review.

Cannabinoid hyperemesis syndrome (CHS) has become more prevalent with increasing cannabis use. CHS is often resistant to standard antiemetics. The objective of this study is to review the current evidence for pharmacologic treatment of CHS. Medline, PsycINFO, DARE, OpenGrey, Google Scholar, and the Cochrane Library were searched from inception to February 2017. Articles were selected and reviewed independently. Evidence was graded using Oxford Center for Evidence-Based Medicine guidelines. The search resulted in 1262 articles with 63 of them eligible for inclusion (205 human subjects). There were 4 prospective level-2, 3 retrospective level-3 studies, 12 level-4 case series, and 44 level-5 case reports. Among level-2 studies (64 subjects), tricyclic antidepressants (TCAs) and lorazepam were discussed as effective long- and short-term treatments, respectively, in two studies. Ondansetron, promethazine, diphenhydramine, and opioids were also mentioned, but the authors did not comment on their efficacy. Among level-3 studies (43 subjects), one reported effective treatment with antiepileptics zonisamide and levetiracetam, but not TCAs. Another reported favorable response to morphine, ondansetron, and lorazepam but did not specify the actual number of patients receiving specific treatment. Among the level-4 case series (54 subjects), benzodiazepines, haloperidol, and capsaicin were reported as helpful. For level-5 case reports (44 subjects), benzodiazepines, metoclopramide, haloperidol, ondansetron, morphine, and capsaicin were reported as effective. Effective treatments mentioned only once included fentanyl, diazepam, promethazine, methadone, nabilone, levomepromazine, piritramide, and pantoprazole. Hot showers and baths were cited in all level-4 and -5 articles as universally effective. High-quality evidence for pharmacologic treatment of CHS is limited. Benzodiazepines, followed by haloperidol and capsaicin, were most frequently reported as effective for acute treatment, and TCAs for long-term treatment. As the prevalence of CHS increases, future prospective trials are greatly needed to evaluate and further define optimal pharmacologic treatment of patients with CHS.

Aprepitant for the management of nausea with inpatient IV dihydroergotamine.

Objective:To assess the efficacy and tolerability of oral aprepitant, a substance P/neurokinin A receptor antagonist, in controlling nausea associated with IV dihydroergotamine (DHE) administered for medically refractory migrainous headache in patients not responding to standard antiemetics or with a history of uncontrolled nausea with DHE.Methods:This was a retrospective chart review of prospectively collected hourly diary data and clinical notes of patients hospitalized between 2011 and 2015 for inpatient treatment with DHE. Patients were classified using the International Classification of Headache Disorders, 3rd edition (beta version). Peak and average daily nausea scores from hourly diaries, or daily entries of notes, and concurrent antiemetic use were collected and tabulated.Results:Seventy-four patients, of whom 24 had daily diaries, with chronic migraine with or without aura, with or without medication overuse, or new daily persistent headache of a migrainous type, were identified. In 36 of 57 cases in which aprepitant was administered during hospitalization, there was a 50% reduction in the average daily number of as-needed antinausea medications. Of 57 patients, 52 reported that the addition of aprepitant improved nausea. Among 21 of 24 patients with hourly diary data, nausea scores were reduced and in all 12 with vomiting there was cessation of emesis after aprepitant was added. Aprepitant was well tolerated with no treatment emergent adverse events.Conclusions:Aprepitant can be effective in the treatment of refractory DHE-induced nausea and emesis. Given the broader issue of troublesome nausea and vomiting in acute presentations of migraine, general neurologists may consider what place aprepitant has in the management of such patients.Classification of evidence:This study provides Class IV evidence that for patients with medically refractory migraine receiving IV DHE, oral aprepitant reduces nausea.

Use of ginger to ease chemotherapy-induced nausea and vomiting shows mixed results

C nausea and vomiting (CINV) is a common, distressing adverse effect of many drugs used to treat cancer, occurring in as many as 80% of patients. CINV leads to reduced quality of life, among other adverse outcomes.1 For symptom relief, patients with cancer may try cinnamon bark, fennel, peppermint, and chamomile in addition to standard antiemetics. Most studies, however, have focused on ginger to treat and prevent CINV.