Education is Needed Among Patients Experiencing CINV

Nurses must educate patients specifically on their risk for chemotherapy-induced nausea and vomiting (CINV) — moreover, when it is likely to occur, which drugs to use and when, according to Beth Eaby-Sandy, MSN, CRNP.

“There are numerous drugs, combinations and routes of administration (to manage CINV). It’s really up to us to know all of these drugs as they come available and choose which ones may be better for patients, and financially which ones are best to use for your institution and the patient,” Eaby-Sandy, thoracic oncology nurse practitioner, Abramson Cancer Center, University of Pennsylvania, said during a presentation at the 3rd Annual School of Nursing Oncology (SONO).

Risk Factors

Treatments with high emetogenic chemotherapy (HEC), moderate emetogenic chemotherapy (MEC), and some oral antineoplastic agents can lead to CINV.

Patient factors that contribute to CINV include female sex, those aged <50 years, a history of low alcohol intake (<1.5 oz/day), a history of prior CINV, a history of motion sickness, a history of morning sickness, and anxiety.

However, a recent study found that, in order of risk, nausea/vomiting during the prior cycle, use of non-prescribed antiemetics at home (like Dramamine), <60 years of age, anticipatory CINV, sleep of <7 hours per day, and a history of morning sickness are the key factors to CINV.

“This highlights the need to make sure in cycle 1 we are preventing that nausea,” Eaby-Sandy added. “Once they have a bad experience it is bad news moving forward.”

The drug itself is the worst risk factor for CINV, she added; however, patient factors should be taken into account as well.

Treatment Strategies

In the acute setting, 5-HT3 receptor antagonists — like ondansetron (with a half-life of 4 to 6 hours), oral granisetron (with a longer half-life of 6.5 hours), and palonosetron (with an even longer half-life of 30 hours) are used.

“When we talk about half-lives, it’s about the therapeutic index of the drug. That means half of it is cleared at that time. Then when you’re on the bottom half of the drug being cleared, you’re not receiving therapeutic benefit anymore,” Eaby-Sandy said.

In addition, NK-1 receptor antagonists like oral or IV injection aprepitant, fosaprepitant, netupitant combined with fosaprepitant, and oral rolapitant are used.

Other classes of agents used for CINV include corticosteroids, benzodiazepines, dopamine, cannabinoids, and antipsychotics.

Among the newer agents being used, netupitant combined with palonosetron is the first combined tablet of an NK-1 receptor antagonist with an oral 5-HT3 receptor antagonist. With this, one capsule is taken 1 hour prior to chemotherapy (with or without food).

Guidelines

CINV guidelines are based on evidence that was formulated by experts who review clinical trials, including organizations like the National Comprehensive Cancer Network, the American Society of Clinical Oncology, the Multinational Association of Supportive Care in Cancer, European Society of Medical Oncology, and the Oncology Nursing Society.

These are important, Eaby-Sandy says because inadequate treatment of CINV leads to higher healthcare costs and the patient will be suffering. Therefore, she added, adherence to guidelines will lead to better outcomes for CINV.

Reference:

Eaby-Sandy B. Staying on the Leading Edge of CINV Management. Presented at: 3rd Annual School of Nursing Oncology; August 2-3, 2019; San Diego, CA.