nausea and vomiting in palliative care pdf

Nausea And Vomiting In Palliative Care Pdf

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The goal was to integrate findings in a comprehensive article that incorporates palliative care concepts into antiemetic treatment. Most articles are written by oncologists who also specialize in palliative care, and those addressing adverse effects of drugs used as antiemetics are found in other literature. Articles addressing more novel therapies, like cannabinoids and medical marijuana, are uncommon in the oncology literature.

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An overview of nausea/vomiting in palliative medicine

Severe nausea, vomiting, or retching can be among the most disabling of symptoms. Wood and colleagues reviewed various instruments available for the assessment of cancer-related nausea, vomiting, and retching 2. Twenty-four tools evaluating nausea were identified that met their inclusion criteria. Thirteen tools measured vomiting as a separate experience. Only 3 tools included a separate assessment of retching. One commonly used tool, the Morrow Assessment of Nausea and Emesis 3 , specifically asked questions regarding pretreatment nausea.

The INVR has questions regarding the number of retching episodes in the previous 12 hours and the distress felt by these episodes. The INVR utilizes a 5-point Likerttype scale; although this has not been shown to be as sensitive to early changes as the VAS, it has been found to be clinically useful and easy for patients to understand 2.

There have been various versions of this tool published 2. The INVR revised in addresses the frequency and distress associated with all 3 symptoms: nausea, vomiting, and retching 5. In , Hesketh et al. Since cisplatin was reported to decrease plasma ghrelin and food intake in rodents, Hiura and colleagues monitored the plasma ghrelin level and its association with nutritional status and adverse events during chemotherapy in patients with esophageal cancer 7. Plasma total ghrelin significantly decreased at days 3 and 8 of chemotherapy and this decrease was associated with a loss of oral intake and appetite 7.

Nausea and vomiting do appear to become more common as death approaches, so it is not surprising that nausea has been found to be a predictor of a shortened survival in one study 8. Glare and colleagues have categorized nausea etiology in palliative medicine into 4 groups: due to the primary disease, due to a side effect of therapy, secondary to debilitation, and caused by an unrelated comorbid condition for non-medical conditions in palliative medicine associated with nausea mat include significant advanced cardiac obstructive pulmonary disease, end-stage renal disease, and advanced dementia Avoidance of environmental stimuli, such as sights, sounds, or smells that may initiate nausea are recommended Fatty, spicy, and highly salted food should be avoided.

Metabolic causes include: uremia, uncontrolled diabetes mellitus, electrolyte imbalance e. In a survey of oncology patients, Coates et al. Over a decade later-with the availability of 5-HT3 receptor antagonists-nausea and vomiting remain a top patient fear from chemotherapy 20 , Martin and colleagues designed a new questionnaire to assess the influence of CINV on QOL; due to the lack of a single, standardized, comprehensive questionnaire which assessed the impact of specific components of CINV [also known as chemotherapy-induced nausea and emesis CINE ] and retching on functioning and well being in the context of cancer-related QOL Additionally, a new retching scale developed in the format of the MANE and other new items specific to nausea, emesis, and retching were added to the questionnaire Delayed emesis can arbitrarily be considered emesis that begins or persists more than 24 hours after chemotherapy.

Highly emetogenic therapy may lead to a biphasic pattern of emesis-occurring hours after chemotherapy peaking at roughly hours, and lasting hours following chemotherapy Therefore, management of CINV for highly emetogenic chemotherapy should be considered over a 5-day period.

Moderately emetogenic chemotherapy - induced emesis follows a monophasic pattern-occurring hours post-chemotherapy, peaking at about 24 hours, and subsiding hours after the administration of chemotherapy 35 , Highly emetogenic chemotherapy e.

Combination of 5-HT3 receptor antagonists with corticosteroids has been advocated as the most effective prophylaxis for CINV 41 , 42 ; however, the triple combination of an NK-1 receptor antagonist, a 5-HT3 receptor antagonist, and a corticosteroid may yield optimal efficacy Kubota and colleagues in a review with meta-analysis concluded that prophylactic treatment with corticosteroids without additional metoclopramide or 5-HT3 receptor antagonists appears preferable for preventing delayed emesis induced by cisplatin, since neither agent demonstrated additional benefits over corticosteroids alone Hirayama et al.

If RIE is severe enough it can lead to an interruption in the radiotherapy treatment schedule 50 , Feyer et al. Yamada et al. The multiple antiemetic agents modulate the actions of one or more receptors Table 1. The onset of action of transdermal scopolamine is generally delayed at least 4 hours and it has been used effectively to abort or ameliorate motion-induced vomiting or PONV Side effects of anticholinergic agents include: sedation, dry mouth, blurred vision, mydriasis, urinary retention, hallucinations, central nervous system excitation, memory loss, confusion, and disorientation Some antiemetic agents may inhibit emesis but not effectively ameliorate nausea and vice versa, while other antiemetic agents are reasonably effective for combating nausea as well as vomiting.

An effective antiemetic for acute chemotherapy-induced emesis may not be effective for the treatment of motion sickness e. A meta-analysis of 26 randomized, controlled studies in 2, patients suggested that the addition of dexamethasone to antiemetic monotherapy improved efficacy Heterocyclic phenothiazines e. Additional side effects which are not rare include dry mouth and hypotension.

Side effects may include: hypotension, restlessness, anxiety, dysphoria, sedation, and extrapyramidal symptoms. Droperidol causes a dose-dependent prolongation of the QT interval on the electrocardiogram Extrapyramidal symptoms can occur but generally at doses higher than 10 mg The repeated use of metoclopramide especially in higher doses should be avoided if possible in renal insufficiency and used with great caution in the elderly. Antihistamines e. Common side effects include: dry mouth, sedation, blurred vision, and urinary retention Benzodiazepines e.

Pharmocologic approaches to anticipatory nausea should probably be used in conjunction with behavioral treatments as well. Steroids e. Glucocorticoids such as dexamethasone are wellestablished antiemetics for chemotherapy-induced as well as postoperative nausea and vomiting.

The mechanism of steroid-induced antiemesis remains uncertain but has been assumed to be due to reducing levels of arachidonic acid metabolites that may be emetic The onset time for reasonable antiemetic effects is usually about hours Tetrahydrocannabinol THC is more effective than placebo in preventing chemotherapy-induced nausea and vomiting Cannabinoid CB1 receptors in the dorsal vagal complex 75 and NTS 76 may be involved in the nausea-reducing effects of cannabinoids.

It appears that cannabinoids not only attenuate vomiting but also play a role in suppressing nausea These effects in the lithium-induced conditioned rejection reaction rat model of nausea seem to also be mediated via CB1 receptors since they were reversed by the CB1 receptor antagonist SRA Common side effects of dronabinol a cannabinoid available for clinical use are drowsiness, orthostatic hypotension, tachycardia, and dry mouth.

Other side effects especially in the elderly may include: manic psychoses, depression, anxiety, and visual hallucinations. These agents are readily absorbed after oral administration and cross the blood-brain barrier without difficulty. Additionally, these agents appear to be relatively free of problems due to drug displacement from binding sites Generally, there is no need to alter dosing in renal insufficiency with conventional dosing However, for patients with significant liver dysfunction a maximal daily dose of 8 mg of ondansetron is recommended The 5HT3 receptor antagonists have a chemical structure that is similar to serotonin.

Serotonin has a six-ring carbon structure and a five-ring nitrogen-based nucleus. Palonosetron exhibits a strong binding affinity to the 5HT3 receptor and a long-plasma elimination half-life roughly 40 hours [at least four times greater than other available 5HT3 receptor antagonists] 86 , Benedict et al.

The antiemetic activity of NK1 receptor antagonists is largely or entirely from their central action This was demonstrated when Tattersall and colleagues compared 2 different NK1 receptor antagonists. When administered centrally both L, and L, have equivalent antiemetic activity 91 , The Aprepitant Protocol Study Group conducted a multinational, randomized, double-blind, placebo-controlled trial in patients receiving high-dose cisplatin The percentage of patients with complete response on days 1 to 5 was significantly higher in the aprepitant group [ They concluded that compared with standard dual therapy 5HT3 receptor antagonist and corticosteroid , addition of aprepitant was generally well tolerated and consistently provided superior protection against CINV Clinicians should be aware that coadministration of aprepitant with dexamethasone or methylprednisolone may result in increased plasma concentrations of the corticosteroids Therefore, adjusting the dose of corticosteroids in this situation may be appropriate.

Fosaprepitant is a prodrug of aprepitant which may be administered intravenously. It is rapidly converted to aprepitant within 30 minutes after the end of infusion. It is indicated for prevention of acute and delayed nausea and vomiting associated with moderaly-and highly-emetogenic chemotherapy in combination with other anitemetics. The dose is generally mg for first day and mg thereafter. It is administered about a helf-hour prior to chemotherapy as an fision over minutes [for mg dose] or over 15 minutes [for mg dose].

Hwang et al. The high-affinity sites D2 high are G protein coupled With the use of these and other techniques e. Gastric electrical stimulation GES has been introduced for treating gastric motility disorders.

GES with long pulses or dual pulses, but not short pulses, are able to alter enhance or inhibit such parameters of gastric motility as gastric slow waves and gastric emptying. Synchronized GES has been reported to improve antral contractions. Although the literature is scant and results have been mixed, behavioral approaches such as relaxation and distraction, relaxation training utilizing muscle relaxation and guided imagery. Massage has been reported to be effective for nausea and pain in bone marrow transplant patients Foot massage was shown to reduce nausea significantly in hospitalized cancer patients A systematic review of complementary and alternative medicine for symptom management at the end of life was unable to identify any large-scale trials in terminally ill patients for nausea and vomiting.

Acupuncture has been fairly well established in the prevention of PONV It consists of stimulating the so-called P6 wrist point located on the ventral surface of the forearm approximately 3 fingerwidths proximal to the wrist joint by using acupuncture, acupressure, and other techniques Acupuncture and ginger have been shown to be effective for chemotherapy-induced emesis and anticipatory nausea , , but have not been evaluated in the nausea of far advanced disease.

Nausea, vomiting and retching are among the worst of symptoms that patients may experience. Despite the existence of evaluation and management guidelines as well as many antiemetic agents, the clinical results of the treatment of nausea, vomiting and retching remain suboptimal.

The author would like to thank Pya Seidner for her enormous assistance in the preparation of this manuscript. Table 1 — Relative Affinities of selected antiemetic agents to various receptors Full table. Ann Palliat Med ;1 2 DOI:

Nausea and vomiting in palliative care

Skip to search form Skip to main content You are currently offline. Some features of the site may not work correctly. DOI: Glare and J. Miller and T. Nikolova and R.


pdf. 5. Bruera E, Hui D, Dalal S, et al. Parenteral hydration in patients with advanced cancer: a multicenter.


A mechanism-based approach to nausea and vomiting in palliative care

When the cause of symptoms is known, the antiemetic should be chosen depending on its receptor affinity. Antiemetic drugs work by binding to specific receptor sites in the chemoreceptor trigger zone CTZ or vomiting centre VC in the brainstem. At each site, there are several receptors; the more strongly the drug binds to the receptor, the more potent its antiemetic activity. Levomepromazine is generally the second line medication used in nausea in palliative care. It has a broad mechanism of action has good symptomatic relief but many side effects including its action as a sedative.

Download PDF. Nausea and vomiting are common and often require attention in palliative-care settings. Treatment is most straightforward if a single cause for a patient's nausea and vomiting can be identified.

Show all documents Top PDF Treating nausea and vomiting in palliative care: a review. Treating nausea and vomiting in palliative care: a review Ondansetron is the oldest selective 5HT 3 receptor antagonist. Newer ones include granisetron, tropisetron, dolasetron, and palonosetron. The recommended dose of ondansetron for chronic nausea is 4—8 mg given once or twice a day.

Top PDF Treating nausea and vomiting in palliative care: a review

Nausea and vomiting in palliative care

The management of nausea and vomiting for individuals receiving palliative care can be complex. Note: prokinetic agents may trigger oesophageal spasm. Non-pharmacological measures are important and should be considered alongside the prescribing of appropriate anti-emetics. Measures include:. Almost all causes of nausea and vomiting can be placed in the following categories, and managed using a specific drug or class of drugs.

Cookie policy : This site uses cookies small files stored on your computer to simplify and improve your experience of this website. Cookies are small text files stored on the device you are using to access this website. For more information please take a look at our terms and conditions. Some parts of the site may not work properly if you choose not to accept cookies. Nausea, an unpleasant feeling of wanting to vomit, and vomiting, the expulsion of gastric contents, are symptoms that can overlap but are individual.


The standard palliative care approach to the assessment and treatment of nausea and vomiting is based on determining the cause and then relating this back to the "emetic pathway" before prescribing drugs such as dopamine antagonists, antihistamines, and anticholinergic agents which block neurotransmitters at different.


Nausea and Vomiting

Metrics details. Olanzapine is an atypical antipsychotic that has affinity for many central nervous system receptors. Its efficacy is supported by several studies in the prevention and treatment of chemotherapy-induced nausea and vomiting. No recommendations exist on the antiemetic use of olanzapine in the palliative care setting. The aim of this work is to complete the initial work of Fonte et al.

Severe nausea, vomiting, or retching can be among the most disabling of symptoms. Wood and colleagues reviewed various instruments available for the assessment of cancer-related nausea, vomiting, and retching 2. Twenty-four tools evaluating nausea were identified that met their inclusion criteria. Thirteen tools measured vomiting as a separate experience. Only 3 tools included a separate assessment of retching.

Click on image for details. Correspondence Address : Dr. The patients often present to palliative care with intractable nausea and vomiting.

Professional Reference articles are designed for health professionals to use. You may find the Nabilone capsules article more useful, or one of our other health articles. NICE has issued rapid update guidelines in relation to many of these.

Professional Reference articles are designed for health professionals to use. You may find the Nabilone capsules article more useful, or one of our other health articles. NICE has issued rapid update guidelines in relation to many of these.

Download PDF. In the table below receptors involved in different types of nausea are highlighted using this acronym. Blockade of these receptors allows rational, focused therapy. Current version re-copy-edited May Fast Facts can only be copied and distributed for non-commercial, educational purposes.

This article will discuss the approach to and management of both treatment-related and non—treatment-related nausea and vomiting in cancer patients. It is important to determine whether the nausea and vomiting is related to treatment chemotherapy, radiation or is independent of cancer treatment. Various national and international antiemetic guidelines have been developed for the prevention of chemotherapy- and radiotherapy-induced nausea and emesis.

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5 Comments

  1. Carol H.

    Nausea and vomiting are common symp- toms experienced by patients who are receiving palliative care. Successful man- agement of these distressing symptoms requires thorough assessment to identify underlying causes and treating the symptom with non-pharmacological measures as well as appropriate anti- emetics.

    20.04.2021 at 22:16 Reply
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  3. Elliot M.

    Nausea and vomiting in palliative care are commonly experienced symptoms, and the aetiology is often multifactorial.

    23.04.2021 at 15:31 Reply
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