Management

For management of 'acute' nausea and vomiting: (1)

• if chemotherapy with high or moderate-high likelihood of causing nausea and vomiting
  • prophylaxis with a 5HT3-receptor antagonist, given orally or intravenously as a single low dose shortly before chemotherapy, together with dexamethasone, is recommended
• for chemotherapy regimens with low-to-moderate emetic risk (10-30%), prophylaxis with dexamethasone alone is usually adequate to prevent acute nausea and vomiting

For 'delayed' nausea and vomiting:

• use of a 5HT3-receptor antagonist beyond the first 24 hours after chemotherapy, to prevent nausea and vomiting over the following 2-5 days (the delayed phase) offers marginal benefit at best
• dexamethasone, or dexamethasone plus either domperidone or metoclopramide, appears a more cost-effective option after the first day of chemotherapy with an emetogenic regimen

For anticipatory nausea and vomiting:

• optimal prophylaxis against acute and delayed nausea and vomiting, from the start of chemotherapy, is the most effective way of preventing the development of anticipatory nausea and vomiting in subsequent cycles (1)
• various interventions such as benzodiazepines (e.g. lorazepam or alprazolam given on the day before or morning of chemotherapy), behavioural and cognitive treatments, hypnosis and muscle relaxation therapy have been shown to ameliorate symptoms

If patient receiving radiotherapy:

• prophylaxis with a 5HT3-receptor antagonist, given as a single dose (usually with dexamethasone) before administration of each fraction, may be of benefit

Note - although not routinely used, Olanzapine may be of use in patients who are not responding to standard antiemetics. at a dose of 10mg stat then days 2 to 4. (An unlicensed indication for delayed nausea and vomiting). Nabilone (a synthetic cannabinoid) is licensed for nausea and vomiting caused by cytotoxic chemotherapy, unresponsive to conventional antiemetics at a dose of 1-2mg b.d. orally. NICE state that the evidence is limited, and of low quality using outdated antiemetics but that it could be an option as an add on where patients have nausea and vomiting despite optimised conventional antiemetics.) (2,3)

Reference

1. Rao K et al. Chemotherapy-Induced Nausea and Vomiting: Optimizing Prevention and Management. Am Health Drug Benefits. 2012 Jul;5(4):232–240.
2. Roila F et al. 2016 MASCC and ESMO guideline update for the prevention of chemotherapy- and radiotherapy-induced nausea and vomiting and of nausea and vomiting in advanced cancer patients. Annals of Oncology 27 (Supplement 5): v119–v133, 2016
3. NICE. Cannabis-based medicinal products. NICE guideline NG144. Published November 2019, last updated March 2021