The Prevention and Treatment of Nausea and Vomiting During Tumor Therapy

Abstract

Background: Nausea and vomiting are common and distressing side effects of tumor therapy. Despite prophylaxis, 40-50% of patients suffer from nausea, and 20-30% from vomiting. Antiemetic prophylaxis and treatment are therefore of great importance for improving patients' quality of life and preventing sequelae such as tumor cachexia.

Methods: The recommendations presented here are based on international and national guidelines, updated with publications retrieved by a selective search in the PubMed and Cochrane Library databases, with special attention to randomized controlled trials and meta-analyses that have appeared in the past 5 years since the German clinical practice guideline on supportive therapy was published.

Results: Risk-adjusted prevention and treatment is based on the identification of treatment-related and patient-specific risk factors, including female sex and younger age. Parenteral tumor therapy is divided into four risk classes (minimal, low, moderate, high), and oral tumor therapy into two (minimal/low, moderate/high). In radiotherapy, the radiation field is of decisive importance. The antiemetic drugs most commonly used are 5-HT3-RA, NK1-RA, and dexamethasone; olanzapine has proven beneficial as an add-on or rescue drug. The use of steroids in patients being treated with drug combinations including checkpoint inhibitors is discussed controversially because of the potentially reduced therapeutic response. Benzodiazepines, dimenhydrinate, and cannabinoids can be used as backup antiemetics. Acupuncture/acupressure, ginger, and progressive muscle relaxation are pos - sible alternative methods.

Conclusion: Detailed, effective, risk profile-adapted algorithms for the prevention and treatment of nausea and vomiting are now available for patients undergoing classic chemotherapy regimens or combined radiotherapy and chemotherapy. Optimal symptom control for patients undergoing oral tumor therapy over multiple days in the outpatient setting remains a challenge.

Figure 1

Treatment algorithm for patients undergoing parenteral chemotherapy for cancer

Figure 2

Treatment algorithm for patients receiving oral chemotherapy for cancer NK₁-RA, neurokinin₁ receptor antagonist; 5-HT₃-RA, 5-HT₃ receptor antagonist *¹ Exception: for procarbazine, add a NK1 receptor antagonist; *² for palonosetron, give on, e.g., days 1, 3, and 5 *³See text, “Patient-related risk factors”

Figure 3

Treatment algorithm for patients undergoing radiotherapy 5-HT₃-RA, 5-HT₃ receptor antagonist; RA, receptor antagonist

eFigure

Differential diagnoses in patients with nausea and vomiting