Chemotherapy-Induced Nausea and Vomiting


Many essential cytostatic agents often cause vomiting and nausea. For this reason, most patients are usually given medication to avoid or prevent such serious side effects before undergoing emetogenic chemotherapy.

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    Cause & Symptoms
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    Diagnosis & Therapy

Diagnosis

A distinction is made between different forms of vomiting caused by chemotherapy: 

  • Acute vomiting: within the first 24 hours of having chemotherapy
  • Delayed vomiting: occurring more than 24 hours after having chemotherapy
  • Anticipatory vomiting: psychologically-induced vomiting that has been learned 

All of these forms can be experienced together or on an individual basis.
Acute vomiting is the most common if untreated. Depending on the type of chemotherapy, it may occur shortly after the treatment or a few hours later. If left untreated, it may result in several bouts of vomiting in a short period of time depending on the emetogenicity of the chemotherapy. 

Delayed vomiting only begins the day after chemotherapy, i.e. in a phase where the patient is not receiving any cytostatic treatment. This is of course particularly unpleasant as the patient feels that they have completed the treatment and does not need to deal with any additional acute side effects. Delayed vomiting often occurs in cases where the patient has already experienced acute bouts of vomiting. 

Anticipatory vomiting is based on negative experiences with previous treatment. The patient associates a thought, odour or the sight of the hospital itself with vomiting, which in turn actually makes them vomit, although they have not received any additional chemotherapy. 

Treatment

Modern anti-emetic treatment consists of three medication classes, which are combined with each other as required or according to emetic risk.

Serotonin receptor antagonists
So-called serotonin receptor antagonists have formed part of treatment since the beginning of the 1990s. They block  serotonin receptors, which play a key role in triggering the vomiting reflex. Serotonin receptors antagonists are effective against nausea and vomiting on the day chemotherapy is administered.

Neurokinin receptor antagonists
Another class of medication is so-called neurokinin receptor antagonists. They block the effect of the substance P neurotransmitter, being used in both highly and moderately emetic chemotherapy both in the acute phase of vomiting and the combination with serotonin receptor antagonists and steroids, as well as in the delayed phase in which it is usually only administered together with steroids. 

Steroids
The general title of steroids refers to cortisone derivatives which strengthen the effect of other anti-emetic medication when used in combination with them. If the aforementioned standard treatment against nausea and vomiting does not work, other medication may be used. This includes cannabinoids, dopamine antagonists, benzodiazepine, neuroleptics and antihistamines. 

Cannabinoids
Cannabinoids work via cannabinoid receptors in the body. Two sub-types of cannabinoid receptors have been described up to now that have been localised in the central (brain / bone marrow) and in the peripheral nervous system. How cannabinoids work has not yet fully been established, but thanks to the occupation and activation of the CB1 receptor (e.g. by cannabinoids) of the presynaptic nerve endings, the release of neurotransmitters is blocked (e.g. glutamate, GABA, dopamine, serotonin, etc.). This ultimately leads to clinical effects such as the prevention of vomiting, a reduction in the sensation of pain or an increase in appetite.

Further information on nausea and vomiting during cancer treatment can be found under (German website):
Krebsinformationsdienst vom Deutsches Krebsforschungszentrum