What is the management for post-chemotherapy (chemotherapy) intractable vomiting, also known as breakthrough nausea and vomiting or refractory nausea and vomiting?

From the Guidelines

Management of post-chemotherapy intractable vomiting requires a multi-drug approach targeting different antiemetic pathways, with the most recent guidelines suggesting the use of olanzapine (5-10mg PO daily for 3-4 days) as a breakthrough treatment, in addition to a 5-HT3 receptor antagonist, dexamethasone, and a neurokinin-1 (NK1) receptor antagonist like aprepitant, as recommended by the 2017 NCCN guidelines 1.

Key Considerations

• The general principle of breakthrough treatment is to add one agent from a different drug class to the current regimen, with options including atypical antipsychotics, benzodiazepines, cannabinoids, and dopamine antagonists 1.
• Hydration and electrolyte replacement are essential supportive measures, and antacid therapy may be considered if patients have dyspepsia 1.
• The choice of agent should be based on assessment of the current prevention strategies used, and multiple concurrent agents may be necessary, perhaps in alternating schedules or by alternating routes 1.

Treatment Options

• Olanzapine (5-10mg PO daily for 3-4 days) is a recommended breakthrough treatment, blocking multiple receptors including dopamine and serotonin pathways 1.
• Benzodiazepines such as lorazepam (0.5-2mg IV/PO every 6 hours) can reduce anticipatory symptoms and anxiety 1.
• Metoclopramide (10mg IV/PO every 6 hours) improves gastric emptying and may help when delayed emptying contributes to symptoms 1.
• Cannabinoids like dronabinol (2.5-5mg PO every 4-6 hours) can be considered for refractory cases 1.

Important Notes

• The oral route may not be feasible due to ongoing vomiting, and rectal or intravenous therapy may be required 1.
• Before administering the next cycle of chemotherapy, patients should be reassessed for other possible non-chemotherapy-related reasons for breakthrough emesis, and the antiemetic regimen should be evaluated and alternatives considered if necessary 1.

From the FDA Drug Label

Aprepitant has not been studied for the treatment of established nausea and vomiting. The FDA drug label does not answer the question.

From the Research

Management of Post-Chemotherapy Intractable Vomiting

The management of post-chemotherapy intractable vomiting involves a combination of pharmacologic and nonpharmacologic strategies.

• Pharmacologic therapies include:
  • Serotonin receptor antagonists, such as palonosetron 2
  • Neurokinin-1 receptor antagonists, such as aprepitant 2, 3
  • Corticosteroids, such as dexamethasone 4, 3
  • Dopamine antagonists, such as metoclopramide 4, 3
• Nonpharmacologic therapies include:
  • Eating small servings of food 4
  • Using aloe 4
  • Other alternative or nonpharmacologic therapies, such as acupuncture or relaxation techniques 5

Treatment of Breakthrough Symptoms

For breakthrough symptoms, medications such as:

• Dopamine antagonists, such as haloperidol or droperidol 3
• Benzodiazepines, such as lorazepam 3
• Olanzapine, casopitant, or gabapentin 3, 5 may be used.

Refractory CINV

For refractory CINV, options include:

• Olanzapine 3
• Dronabinol or nabilone 3
• Gabapentin 3, 5