Distinct Types of Chemo-Induced Nausea & Vomiting

Experts in the management of chemotherapy-induced nausea and vomiting (CINV) provide a summary of the distinct types of CINV.

Katherine Lin, PharmD, BCOP: Bhavesh, I was wondering if you could please tell us a little more about the distinct types of chemotherapy-induced nausea and vomiting [CINV]?

Bhavesh Shah, RPh, BCOP: There are quite a few different chemotherapy-induced nausea and vomiting phases. I’m not going to be able to give the extensive summary in the pathophysiology that you gave, but obviously I’ll try to summarize a little. The acute part is probably the most important part.

I know that 1 of the biggest culprits of acute emesis is cisplatin. We know that’s the most horrific nausea and vomiting that you can have. That was the only agent that we used to have in the armamentarium chemotherapy. We know that within 24 hours, these patients will have nausea and vomiting that peaks about 5 to 6 hours after the initiation. Cisplatin [is] very, very highly emetogenic. We know that those patients who did not receive 5-HT3 were very, very likely of having nausea and vomiting in that acute phase.

The delayed phase is basically beyond the 24 hours. It probably peaks after 48 hours, and then, depending on the agent you have, you basically have these peaks that go beyond 72 hours. And then of course it could last up to 5 to 7 days after a patient finishes chemotherapy. Agents that have delayed emesis are cisplatin, carboplatin, cyclophosphamide, and doxorubicin. Many of those agents have been classified as having delayed emesis beyond the 24 hours.

Breakthrough is what I consider if you actually didn’t receive the proper antiemetics and have emesis, or a nausea-vomiting type of reaction after you’ve received that therapy.

Going on to anticipatory, this is basically a learned response that some people call white coat syndrome. Before a patient even gets their therapy, when they’re in their chair, they actually start having this emesis. Believe it or not, 1 of my mentors used to tell me how patients used to come into the clinic and would actually get a basin before they even started their treatment because of this anticipatory problem that they would have. Can you imagine having patients coming in today? If you were giving them a basin before they would get their treatment, I think they would probably walk out and go to a different hospital. Luckily, we don’t have that today.

Katherine Lin, PharmD, BCOP: Kind of what you were saying along those lines with anticipatory, and it really is before patients even get a drop of chemotherapy. It can be triggered by anything—a sound, an odor, a site. We had 1 patient we were treating in our breast cancer clinic who had a pretty horrific round of nausea and vomiting. There was a song playing when this happened to her. She came in and told us a story a couple of months later. Two weeks later, she was at the grocery store. This song came on and she started throwing up in the grocery store. So kind of as you said, it really is this conditioned response that comes from inappropriate control. You really want to make sure that you are providing patients with the care up front, because if patients have these negative experiences, unfortunately it makes them more likely to experience anticipatory nausea and vomiting.

Bhavesh Shah, RPh, BCOP: Absolutely. I can definitely talk about a patient 1 of the nurses saw in the grocery store. The patient had this anticipatory nausea when she wasn’t even getting the treatment in the chair.

Katherine Lin, PharmD, BCOP: Because she saw the nurse?

Bhavesh Shah, RPh, BCOP: Yeah. It was pretty powerful.

And then refractory, obviously, occurs in patients who’ve actually completed their cycle. And then with their antiemetics, with their prophylaxis regimen, and in the subsequent cycle, they actually have this emesis. That sometimes happens within the late cycles, where they’ve done fine with the initial cycles, they’d received this prophylaxis, and they still end up having this nausea and vomiting. So those are the major categories of the distinct types of CINV.