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Managing CINV :neutral_face: (Pharmacological treatment (Principlesā¦
Managing CINV :neutral_face:
Non-pharmacological approach
Muscle relaxation, hypnosis, distraction, good environment
Reduce CIMV severity and duration as well as anxiety
Pharmacological treatment
Studies show that antiemetics are no longer effective once CINV occurs - focus is on PREVENTION
Principles
Aggressive treatment
For appropriate dosing duration
Using suitably selected antiemetics
With adequate doses
Alongside non-drug therapy
Acute NV
Level 1 Emesis
No drug needed
If severe, give metoclopramide
Level 2
Antiemetic on each day of therapy as a single agent
Dexamethasone 20mg IV 30mins pre-chemotherapy
Metoclopramide 1-2mg/kg IV Q2-4 hrs (2-5 doses) - if Oral is 2mg/kg
For delayed - Dexamethasone + metoclopramide (D5-6)
Level 3,4
Dexamethasone
5HT3 antagonists
Ondansetron
8mg IV 30 mins prior to chemotherapy up to 32 mg; 12-24 mg PO prior to chemotherapy, 8mg PO BD after chemotherapy
Granisetron
10mcg/kg IV 30 mins prior to chemotherapy up to 1g, 2 mg/d or 1mg BID 1 hour prior to chemotherapy
Delayed - DXM and Metoclopramide (D5-6) + Aprepitant (D1-3)
Level 5
Similar to L3 and 4
Except aprepitant is used for D1-3 and DXM is extended in duration
Breakthrough emesis
Use antiemetic from another class
Haloperidol, chlorpromazine
Add another antiemetic
Metoclopramide + 5HT3, DXM
Prolonged treatment
For highly emetogenic drugs
Cisplatin
DXM 10-20mg PO/IV Q4-6 hr
Metoclopramide (0.5mg/kg or 30mg PO/IV Q4-6 for 3-5 days
Cyclophosphamide
DXM + 5HT3
Anticipatory
Prevent emesis from the onset
Antiemetic with antianxiety are given - lorazepam is widely used
Emesis due to chemo combination
Select based on highest emetogenic potential (Highest level + 1 (for all L2) and +1 (for each L3)
Refractory
Use dopamine antagonists
chlorpromazine
Benzodiazepines and neuroleptics
olanzapines