Impact of a reduced palonosetron maximum dose on the incidence of chemotherapy-induced nausea and vomiting in pediatric patients

Background Palonosetron is a serotonin-3 (5-HT3) receptor antagonist indicated in the prevention of chemotherapy-induced nausea and vomiting (CINV) in pediatric and adult patients. Traditional dosing for palonosetron in the pediatric population has been 20 mcg/kg with a maximum dose of 1500 mcg. This study aimed to evaluate the impact of an institutional dose cap of 750 mcg on pediatric CINV. Procedure This is a retrospective chart review of admitted patients given palonosetron intended for prevention of CINV at a pediatric medical center between July 1, 2018 and June 30, 2020. Patients 1 month up to 17 years of age who received at least one dose of palonosetron prior to chemotherapy (not preceding stem cell transplant) were included. Information regarding chemotherapy, antiemetic premedication, emesis, and breakthrough antiemetic agents were recorded to quantify the instances of CINV. Results Seven hundred and seventy-one patient encounters met inclusion criteria (n=485 traditional dose, n=286 dose capped). There was no statistical difference in the instances of emesis (p=0.98) or breakthrough agents administered (p=0.65) between the two groups. Dose capping patients at 750 mcg reduced cost by approximately 34.9% compared to traditional dosing. Conclusions The use of a dose cap of palonosetron at 750 mcg maintains efficacy for prevention of CINV while reducing cost in pediatric patients receiving chemotherapy.

Antiemetic Effect of Fruit Extracts of Trapa bispinosa Roxb. in Chick Emesis Model

Background: Vomiting and nausea are common symptoms associated with many diseased conditions. They also occur as side effects due to intake of certain medications. Natural remedies are nowadays being considered as a better alternate compared to allopathic medicine. Aim: The current study was designed to evaluate the antiemetic effect of hexane and ethanolic extracts of Trapa bispinosa Roxb fruit. Methodology: The study was conducted on young chicks aged 6-7 days using Copper sulfate (50 mg/kg) for the induction of emesis using oral route. Antiemetic effect was determined by observing the reduction in the number of retches in different groups of chicks. Metoclopramide and Chlorpromazine (150 mg/kg) were used as standard antiemetic agents. Chicks were treated with both extracts (ethanolic and hexane) at the dose of 150 mg/kg. Results: Hexane extract was found to be most effective when compared with all the groups. The results showed that T.bispinos Roxb. hexane extract was able to effectively prevent the copper sulfate induced emesis in chicks. Phytochemical analysis was also performed and it was predicted that the antiemetic effect of hexane extract might be due to the presence of alkaloids and triterpenoids. Conclusion: The positive effects obtained from this study showed that natural remedy might also be used as an alternate to allopathic medicine for nausea and vomiting.

Unscheduled hydrations: redefining complete response in chemotherapy-induced nausea and vomiting studies

Breakthrough chemotherapy-induced nausea and vomiting (CINV) is nausea and/or vomiting occurring within 5 days of chemotherapy administration despite using guideline-directed prophylactic antiemetic agents. It is highly prevalent (30–40%), usually requiring immediate treatment or “rescue” medication. If breakthrough CINV occurs, antiemetic guidelines recommend using an antiemetic agent from a different class not used in prophylaxis, along with intravenous hydration and/or dexamethasone. Data supporting these guideline recommendations are limited. Importantly, costs associated with breakthrough CINV can be substantial (i.e., unscheduled hydrations). Two retrospective analyses evaluating guideline-adherent CINV prophylaxis suggest that the initial antiemetic selection may decrease breakthrough CINV. Here we review optimal CINV prophylactic strategies and introduce unscheduled hydration as a potential important surrogate for breakthrough CINV aligning with cost-effective cancer care.

From guidelines to practice: Patient-focused and evidence-informed update of antiemetic recommendations in Ontario.

39 Background: Cancer Care Ontario (CCO) last updated their guidance for the management of chemotherapy-induced nausea and vomiting (CINV) in 2013. Since then, new evidence emerged which changed antiemetic recommendations internationally. The CCO Antiemetic Working Group reviewed the current literature and updated existing recommendations for the prevention and management of CINV in adult patients. Methods: Ontario subject matter experts consisting of oncologists, pharmacists and nurses formed the Group. Relevant guidelines published from prominent jurisdictions were assessed. A literature search was done to incorporate the latest evidence. All chemotherapy regimens in the CCO Drug Formulary were reviewed. Ontario Cancer Leads for each disease site were consulted to ensure emetic classifications for all regimens and antiemetic recommendations reflected both the evidence (including gaps in the literature) and clinical practice (including gaps between evidence and practice). Results: Recommendations for antiemetic agents for highly, moderately, low and minimal emetic risk intravenous and oral chemotherapy are outlined. Chemotherapy regimens in the CCO Drug Formulary were reviewed and emetic risks updated. Recommendations differed from those of major international guidelines (including ASCO) around olanzapine dosing, cannabinoids and emetic risk classification. Conclusions: A systematic approach to updating antiemetic recommendations resulted in evidence-informed recommendations that are patient-focused and clinically feasible.

Tachykinin receptors (version 2019.4) in the IUPHAR/BPS Guide to Pharmacology Database

Tachykinin receptors (provisional nomenclature as recommended by NC-IUPHAR [90]) are activated by the endogenous peptides substance P (SP), neurokinin A (NKA; previously known as substance K, neurokinin α, neuromedin L), neurokinin B (NKB; previously known as neurokinin β, neuromedin K), neuropeptide K and neuropeptide γ (N-terminally extended forms of neurokinin A). The neurokinins (A and B) are mammalian members of the tachykinin family, which includes peptides of mammalian and nonmammalian origin containing the consensus sequence: Phe-x-Gly-Leu-Met. Marked species differences in in vitro pharmacology exist for all three receptors, in the context of nonpeptide ligands. Antagonists such as aprepitant and fosaprepitant were approved by FDA and EMA, in combination with other antiemetic agents, for the prevention of nausea and vomiting associated with emetogenic cancer chemotherapy.

A retrospective review of treatment patterns of antiemetic agents for chemotherapy-induced nausea and vomiting

Objectives: To evaluate the treatment pattern of antiemetic agents used for chemotherapy-induced nausea and vomiting in a tertiary hospital in Saudi Arabia. Methods: Over a period of 7 weeks, all new chemotherapy order sheets were collected and evaluated for chemotherapy-induced nausea and vomiting management. We compared each antiemetic regimen used for chemotherapy-induced nausea and vomiting prophylaxis with three international antiemetic guidelines by the following organizations: the Multinational Association of Supportive Care in Cancer, the American Society of Clinical Oncology, and the National Comprehensive Cancer Network for the clinician. Results: A total of 152 cancer patients were included in the study, for whom 289 chemotherapy physician orders included antiemetic regimens. Approximately 17.3% of the chemotherapy protocols had total minimal emetogenicity risk, 22.5% had low risk, 37.02% had moderate risk, and 23.18% had high risk. For acute emesis, 27.57% of the antiemetic regimens followed at least one of the three reference guidelines. For delayed emesis, only 20.16% of the antiemetic regimens adhered to at least one of the three reference guidelines. Conclusion: Adherence to treatment recommendations and antiemetics prescribing for chemotherapy-induced nausea and vomiting was suboptimal at this hospital. However, institutional antiemetic guidelines and oncology pharmacists could play an important role in better assessment and management of chemotherapy-induced nausea and vomiting.