ANTIEMETICS FOR NAUSEA AND VOMITING

Systematic review of the effectiveness of antiemetic medication for prevention and treatment of chemotherapy induced nausea and vomiting in childhood

Background

Nausea and vomiting continue to be a problem for children undergoing treatment for malignancies and are highly unpleasant despite modern antiemetic (anti-sickness) therapies. Selecting the most appropriate and effective antiemetic regimen has the potential to significantly impact on quality of life. The most effective doses of many of these drugs, and the best routes to give them, remain uncertain in children, due to limited studies, which results in inconsistencies and variation in prescribing, often underpinned by the personal preference and experience of the doctors as opposed to research based evidence.

Nausea and vomiting can have profound physical and psychological consequences. The physical consequences may include dehydration, abnormal blood chemistry, lack of appetite, weight loss, weakness, increased susceptibility to infections and a disruption of normal childhood activities. Chemotherapy induced nausea and vomiting are considered to be among the worst side effects of chemotherapy, causing much distress to the child and family.

There appear to be distinct clinical phases of nausea and vomiting related to chemotherapy. These commence with anticipatory nausea and vomiting (ANV) – symptoms preceding the administration of chemotherapy, often following a previous bad chemotherapy experience. This can happen in up to 1 in 5 children. This type of nausea and vomiting is difficult to treat with anti-sickness medication. Symptoms following administration of chemotherapy, and within 24 hours, are described as “acute” nausea and vomiting. The incidence of this varies by the chemotherapy received, but can be upwards of 90% likely for some commonly used agents (e.g. cisplatin). Symptoms occurring after 24hrs are described as delayed nausea and vomiting, and may occur in up to half of patients.

Our aim is to undertake a systematic review of pharmacological approaches to nausea and vomiting in children and young people who have cancer in order to prevent or reduce anticipatory, acute and delayed symptoms.

Findings

Chemotherapy to treat cancer in children and young people can produce nausea (feeling sick) and vomiting (actually being sick). These are extremely unpleasant sensations, and continue to be a problem despite better antiemetic (anti-sickness) drugs. This review found that only 28 good quality trials had been undertaken in children, examining 23 drug combinations. Trials tended to report vomiting rather than nausea, even though nausea is generally a more distressing experience for individuals. No very firm conclusions can be made about which drugs are best, what dose of drug is most effective or whether to use them as oral (by mouth) or intravenous (injected) treatments. It seems that the 5HT3 antagonists (the "trons", for example ondansetron, granisitron or tropisitron) are better than older agents, and that giving dexamethasone as well as these drugs makes them even better. We suggest future new research needs to look at things that patients and families deem important, use established measures of nausea and vomiting, and try to use even newer techniques to undertaken reviews to maximise the information available.

Conducted by: Bob Phillips1, Shireen Gopaul2, Faith Gibson3, Elizabeth Houghton4, Jean V Craig5, Kate Light1, Barry Pizer6

1 Centre for Reviews and Dissemination, University of York; 2 Section of Experimental Oncology, Leeds Institute of Molecular Medicine/Cancer Research UK Clinical Centre/St James University Hospital; 3 Patient Care Research & Innovation Centre, UCL Institute of Child Health and Great Ormond Street Hospital for Children NHS Trust; 4 Pharmacy, Alder Hey Children's NHS Foundation Trust; 5 School of Medicine, Health Policy and Practice, Norwich; 6 Oncology Unit, Alder Hey Children's NHS Foundation Trust

Publications

Phillips B, Gopaul S, Gibson F, Houghton E, Craig JV, Light K, Pizer B. Antiemetic medication for prevention and treatment of chemotherapy induced nausea and vomiting in childhood. Cochrane Database Syst Rev. 2010; 9: CD007786

Posters

Phillips R, Gibson F, Gopaul S, Light K, Craig JV, Pizer B, Houghton E. Antiemetic medication for prevention and treatment of chemotherapy induced nausea and vomiting in childhood. NCRI Cancer Conference; 2009 October; Birmingham, UK

Funding

Commissioned by Candlelighters