1. The EPEC-O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation. Education in Palliative and End-of-life Care - Oncology The Project EPEC-O TM

2. EPECEPECOOEPECEPECOOO EPECEPECOOEPECEPECOOO Module 3p Symptoms – Nausea / vomiting Module 3p Symptoms – Nausea / vomiting EPEC – Oncology Education in Palliative and End-of-life Care – Oncology

3. Nausea / vomiting... l Definition Nausea is an unpleasant subjective sensation of being about to vomit Vomiting is the reflex expulsion of gastric contents through the mouth l Definition Nausea is an unpleasant subjective sensation of being about to vomit Vomiting is the reflex expulsion of gastric contents through the mouth

4. ... Nausea / vomiting l Impact very distressing: Awareness of nausea Inability to keep food or fluids down Acid and bitter tastes Unpleasant smells of vomitus l Impact very distressing: Awareness of nausea Inability to keep food or fluids down Acid and bitter tastes Unpleasant smells of vomitus

5. Key points 1.Pathophysiology 2.Assessment 3.Management 1.Pathophysiology 2.Assessment 3.Management

6. Pathophysiology l Nausea Subjective sensation (easily learned) Stimulation Gastrointestinal lining, CTZ, vestibular apparatus, cerebral cortex l Vomiting Neuromuscular reflex l Nausea Subjective sensation (easily learned) Stimulation Gastrointestinal lining, CTZ, vestibular apparatus, cerebral cortex l Vomiting Neuromuscular reflex

7. Pathophysiology CortexCortex Vestibular apparatus GI tract Chemoreceptor Trigger Zone (CTZ) Neurotransmitters l Acetylcholine l Dopamine l Histamine l Neurokinin l Serotonin Neurotransmitters l Acetylcholine l Dopamine l Histamine l Neurokinin l Serotonin Vomiting center

8. Causes l Metastases l Meningeal irritation l Movement l Mental anxiety l Medications l Mucosal irritation l Metastases l Meningeal irritation l Movement l Mental anxiety l Medications l Mucosal irritation l Mechanical obstruction l Motility l Metabolic l Microbes l Myocardial

9. Assessment l When l Acute versus chronic l Intermittent or constant l Associated with sights or smells l Eating patterns l Bowel patterns l Medications l When l Acute versus chronic l Intermittent or constant l Associated with sights or smells l Eating patterns l Bowel patterns l Medications

10. Management l Dopamine antagonists l Antihistamines l Anticholinergics l Serotonin antagonists l Neurokinin antagonists l Dopamine antagonists l Antihistamines l Anticholinergics l Serotonin antagonists l Neurokinin antagonists l Prokinetic agents l Antacids l Cytoprotective agents l Other medications Gralla R, et al. J Clin Oncol, 1999.

11. Chemotherapy nausea l Acute < 24 hr Chemoreceptor trigger zone Serotonin release in the gut l Delayed 24 hr (may be days) Unclear mechanism l Acute < 24 hr Chemoreceptor trigger zone Serotonin release in the gut l Delayed 24 hr (may be days) Unclear mechanism

12. Chemotherapy emetogenicity Emetogenic Class Incidence acute vomiting I Minimal < 10 % II Low 10 – 30 % III Mild 30 – 60 % IV Moderate 80 – 90 % V High > 90 %

13. Dopamine antagonists l Haloperidol l Prochlorperazine l Droperidol l Thiethylperazine l Promethazine l Haloperidol l Prochlorperazine l Droperidol l Thiethylperazine l Promethazine l Trimethobenzamide l Metoclopramide l Olanzapine l Perphenazine

14. Histamine antagonists (antihistamines) l Diphenhydramine l Meclizine l Hydroxyzine l Diphenhydramine l Meclizine l Hydroxyzine

15. Acetylcholine antagonists (anticholinergics) l Scopolamine

16. Serotonin antagonists l Ondansetron l Granisetron l Dolasetron l Palonosetron l Ondansetron l Granisetron l Dolasetron l Palonosetron

17. Neurokinin-1 antagonists l Aprepitant

18. Prokinetic agents l Metoclopramide l Domperidone l Macrolide antibiotics, eg, erythromycin l Metoclopramide l Domperidone l Macrolide antibiotics, eg, erythromycin

19. Antacids l Antacids l H 2 receptor antagonists CimetidineFamotidineRanitidine l Proton pump inhibitors OmeprazoleLansoprazole l Antacids l H 2 receptor antagonists CimetidineFamotidineRanitidine l Proton pump inhibitors OmeprazoleLansoprazole

20. Other medications l Dexamethasone 6 – 20 mg PO daily l Tetrahydrocannabinol 2.5 – 5 mg PO tid l Lorazepam 0.5 – 2 mg PO q 4 – 6 h Octreotide 10  g / hr IV / SC infusion Octreotide 10  g / hr IV / SC infusion or 100  g SC q 8 h for bowel obstruction l Dexamethasone 6 – 20 mg PO daily l Tetrahydrocannabinol 2.5 – 5 mg PO tid l Lorazepam 0.5 – 2 mg PO q 4 – 6 h Octreotide 10  g / hr IV / SC infusion Octreotide 10  g / hr IV / SC infusion or 100  g SC q 8 h for bowel obstruction

21. EPECEPECOOEPECEPECOOO EPECEPECOOEPECEPECOOO Summary Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience