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Cancer and Nausea, Part II: Non-CINV Nausea and Treatment Strategies

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Nausea is a very complex symptom involving numerous pathways between the brain and the gut, and it can have many different causes. While chemotherapy is a big culprit in causing nausea and vomiting, there are multiple other causes unique to cancer. Here are few that stand out:

* Radiation-induced nausea and vomiting occurs when a portion of the GI tract (including the esophagus) are located in the field of radiation. The primary treatment will depend on what part of the GI tract is affected; for example, acid reducers are helpful if the stomach or esophagus have been inflamed from radiation therapy plus general anti-nausea medications.

* Intestinal obstruction is a very serious complication of cancer which can occur due to prior cancer surgeries (scar tissue can cause the intestines to twist and obstruct) or due to the cancer itself causing a blockage. This can warrant surgery at times if the obstruction cannot reverse itself on its own.

* Brain involvement of the cancer can cause nausea and vomiting due to swelling and increased pressure on the brain. Steroids, like dexamethasone, help reduce the swelling, and they are often used concurrently with tumor-directed treatments.

* Uncontrolled pain, regardless of its location, can cause nausea and vomiting. Compounding this, opioid medications (like morphine) can also contribute. This is often transient, for the first few days of use, but it can sometimes be more persistent.

    Common Anti-nausea Medications and How They Work

    If at all possible, a primary treatment strategy is to treat the underlying cause. The other part of anti-nausea strategy is to choose anti-nausea medications that will target the nausea mechanisms on the receptor level.

    Compazine (prochlorperazine) is a very common and versatile anti-nausea medication used in the treatment of nausea and vomiting. It is versatile because it targets nausea receptors both in the gut and in the brain. It comes in oral, IV and suppository forms. The possible side effects of compazine include sedation and dystonia (muscle stiffening). Another similar medication is haldol (haloperidol)—while haldol is most commonly known for its use in delirium or mental illness, in lower doses it is an anti-nausea medication because it hits nausea receptors like compazine does. It has been particularly effective for nausea related to opioids.

    Anti-histamines are another group of medications that are effective for certain types of nausea and vomiting. A popular anti-histamine in disguise is phenergan (promethazine); it is not often thought of as an anti-histamine like benadryl, but that is the primary way phenergan works. Anti-histamines not only help with the nausea from motion sickness but also from gut injury or infection. Both phenergan and benadryl come in oral and IV forms. Phenergan also comes in a suppository form. The major common side effect is sedation. Another medication that helps with nausea from motion sickness is scopolamine—people often use it in a patch form for sea-sickness.

    The 5HT3-antagonists—the “-trons”, like zofran (ondanseTron) and kytril (graniseTron)—are now more universally used than when they arrived on the scene in the 1990s. They can be used apart from chemotherapy, though their cost can be a big factor for accessing them. While they do act on receptors in the brain, they also act on receptors in the gut, so they are helpful in cases of nausea due to gut inflammation and obstruction as well as drug-related nausea. They have a more favorable set of side effects—they don’t cause sedation, but can cause mild headache or constipation (in up to 10% of patients).

    Motility agents are medications that work when the gut is slowed or not moving. If you can imagine yards of intestine moving things along, any slowing or “traffic jam” can cause distention and nausea/vomiting. Reglan (metoclopramide) is one of the common “pro-motility” agent used—it works on the upper gut to promote movement. Reglan comes in oral and IV forms. It can have side effects such as muscle stiffening, though this is seen more at high doses or in elderly patients. Senna (yes, good old senna) is also a motility agent, but it works on the lower gut (colon) which is why it is used for constipation.

    Steroids have been used in the treatment of nausea and vomiting as well; they are potent anti-inflammatories and can also help stimulate appetite. Commonly used steroids are dexamethasone and prednisone. Their side effects can be quite harmful if used for an extended period of time (beyond several weeks) at high doses, such as loss of bone density and muscle weakness. With short term use, the more common side effects are insomnia and changes in mood, fluid retention, thrush (a fungal infection in the back of the mouth and throat), and elevated blood sugars. Steroids come in oral and IV forms.

    Marinol (dronabinol) is another anti-nausea medication that is the medical, manufactured form of marijuana. While it has not proven in studies to be more effective than standard anti-nausea medications, it can be helpful in patients with persistent nausea and no appetite (anorexia). It comes in an oral form. The primary side effects are feeling “loopy” or sedated, particularly in older patients.

    You can also see my previous post on chemotherapy-induced nausea for a few additional medicines.

    There are also non-medication-based strategies to help with nausea and vomiting, which I will review separately.

    This post is not meant to be exhaustive, but to give a better sense of strategy to the treatment of nausea and vomiting. We still don’t fully understand all the different receptors that are involved in this debilitating symptom, but there continue to be new developments in novel anti-nausea medications (such as Emend) as our understanding improves.


    4 Responses to Cancer and Nausea, Part II: Non-CINV Nausea and Treatment Strategies

    • Catharine says:

      Dr. Harman –

      Wow, what a clear and informative post. Many thanks.

      -Catharine

    • mag2554 says:

      Is there anything that we can do with nausa brought on by anxity? My husband get sick just thinking about the upcoming chemo – Alimta every 21 days. He starts throwing up as soon as we get in the car after treatment if that long. It makes the patient really trent toward not receiving chemo. He’s been at it for 19 months with three different regiments and the last ct scan after a 5 month break he really lite up. He’s even throught of Hypnosis. He is not, I repeat not a pill taker and get sick just taking a pill. It makes my job and the job of the health care hard.

    • Dr West
      Dr West says:

      I think acupuncture or hypnosis could potentially be valuable in that situation. I think ativan might be a very effective medication for treating the anxiety and also alleviating a sensation of nausea, but of course that’s only if he’s inclined to take a medication for it.

    • Dr Sanborn says:

      One of the nice things about Ativan is that it can be dissolved under the tongue if swallowing a pill might trigger vomiting. Ativan can be helpful for the “anticipatory nausea” around treatments. Zofran tablets also can be dissolved on the tongue.

      I have some patients who have had a good effect using “sea bands” as a non-medicine approach. They are wristbands that place pressure on wrist “trigger points” that may have antinausea effects. I am not aware of any research about these, but they seem a safe enough consideration to try.

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