Nausea and vomiting used to be among the most debilitating side effects of chemotherapy. The development of new and more effective antiemetic (anti-vomiting) drugs has provided relief and many patients no longer experience nausea or vomiting at all.
Management of nausea may be effective and convenient-there are now many choices.
It’s no surprise that cancer patients name nausea and vomiting among the side effects of chemotherapy that they most fear. And though its impact on patient comfort and quality of life is a significant concern, chemotherapy-induced nausea and vomiting (CINV) can also have a major adverse effect on the course of treatment and subsequent outcomes. Because severe CINV can result in the delay or complete halt of a patient’s chemotherapy regimen, this side effect can drastically interfere with treatment.
- What is nausea and vomiting?
- Why do cancer patients experience nausea and vomiting?
- How can nausea and vomiting be prevented?
- Pill? IV? Patch?
- What can I do to help manage nausea and vomiting?
- What if I have anticipatory nausea and vomiting?
- Complementary & Alternative approaches to control nausea.
- Are some treatments more likely to cause nausea and vomiting?
What is nausea and vomiting?
Nausea is feeling queasy or sick to your stomach, like you’re going to throw up. Vomiting is emptying your stomach by throwing up. Nausea and/or vomiting are frequent side effects of chemotherapy and radiation therapy. Chemotherapy-induced nausea and vomiting can be acute (within the first 24 hours), delayed (vomiting that occurs after 24 hours) and/or anticipatory. Anticipatory vomiting is a learned response, which means it happens in response to a stimulus, chemotherapy. With this type of nausea and vomiting, the symptoms usually occur after initial exposure to chemotherapy drugs and before subsequent treatments.
Why do cancer patients experience nausea and vomiting?
A specific location in the brain controls emesis (vomiting), called the vomiting center. Emesis occurs when the vomiting center receives a signal from the brain, the gastrointestinal tract, the heart and/or the inner ear, which detects motion. Chemotherapy causes the release of a substance called serotonin (5-HT), and of other chemicals in the small intestine, which through a series of signals stimulate the vomiting center in your brain to induce emesis.
How can nausea and vomiting be prevented?
The best way to treat nausea and vomiting is to prevent it from occurring in the first place. Many new and improved medicines for controlling nausea and vomiting, called antiemetics, have been developed over the last several years. These drugs block the signal in the brain that causes nausea and vomiting. As a result of widespread use of antiemetics, nausea and/or vomiting is not as severe and does not occur as frequently as in the past.
The 5HT-3 Inhibitors are the most effective antiemetics and constitute the single greatest advance in the management of nausea and vomiting in patients with cancer. These drugs are designed to block one or more of the signals that cause nausea and vomiting. The most sensitive signal during the first 24 hours after chemotherapy appears to be 5-HT3. Blocking the 5-HT3 signal is one approach to preventing acute emesis, or emesis that is severe, but relatively short-lived. Antiemetics that block 5-HT3, called 5-HT3 inhibitors, are the most effective agents developed to date for preventing emesis.
The NK-1-receptor antagonists reduce the probability of both acute and delayed CINV. Over the five-day study period, 68% of patients treated with Emend, Zofran, and dexamethasone did not vomit, compared to 48% of those treated with Zofran and dexamethasone.(5,6)
- Aprepitant (Emend®): Aprepitant is part of a three-drug therapy that works to prevent delayed nausea and vomiting. Aprepitant is not used to treat nausea and vomiting that you already have; it must be taken before the symptoms occur to be effective. This is because it blocks the NK1 receptor in the brain which helps with nausea and vomiting that persists beyond 2 days after treatment.
- Varubi (rolapitant) added to granisetron and dexamethasone had a reduction of vomiting in the delayed-phase of CINV and a reduction in the use of rescue medication used to reduce delayed-phase CINV.(7)
Dronabinol (Marinol®)—stimulates appetite and controls nausea
Dronabinol is a cannabinoid, which is a pharmaceutical version of tetrahydrocannabinol (THC) and is the active ingredient in both Syndros and Marinol which are approved by the FDA for treatment of nausea and vomiting. Syndros is an oral liquid formulation and is comparable to the pharmaceutical version of Marinol®(dronabinol capsules).(8,9)
Cesamet is an oral agent that interacts with CB1, a cannabinoid receptor found throughout the nervous system. It is involved in regulating nausea and vomiting. Cesamet is a synthetic version of the active agent in marijuana.
Results from clinical trials comparing cesamet to other standard antiemetic agents or placebo (inactive substitute) have demonstrated its effectiveness in reducing nausea and vomiting among patients who do not respond to standard antiemetic therapies.(10)
Other drug therapy approaches: Other drugs commonly used to prevent or treat nausea and vomiting, either alone or in combination with antiemetics, include:
- Corticosteroids (dexamethasone, methylprednisolone, Prednisone®, and others
- Prochlorperazine (Compazine®)
- Benzodiazapines (Valium® and others)—may help control anticipatory nausea
In order to control the full range of chemotherapy-induced nausea and vomiting (acute as well as delayed), more than one antiemetic treatment approach may be used. Antiemetic drugs may be administered intravenously (IV), orally, and/or through a patch placed on the skin. The patch (Sancuso®) is an approach that delivers a steady dose of the drug granisetron over a several-day period. Your doctor will help you decide which approach or which combination of approaches is right for you.
What else can I do to help manage nausea and vomiting
There are several things you can do to prevent nausea and vomiting. First and foremost, make sure you receive and take your antiemetics as your doctor has ordered. Let your doctor or nurse know if your drugstore does not have them, you cannot afford to pay for them, or you are not sure how to take them. Also, call your doctor if you experience any of the following:
- You have vomiting and cannot take your medication
- Your antiemetics help reduce your nausea and vomiting, but not as much as you would like. The dose may have to be changed or the doctor may change you to a different antiemetic.
In addition to taking your medication, the following general suggestions may help you prevent or control nausea and vomiting:
- Try eating foods and drinking beverages that have been easier for you to take or have made you feel better when you had the flu, morning sickness or were nauseated from stress. These might be bland foods, sour candy, pickles, dry crackers, ginger ale, flat soda or others. Eat small, frequent meals (5-6), instead of 3 large meals each day.
- Ginger supplements can reduce nausea and vomiting.
- Do not eat fatty or fried foods, very spicy foods or very sweet foods.
- If possible, have somebody else make the meals when you are nauseated.
- Do not eat your favorite foods when you are nauseated.
- If you have nausea and vomiting only for a few days after chemotherapy, cook and freeze several meals that you can reheat during times when you are nauseated.
- Eat foods that are at room temperature or cold. The smells from hot foods may make your nausea worse.
- Keep your mouth clean; brush at least twice a day.
- Consider shakes or liquid nutritional supplements to help maintain your nutrition.
- Ask your doctor or nurse about using acupressure (BioBands) on your wrists, which may help to decrease your nausea.
- Anticipatory nausea associated with chemotherapy is best controlled with relaxation techniques.
- Ask your doctor or nurse if they can help you learn a relaxation exercise. This might make you feel less anxious and more in control, and decrease your nausea.
What if I have anticipatory nausea and vomiting?
Anticipatory nausea and vomiting is poorly controlled with standard antiemetic treatment. In some clinical studies, drugs that treat anxiety (benzodiazepines) have provided some relief. A number of non-drug approaches, also called cognitive and behavioral intervention, may help. These include:
- Systematic desensitization
- Distraction from the negative experience with guided imagery or relaxation
- Elimination of consistently repeating patterns
- Manipulation of the setting and personnel associated with chemotherapy administration
- Blocking taste sensation with another strong taste (e.g., lemon)
What About Complementary Medicines?
Complementary medicine modalities that are effective at reducing anticipatory nausea and vomiting in adults and children with cancer include acupuncture and mind/body medicine approaches such as guided imagery, hypnosis, and relaxation training.
The National Institutes of Health consensus study recommends acupuncture as an effective modality for chemotherapy-associated nausea and vomiting.(11,12)
Acupuncture May Prevent Some Cases of Chemotherapy-Induced Nausea and Vomiting
Certain types of acupuncture-point stimulation may relieve chemotherapy-induced nausea or vomiting, but few well-designed studies have been conducted. The acupuncture point thought to be associated with relief of nausea is P6, which is located on the wrist. This point can be stimulated through a variety of methods, including manual acupuncture (insertion of needles), electroacupuncture (passing electric current through the inserted needle), noninvasive electrostimulation (application of electric current without a needle), or acupressure (pressure applied by the fingers or an elastic wristband).
In order to summarize what is known about the effects of these methods on relief of CINV, researchers combined data from 11 published clinical trials. These studies involved a total of 1,247 patients and used a variety of methods for acupuncture-point stimulation. For all methods combined, there was some evidence of a reduced risk of acute vomiting. Specific methods performed as follows:
- Electroacupuncture appeared to have the greatest effect on vomiting.
- Acupressure appeared to have the greatest effect on nausea.
- Noninvasive electrostimulation did not appear to provide a benefit.
In one trial of breast cancer patients receiving a particularly nausea-inducing form of chemotherapy, electroacupuncture diminished symptoms of both nausea and vomiting. Compared with patients taking only antiemetic drugs, those who received electroacupuncture at the PC6 point once daily for five days had significantly fewer instances of vomiting. Patients in the acupuncture group had an average (median) of five episodes, compared with 15 in the medication-only group.91)
Notably, the well-respected Cochrane Collaboration published reviews on this topic in 2006 and 2009. After examining all the existing evidence, reviewers concluded that acupuncture can reduce the nausea and vomiting in cancer patients caused by chemotherapy or surgery. The first review, published in 2006, evaluated 11 randomized controlled trials and determined that electroacupuncture helps reduce chemotherapy-induced nausea and vomiting. Further, they found that self-acupressure—in which the patient stimulates certain acupoints on their own by pressing, without needles—can help prevent nausea.(2)
The second Cochrane review, published in 2009, concluded that acupuncture at the PC6 point can effectively reduce nausea and vomiting after surgery. This was based on an examination of 40 prior randomized controlled trials. It was not clear, however, whether acupuncture was more effective than conventional antiemetic drugs alone (no significant difference was found).(3)
Remarkably, needles may not be required to reduce nausea in this way. A recent randomized controlled trial in craniotomy patients found that transcutaneous electrode stimulation—that is, electrical stimulation without actually inserting a needle—at the PC6 point before, during, and after surgery significantly reduced the incidence of nausea and vomiting over the course of 24 hours after the operation. Craniotomy is a procedure in which a section of bone is removed from the skull to expose the brain. Afterward nausea and vomiting are very common, affecting up to 60 percent of patients despite the use of antiemetic medications. Patients who received the acupoint stimulation experienced a 40 percent lower incidence of nausea and a 60 percent decrease in vomiting compared with the placebo group, who received electrical stimulation at a non-acupoint.(4)
Although acupuncture is frequently more effective than usual care, some studies have found that some beneficial effects of properly performed acupuncture are mimicked by sham procedures, in which needles are inserted at non-acupoints (and should theoretically not have any effect). A recent investigation of acupuncture’s effects on radiation-induced nausea, for example, found no significant difference in nausea frequency or intensity between the groups receiving true or sham acupuncture, although both groups experienced less intense nausea than patients receiving usual antiemetic care. As a result, some wonder whether acupuncture’s benefits are at least partly the result of attention, doctor/patient interaction, or a placebo response.(5)
Actually, it hardly matters what exactly produces the benefit—whether it is attention, doctor/patient interaction, a placebo response, the acupuncture alone, a combination of these possibilities, or something else—so long as it works. Further research will help sort this out, but for purposes of the patient it really doesn’t matter. Whatever the specific mechanism by which acupuncture works, it is very safe, is relatively inexpensive, and can provide a significant benefit, particularly if nausea and related symptoms are an issue for you.
Managing Nausea and Vomiting with Mind-Body Therapies
Mind-body therapies, including meditation, hypnosis, and guided imagery, can greatly reduce nausea and vomiting. These methods help you relax or distract you and help put you in control of your body and mind.
Mind-body practices are particularly effective for anticipatory nausea, which is itself an example of the mind affecting the body. Just as vomiting can be a result of stage fright, there is no physical cause for anticipatory nausea. It is the body’s response to the mind’s anticipation of something unpleasant, such as chemotherapy. Using techniques such as self-hypnosis or guided imagery, you can learn to disrupt this process—to break the association and bring about relief.
Self-hypnosis was one of the first mind-body techniques used to control nausea and vomiting. It puts you in a state of deep attention or “restful alertness” and makes you receptive to new ideas. Hypnosis has been shown to effectively treat anticipatory nausea in both adult and pediatric cancer patients. In a study of 54 pediatric patients, children were assigned to receive either hypnosis, distraction/relaxation techniques, or no intervention. Patients in the hypnosis group had a substantial reduction in both anticipatory and post-chemotherapy nausea. In contrast, nausea levels in the children who practiced distraction/relaxation remained unchanged, and symptoms in the no-intervention group consistently worsened over time. In another study, however, adding distraction and relaxation training reduced nausea prior to chemotherapy more effectively than when these techniques were not used. (6)
Training in guided imagery also can be valuable. This technique allows you to mentally remove yourself from your current situation and arrive at a place that is pleasant and relaxing. Without leaving the treatment room, you can imagine what you would be feeling, hearing, and seeing in this other, more restful place. In so doing it is possible to mentally block physical symptoms such as nausea and vomiting. Guided imagery is a relaxation technique that can be worthwhile for many aspects of day-to-day life, and it is not hard to learn.
Trained therapists can teach you self-hypnosis, guided imagery, and other mind-body techniques, and then you can practice them on your own. Some hospitals may have these therapists on staff; otherwise, you can ask for a referral.
Managing Nausea and Vomiting with Massage Therapy
A few studies suggest that massage can help ease nausea in patients undergoing cancer therapy, most likely by providing a source of relaxation and distraction. In one small randomized controlled trial, 39 breast cancer patients currently undergoing chemotherapy were assigned to a massage group (five 20-minute visits with massage) or to a control group (five 20-minute visits without massage). The massage treatments significantly reduced nausea levels. In another randomized study, patients’ nausea scores decreased by about one-third after a single massage, with little or no change in the control subjects who did not receive the massage.
Massage therapy is probably most worthwhile if you have low-grade nausea, but it may not be the best or most helpful option if nausea is more severe. Still, massage is extremely relaxing and can help treat a wide range of other symptoms, from pain to stress and anxiety.
Managing Nausea and Vomiting with Music Therapy
Music therapy is conducted by specially trained professionals who use music to help alleviate symptoms. They bring portable instruments to the bedside and may perform music for or with patients. When used with typical antiemetic medications, music therapy may help further reduce nausea and vomiting from chemotherapy. At the very least, it can relieve stress, reduce blood pressure, lower heart rate, and promote general well-being. Even something as simple as music can be very powerful.
Are some treatments more likely to cause nausea and vomiting
Certain chemotherapy drugs are more likely to cause nausea and vomiting than others. Chemotherapy drugs are classified as mildly, moderately or highly likely to cause nausea and vomiting.
The table at the end of this article lists the degree of nausea and vomiting patients would experience without effective antiemetic drugs. High-dose chemotherapy is almost always associated with a high probability of nausea and vomiting and appropriate antiemetics are indicated. Most chemotherapy treatment regimens use more than one drug. The degree of nausea and vomiting produced by a combination chemotherapy treatment regimen is typically greater than the amount of nausea expected from the single drug producing the greatest amount of nausea and vomiting.
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- Eisenberg P, Figueroa-Vadillo J, Zamora R, et al. Improved prevention of moderately emetogenic chemotherapy-induced nausea and vomiting with palonosetron, a pharmacologically novel 5-HT3 receptor antagonist: results of a phase III, single-dose trial versus dolasetron. Cancer. 2003;98:2473-2482.
- Gralla R, Lichinitser M, Van der Vegt, S, et al. Palonosetron improves prevention of chemotherapy-induced nausea and vomiting following moderately emetogenic chemotherapy: results of a double-blind randomized phase III trial comparing single doses of palonosetron with ondansetron. Ann Oncol. 2003;14:1570-1577.
- Hesketh PJ, Grunberg SM, Gralla RJ, Warr DG, et al. The oral neurokinin-1 antagonist aprepitant for the prevention of chemotherapy-induced nausea and vomiting: a multinational, randomized, double-blind, placebo-controlled trial in patients receiving high-dose cisplatin–the Aprepitant Protocol 052 Study Group. Journal of Clinical Oncology 2003 Nov 15;21(22):4112-9.
- de Wit R, Herrstedt J, Rapoport B, Carides AD, et al. Addition of the oral NK1 antagonist aprepitant to standard antiemetics provides protection against nausea and vomiting during multiple cycles of cisplatin-based chemotherapy. Journal of Clinical Oncology. 2003 Nov 15;21(22):4105-11.
- Gralla RJ, de Wit R, Herrstedt J et al. Antiemetic efficacy of the neurokinin-I antagonist, aprepitant, plus a 5HT3 antagonist and a corticosteroid in patients receiving anthracyclines or cyclophosphamide in addition to high-dose cisplatin. Cancer. 2005;104:864-8.
- de Wit R, Herrstedt J, Rapoport B, et al. Addition of the oral NK1 antagonist aprepitant to standard antiemetics provides protection against nausea and vomiting during multiple cycles of cisplatin-based chemotherapy. Journal of Clinical Oncology. Early release. Published online ahead of print October 14, 2003. Available at: jco.org/cgi/content/abstract/JCO.2003.10.128v1?ck=nck. Accessed October 28, 2003.
- U.S FDA. FDA approves new drug treatment for nausea and vomiting from chemotherapy. Available at: fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm460838.htm. Accessed September 2, 2015.
- Insys Pharmaceuticals. Insys Pharmaceuticals Announces FDA Approval of Syndros. Available at: . Accessed June 6, 2016.
- United States Food and Drug Administration. Drug Approvals and Product Devices. Available at: . Accessed June 6, 2016.
- Valeant Pharmaceuticals International. Valeant Pharmaceuticals Receives FDA Marketing Approval for Cannabinoid Cesamet(TM) (CII). Available at: valeant.com/mediaCenter/newsArticle/newsArticle.jspf;jsessionid=%20CF529997CDFD34398E88F25855823E24.frank?objectId=4158. Accessed May 2006.
- Mansky PJ, Wallerstedt DB. Complementary medicine in palliative care and cancer symptom management. Cancer Journal. 2006;12(5):425-31.
- Ezzo J, Vickers A, Richardson MA et al. Acupuncture-point stimulation for chemotherapy-induced nausea and vomiting. Journal of Clinical Oncology . 2005;23:7188-7198.
- Choo SP, Kong KH, Lim WT, Gao F, Chua K, Leong SS. Electroacupuncture for refractory acute emesis caused by chemotherapy. Journal of Alternative and Complementary Medicine. 2006;12(10):963-9. doi: 10.1089/acm.2006.12.963.
- PubMed Health. Acupuncture for nausea and vomiting which has been induced by having chemotherapy treatment. Cochrane Database of Systematic Reviews: Plain Language Summaries. First published April 19, 2006.
- PubMed Health. P6 acupoint stimulation prevents postoperative nausea and vomiting with few side effects. Cochrane Database of Systematic Reviews: Plain Language Summaries. First published April 15, 2009.
- Ni JW, Meng YN, Xiang HF, Ren QS, Wang JL. Effect of transcutaneous acupoint electrical stimulation on lipid peroxidation and cognitive function in patients experiencing craniotomy. Zhen Ci Yan Jiu. 2009;34(1):52-56 (abstract in English; article in Chinese).
- Azad A, John T. Do randomized acupuncture studies in patients with cancer need a sham acupuncture control arm? Correspondence. Journal of Clinical Oncology. 2013;31(16):2057-58. doi: 10.1200/JCO.2012.47.8750.
- Richardson J, Smith JE, McCall G, Pilkington K. Hypnosis for procedure-related pain and distress in pediatric cancer patients: A systematic review of effectiveness and methodology related to hypnosis interventions. Journal of Pain and Symptom Management. 2006;31(1):70-84. doi: 10.1016/j.jpainsymman.2005.06.010.