Medically reviewed by C.H. Weaver M.D. Medical Editor 2/2019
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?
- 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.
- Palonosetron (Aloxi®)
- Dolasetron (Anzemet®)
- Granisetron (Kytril®, Sancuso®)
- Ondansetron (Zofran®)
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)
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.
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)
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.
Although this review describes possible benefits of acupuncture-point stimulation for CINV, it’s still unclear whether these methods will improve outcomes among patients who are treated with current antiemetic medications. There’s also little information available about the use of acupuncture-point stimulation for delayed CINV. Fortunately, an increasing number of well-designed studies are focusing on complementary and alternative therapies. More thorough information about the role of acupuncture in the prevention of CINV and other symptoms should be forthcoming.(12)
- 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: http://www.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: http://www.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: http://www.valeant.com/mediaCenter/newsArticle/newsArticle.jspf;jsessionid =CF529997CDFD34398E88F25855823E24.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.