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Ganguly S, Sasi A, Nagaraju SKK, Bakhshi S. Anti-Emetics in Children Receiving Chemotherapy for Solid Tumors and Leukemia: Pharmacology and Optimization of Therapy for Nausea and Vomiting. Pharmaceuticals (Basel) 2024; 17:616. [PMID: 38794186 PMCID: PMC11124061 DOI: 10.3390/ph17050616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 04/17/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
The management of chemotherapy-induced nausea and vomiting (CINV) in children remains challenging due to differences in the chemotherapy regimens, their relative emetogenicity compared to that in adults and differences in drug metabolism and the available formulations. The common four classes of anti-emetics used for the treatment and prophylaxis of CINV in children include dexamethasone, neurokinin-1 receptor antagonists, 5-hydroxytryptamine-3 receptor antagonists (5HT3RAs), and olanzapine. The appropriate dose of dexamethasone for CINV prophylaxis in children is unknown, with a significant variability in dosage ranging between 6 and 32 mg/m2/day. The dose of dexamethasone is decreased by 30% when this drug is combined with (fos)aprepitant in children, in contrast to a decrease of 50% required in adults. The use of aprepitant in younger children (<12 years) is often hampered by the non-availability of oral suspension formulations in many countries; alternatively, 80 mg capsules are administered for 1-3 days in certain institutes to children weighing between 15 and 40 kg. Among the different 5HT3RAs, palonosetron is comparatively metabolized faster in children than in adults, requiring a higher dosage for similar efficacy to that achieved in adults. Olanzapine is a newer agent, used in doses between 0.1 and 0.14 mg/kg/day in children, with good anti-emetic efficacy, but has sedation and hyperglycemia as concerning adverse effects. Drug interactions between anti-emetics and between anti-emetics and chemotherapy/supportive agents (azole antifungals, cyclosporine, arsenic trioxide), especially QTc prolongation, should be considered during prescription.
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Affiliation(s)
| | | | | | - Sameer Bakhshi
- Department of Medical Oncology, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi 110029, India; (S.G.); (A.S.); (S.K.K.N.)
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2
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Meena JP, Gupta AK, Jat KR, Anandani G, Sasidharan A, Tanwar P. Efficacy and Safety of Olanzapine for the Prevention of Chemotherapy-induced Nausea and Vomiting in Children: A Systematic Review and Meta-analysis of Randomized Controlled Trials. J Pediatr Hematol Oncol 2023; 45:361-369. [PMID: 37539996 DOI: 10.1097/mph.0000000000002737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 06/25/2023] [Indexed: 08/05/2023]
Abstract
Chemotherapy-induced nausea and vomiting (CINV) remain the most distressing event in patients receiving highly emetogenic chemotherapy (HEC) and moderately emetogenic chemotherapy (MEC). This meta-analysis was conducted to evaluate the efficacy and safety of olanzapine containing regimen in preventing CINV in children on HEC and MEC. We searched PubMed, Embase, and Cochrane central register of controlled trials electronic databases to identify randomized clinical trials that compared 2 groups who either got olanzapine (olanzapine group) or placebo/no olanzapine (control group) for the prevention of CINV in children. The primary outcome was to determine the efficacy of olanzapine (complete response). The secondary outcomes were nausea control, the need for rescue medications, and adverse events of olanzapine. Three randomized clinical trials (n=394 patients) were included in this meta-analysis (olanzapine group, n=194, and placebo/control group, n=200). The pooled analysis of this meta-analysis found that olanzapine had a higher complete response in all phases of emesis in the HEC group and only in the acute phase in HEC/MEC groups compared with the control group. Olanzapine had higher nausea control in all phases of HEC but no nausea control in HEC/MEC. Olanzapine also reduced the need for rescue medications. A significant number of patients in the olanzapine group experienced somnolence (grades 1 and 2), but none of the participants discontinued the study due to side effects. In conclusion, this meta-analysis showed that olanzapine significantly prevented CINV in HEC. There was also a lesser need for rescue medications in the olanzapine group. Somnolence was higher in the olanzapine group, but it was clinically insignificant.
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Affiliation(s)
| | | | - Kana Ram Jat
- Laboratory Oncology Unit, Dr B. R. A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Garima Anandani
- Department of Pathology, All India Institute of Medical Sciences
| | - Anju Sasidharan
- Department of Pathology, All India Institute of Medical Sciences
| | - Pranay Tanwar
- Laboratory Oncology Unit, Dr B. R. A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
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3
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Esbenshade AJ, Sung L, Brackett J, Dupuis LL, Fisher BT, Grimes A, Miller TP, Ullrich NJ, Dvorak CC. Children's Oncology Group's 2023 blueprint for research: Cancer control and supportive care. Pediatr Blood Cancer 2023; 70 Suppl 6:e30568. [PMID: 37430431 PMCID: PMC10528808 DOI: 10.1002/pbc.30568] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 07/03/2023] [Indexed: 07/12/2023]
Abstract
The objective of the Cancer Control and Supportive Care (CCL) Committee in the Children's Oncology Group (COG) is to reduce the overall morbidity and mortality of therapy-related toxicities in children, adolescents, and young adults with cancer. We have targeted five major domains that cause clinically important toxicity: (i) infections and inflammation; (ii) malnutrition and metabolic dysfunction; (iii) chemotherapy-induced nausea and vomiting; (iv) neuro- and oto-toxicty; and (v) patient-reported outcomes and health-related quality of life. Subcommittees for each domain prioritize randomized controlled trials and biology aims to determine which strategies best mitigate the toxicities. The findings of these trials are impactful, informing clinical practice guidelines (CPGs) and directly leading to changes in the standard of care for oncology practice. With the development of new therapies, there will be new toxicities, and the COG CCL Committee is dedicated to developing interventions to minimize acute and delayed toxicities, lessen morbidity and mortality, and improve quality of life in pediatric and young adult patients with cancer.
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Affiliation(s)
- Adam J Esbenshade
- Department of Pediatrics Vanderbilt University Medical Center and the Vanderbilt Ingram Cancer, Nashville, Tennessee, USA
| | - Lillian Sung
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Julienne Brackett
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, Texas Children's Cancer and Hematology Center, Baylor College of Medicine, Houston, Texas, USA
| | - L Lee Dupuis
- Department of Pharmacy and Research Institute, The Hospital for Sick Children and Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Brian T Fisher
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Allison Grimes
- Department of Pediatrics, University of Texas San Antonio, San Antonio, Texas, USA
| | - Tamara P Miller
- Department of Pediatrics, Emory University School of Medicine/Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Nicole J Ullrich
- Department of Neurology, Boston Children's Hospital, Pediatric Brain Tumor Program, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Christopher C Dvorak
- Division of Pediatric Allergy, Immunology & Bone Marrow Transplantation, University of California San Francisco, San Francisco, California, USA
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4
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Barušić AK. The emerging role of olanzapine in paediatric CINV control: A review. Medicine (Baltimore) 2022; 101:e32116. [PMID: 36550859 PMCID: PMC9771166 DOI: 10.1097/md.0000000000032116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 11/09/2022] [Indexed: 12/24/2022] Open
Abstract
Chemotherapy-induced nausea and vomiting (CINV) is a serious side effect of chemotherapy that negatively impacts the quality of life of oncological patients and is associated with the emetogenic risk specific to administered chemotherapy. Current practice guidelines on the use of antiemetics in CINV include the option of adding olanzapine to antiemetic regimens in the management of adult CINV. The use of olanzapine in pediatric CINV has been restricted to children with poor CINV control. Research on the use of olanzapine in pediatric CINV has been limited. The aim of this review was to evaluate current evidence on the effective and safe antiemetic use of olanzapine in pediatric CINV of any type following chemotherapy of any emetogenicity. Ovid MEDLINE, Embase, CENTRAL databases were searched for any literature on the use of olanzapine in pediatric CINV published from 2015 to 2022. Studies that reported on the olanzapine-containing antiemetic regimen in peadiatric CINV control specifically were included. Search restrictions were placed on research published in English. The search generated 43 records that were assessed for eligibility. Out of 10 identified eligible studies a third were RCT. Findings of this review suggest that adding olanzapine to antiemetic regimen in pediatric CINV control is a worthwhile consideration. Further research is needed to establish the efficacy and safety of antiemetic olanzapine use in pediatric CINV.
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Affiliation(s)
- Anabella Karla Barušić
- The datasets generated during and/or analyzed during the current study are publicly available. The Psychoncology Team, Department of Child & Adolescent Psychological Medicine, University Collage Hospital, London, UK
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5
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Moothedath AW, Meena JP, Gupta AK, Velpandian T, Pandey RM, Seth R. Efficacy and Safety of Olanzapine in Children Receiving Highly Emetogenic Chemotherapy: A Randomized, Double-blind Placebo-controlled Phase 3 Trial. J Pediatr Hematol Oncol 2022; 44:446-453. [PMID: 35091522 DOI: 10.1097/mph.0000000000002408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 12/26/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND In this trial, we evaluated the safety and efficacy of olanzapine in children receiving highly emetogenic chemotherapy. MATERIALS AND METHODS In this study, patients aged 3 to 18 years were randomly assigned to either the olanzapine group or the placebo group. All patients received intravenous ondansetron and dexamethasone 30 minutes before highly emetogenic chemotherapy, followed by oral ondansetron for 48 hours. Participants in the olanzapine group received olanzapine once daily on days 1 and 2, while those in the control group received a placebo in the same dosage and schedule. The primary objective was: (a) to compare the complete control rates of vomiting in the delayed phase and (b) to compare the complete control rates of vomiting in acute and overall phases. The secondary objective was to evaluate the safety of olanzapine and the need for rescue medications. RESULTS A total of 128 patients were randomly assigned either to the olanzapine group (n=63) or the control group (n=65). Complete control of vomiting between olanzapine and placebo group was 73% versus 48% ( P =0.005) in the delayed phase, 60% versus 54% ( P =0.46) in the acute phase, and 48% versus 34% ( P =0.117) in the overall phase, respectively. Grades 1 and 2 sedation was greater in the olanzapine group (46% vs. 14%; P <0.001). A significantly higher proportion of patients in the placebo group required rescue medications for vomiting compared with in the olanzapine group ( P =0.025). CONCLUSIONS Olanzapine significantly improved complete control of vomiting in the delayed phase. A considerably lesser proportion of patients in the olanzapine group needed rescue medications.
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Affiliation(s)
| | | | - Aditya K Gupta
- Division of Pediatric Oncology, Department of Pediatrics
| | | | - Ravindra M Pandey
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Rachna Seth
- Division of Pediatric Oncology, Department of Pediatrics
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Moshayedi M, Salehifar E, Karami H, Hendouei N, Mousazadeh M, Alizadeh Haji S. Efficacy and Safety of Adding Olanzapine to the Standard Preventive Regimen for Chemotherapy-induced Nausea and Vomiting in Children: A Randomized Double-blind Controlled Trial. IRANIAN JOURNAL OF PHARMACEUTICAL RESEARCH : IJPR 2021; 20:318-326. [PMID: 34400961 PMCID: PMC8170772 DOI: 10.22037/ijpr.2019.112514.13803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This study aimed to assess the additive value of olanzapine to a combination of ondansetron and dexamethasone to prevent chemotherapy-induced nausea and vomiting (CINV) in pediatric patients. A total of 40 patients between 4 to 18 years of age were enrolled in this randomized clinical trial. Both groups received a combination of ondansetron and dexamethasone, and 0.14 mg/kg olanzapine or matched placebo were administered for olanzapine and control groups, respectively. The primary end points were complete response and lack of nausea as far as three days after chemotherapy evaluated by the Common Terminology Criteria for Adverse Effects (CTCAE) v5.0 and the Multinational Association of Supportive Care in Cancer (MASCC) Anti-emesis Tool (MAT). Side effects of olanzapine were also analyzed. In patients receiving the standard regimen of ondansetron and dexamethasone, nausea was observed in 10.5% and 21% of patients according to MAT and CTCAE scales, respectively. In the olanzapine group, 37.5% (MAT scale) and 31.3% (CTCAE scale) of patients developed nausea. Complete response was observed in 84% (MAT scale) and 94.7% (CTCAE scale) of patients in the placebo group receiving ondansetron and dexamethasone. In comparison, it was observed in 87.5% (MAT scale) and 81.25% (CTCAE scale) for patients allocated to the olanzapine group. Neither acute nor delayed CINV was statistically different between placebo and olanzapine groups. The frequency of adverse effects was higher in the olanzapine group. Adding olanzapine to the standard regimen of CINV prophylaxis was only unhelpful in pediatric patients receiving moderately emetogenic chemotherapy but also associated with a higher rate of minor side effects.
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Affiliation(s)
- Mona Moshayedi
- Student Research Committee, Pharmaceutical Sciences Research Center, Hemoglobinopathy Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Ebrahim Salehifar
- Pharmaceutical Sciences Research Center, Hemoglobinopathy Institute, Department of Clinical Pharmacy, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
| | - Hossein Karami
- Thalassemia Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Narjes Hendouei
- Psychiatry and Behavioral Sciences Research Center, Addiction Institute, Department of Clinical Pharmacy, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mahmoud Mousazadeh
- Health Sciences Research Center, Addiction Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Somaye Alizadeh Haji
- Thalassemia Research Center, Mazandaran University of Medical Sciences, Sari, Iran
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7
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Olanzapine for the Treatment of Breakthrough Vomiting in Children Receiving Moderate and High Emetogenic Chemotherapy. Indian Pediatr 2020. [DOI: 10.1007/s13312-020-2038-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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8
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Naik RD, V S, Singh V, Pillai AS, Dhawan D, Bakhshi S. Olanzapine for Prevention of Vomiting in Children and Adolescents Receiving Highly Emetogenic Chemotherapy: Investigator-Initiated, Randomized, Open-Label Trial. J Clin Oncol 2020; 38:3785-3793. [PMID: 32931400 DOI: 10.1200/jco.20.00871] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Chemotherapy-induced nausea and vomiting (CINV) is a significant toxicity of chemotherapy. Olanzapine is recommended in adult patients for the prevention of CINV but has not been prospectively investigated in children. METHODS This investigator-initiated, randomized, open-label trial evaluated olanzapine in children (ages 5-18 years) scheduled to receive the first cycle of highly emetogenic chemotherapy (HEC). All participants received aprepitant, ondansetron, and dexamethasone during and 2 days after chemotherapy. Participants in the study group additionally received oral olanzapine 0.14 mg/kg/day (rounded to the nearest 2.5 mg; maximum, 10 mg) during the chemotherapy block and 3 days postchemotherapy. The primary objective was to compare complete response (CR) rates (no vomiting and no rescue medication) between the groups in the acute, delayed, and overall periods. Nausea comparison and safety evaluation were secondary and additional objectives, respectively. The collection of outcomes and adverse events was performed daily until the completion of the overall period. RESULTS A total of 240 patients underwent randomization. We performed a modified intention-to-treat analysis on 231 patients (116 in the control group and 115 in the study group). A higher proportion of patients in the olanzapine group achieved CR in the acute period (78% v 59%; P = .001), delayed period (74% v 47%; P < .001) and overall period (64% v 38%; P < .001) than in the control group. The proportion of patients with no nausea was significantly higher in the olanzapine group in the acute period (74% v 52%; P < .001), delayed period (74% v 47%; P < .001), and overall period (64% v 37%; P < .001). Grade 1/2 somnolence was greater in the olanzapine group (35% v 11%; P < .001). There was no grade 3/4 somnolence reported. CONCLUSION Olanzapine significantly improved CR rates for vomiting in children receiving the first cycle of HEC.
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Affiliation(s)
- Ramavath D Naik
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Sreenivas V
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Vishwajeet Singh
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Ashwati S Pillai
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Deepa Dhawan
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Sameer Bakhshi
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
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Peled O, Lavan O, Stein J, Vinograd I, Yahel A, Valevski A, Weizman A, Kimmel-Tamir E, Apter A, Fennig S, Yaniv I, Bernfeld Y, Benaroya-Milshtein N. Psychopharmacology in the Pediatric Oncology and Bone Marrow Transplant Units: Antipsychotic Medications Palliate Symptoms in Children with Cancer. J Child Adolesc Psychopharmacol 2020; 30:486-494. [PMID: 32845729 DOI: 10.1089/cap.2019.0164] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Objectives: The present study characterized the psychiatric diagnoses and symptoms that led to the administration of antipsychotic medications in children and adolescents with cancer, and to evaluate the benefits and tolerability of these drugs in a large hospital-based pediatric hematology-oncology practice. Methods: Efficacy and adverse effects of two second-generation antipsychotics were retrospectively analyzed in 43 patients 2.9-19.6 (mean 12.1) years of age. The Clinical Global Impression-Severity (CGI-S) Scale and Improvement (CGI-I) Scale were used to evaluate psychiatric symptom severity before and following treatment, while the incidence of side effects and drug-drug interactions were collected from medical records. Results: Olanzapine was administered to 58% of patients and risperidone to 42%; the choice of drug was at the discretion of the treating psychiatrist. The common psychiatric diagnoses among these patients included adjustment disorder (37%) and medication-induced psychiatric disorders (23%). The most common psychiatric-medical symptoms included irritability/agitation (79%) and depressed mood (74%). CGI-S improved significantly (p < 0.001) between assessments, with no statistically significant difference between olanzapine- and risperidone-treated patients. CGI-I scores at reassessment indicated superiority of olanzapine as compared with risperidone. Adverse effects of treatment were mild. Conclusions: Olanzapine and risperidone can be well tolerated and ameliorate severe psychiatric-medical symptoms in children and adolescents with cancer. The potential palliative benefits of these second-generation antipsychotics (e.g., rapid onset of action, antiemesis, sedation, and appetite stimulation) increase the utility of their use in children treated in oncology and bone marrow transplant units.
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Affiliation(s)
- Orit Peled
- Department of Pharmacy, Schneider Children's Medical Center of Israel, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Lavan
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Psychological Medicine, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Jerry Stein
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Hematology-Oncology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Inbal Vinograd
- Department of Pharmacy, Schneider Children's Medical Center of Israel, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Yahel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Hematology-Oncology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Avi Valevski
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Research Unit, Geha Mental Health Center, and Laboratory of Biological Psychiatry, Felsenstein Medical Research Center, Petah Tikva, Israel
| | - Abraham Weizman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Research Unit, Geha Mental Health Center, and Laboratory of Biological Psychiatry, Felsenstein Medical Research Center, Petah Tikva, Israel
| | - Ella Kimmel-Tamir
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Psychological Medicine, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Alan Apter
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Psychological Medicine, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Silvana Fennig
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Psychological Medicine, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Isaac Yaniv
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Hematology-Oncology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Yael Bernfeld
- Department of Pharmacy, Schneider Children's Medical Center of Israel, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noa Benaroya-Milshtein
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Psychological Medicine, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
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10
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Lee SR, Kim SM, Oh MY, Lee JM. Efficacy of Olanzapine for High and Moderate Emetogenic Chemotherapy in Children. CHILDREN-BASEL 2020; 7:children7090140. [PMID: 32948015 PMCID: PMC7552625 DOI: 10.3390/children7090140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/11/2020] [Accepted: 09/15/2020] [Indexed: 11/16/2022]
Abstract
This study was conducted to investigate the safety and efficacy of olanzapine for high and moderate emetogenic chemotherapy in children and young adults. We retrospectively reviewed the records of pediatric patients (n = 13) with cancer who had been administered olanzapine as an anti-emetic drug (AED) during a high and moderate emetogenic chemotherapy block from January 2018 to March 2020. Patients were administered other prophylactic AEDs according to practice guidelines. The mean age of the patients was 14.1 ± 5.5 years. The total number of chemotherapy cycles was 41. Twenty-one (51.2%) chemotherapy blocks were high emetogenic chemotherapy and 20 (48.8%) blocks were moderate emetogenic chemotherapy. Olanzapine was used for prophylaxis in 20 (48.8%) blocks of chemotherapy and rescue in 21 (51.2%). Of the 41 cycles, a complete response to olanzapine was achieved in 31 (75.6%), partial response in 6 (14.6%), and no response in 4 (9.8%). The mean dose was 0.07 ± 0.04 mg/kg/dose and 2.50 ± 1.37 mg/m2/dose. Adverse effects included somnolence, hyperglycemia, fatigue, and disturbed sleep. Our findings indicate that olanzapine was effective and safe for treating chemotherapy-induced nausea and vomiting in children. A prospective controlled study is needed to confirm these findings.
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Affiliation(s)
- So Rae Lee
- Department of Medicine, College of Medicine, Yeungnam University, Daegu 42415, Korea; (S.R.L.); (S.M.K.); (M.Y.O.)
| | - Su Min Kim
- Department of Medicine, College of Medicine, Yeungnam University, Daegu 42415, Korea; (S.R.L.); (S.M.K.); (M.Y.O.)
| | - Min Young Oh
- Department of Medicine, College of Medicine, Yeungnam University, Daegu 42415, Korea; (S.R.L.); (S.M.K.); (M.Y.O.)
| | - Jae Min Lee
- Department of Pediatrics, College of Medicine, Yeungnam University, Daegu 42415, Korea
- Correspondence: ; Tel.: +82-53-620-3536
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11
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Radhakrishnan V, Pai V, Rajaraman S, Mehra N, Ganesan T, Dhanushkodi M, Perumal Kalaiyarasi J, Rajan AK, Selvarajan G, Ranganathan R, Karunakaran P, Sagar TG. Olanzapine versus metoclopramide for the treatment of breakthrough chemotherapy-induced vomiting in children: An open-label, randomized phase 3 trial. Pediatr Blood Cancer 2020; 67:e28532. [PMID: 32568452 DOI: 10.1002/pbc.28532] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 06/07/2020] [Accepted: 06/08/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Breakthrough chemotherapy-induced vomiting (CIV) is defined as CIV occurring after adequate antiemetic prophylaxis. Olanzapine and metoclopramide are two drugs recommended for the treatment of breakthrough CIV in children, without adequate evidence. We conducted an open-label, single-center, phase 3 randomized controlled trial comparing the safety and efficacy of olanzapine and metoclopramide for treating breakthrough CIV. PROCEDURE Children aged 5-18 years who developed breakthrough CIV after receiving highly emetogenic chemotherapy or moderately emetogenic chemotherapy were randomly assigned to the metoclopramide or olanzapine arm. The primary objective of the study was to compare the complete response (CR) rates between patients receiving olanzapine or metoclopramide for treating breakthrough CIV during 72 hours after the administration of the study drug. Secondary objectives were to compare CR rates for nausea and toxicities between the two arms. RESULTS Eighty patients were analyzed (39 in the olanzapine arm and 41 in the metoclopramide arm). CR rates were significantly higher in the olanzapine arm compared with the metoclopramide arm for vomiting (72% vs 39%, P = 0.003) and nausea (59% vs 34%, P = 0.026). Seven patients in the metoclopramide arm crossed over to the olanzapine arm and none crossed over in the olanzapine arm (P < 0.001). The mean nausea score in the olanzapine arm was significantly lower than the metoclopramide arm after the initiation of the rescue antiemetic (P = 0.01). Hyperglycemia and drowsiness were more commonly seen in the olanzapine arm. CONCLUSION Olanzapine is superior to metoclopramide for the treatment of breakthrough CIV in children. Drowsiness and hyperglycemia need to be monitored closely in children receiving olanzapine for breakthrough CIV.
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Affiliation(s)
- Venkatraman Radhakrishnan
- Department of Medical Oncology (Pediatric Oncology Division) and Biostatistics, Cancer Institute (WIA), Adyar, Chennai, Tamilnadu, India
| | - Vishwajeeth Pai
- Department of Medical Oncology (Pediatric Oncology Division) and Biostatistics, Cancer Institute (WIA), Adyar, Chennai, Tamilnadu, India
| | - Swaminathan Rajaraman
- Department of Medical Oncology (Pediatric Oncology Division) and Biostatistics, Cancer Institute (WIA), Adyar, Chennai, Tamilnadu, India
| | - Nikita Mehra
- Department of Medical Oncology (Pediatric Oncology Division) and Biostatistics, Cancer Institute (WIA), Adyar, Chennai, Tamilnadu, India
| | - Trivadi Ganesan
- Department of Medical Oncology (Pediatric Oncology Division) and Biostatistics, Cancer Institute (WIA), Adyar, Chennai, Tamilnadu, India
| | - Manikandan Dhanushkodi
- Department of Medical Oncology (Pediatric Oncology Division) and Biostatistics, Cancer Institute (WIA), Adyar, Chennai, Tamilnadu, India
| | - Jayachandran Perumal Kalaiyarasi
- Department of Medical Oncology (Pediatric Oncology Division) and Biostatistics, Cancer Institute (WIA), Adyar, Chennai, Tamilnadu, India
| | - Arun Kumar Rajan
- Department of Medical Oncology (Pediatric Oncology Division) and Biostatistics, Cancer Institute (WIA), Adyar, Chennai, Tamilnadu, India
| | - Gangothri Selvarajan
- Department of Medical Oncology (Pediatric Oncology Division) and Biostatistics, Cancer Institute (WIA), Adyar, Chennai, Tamilnadu, India
| | - Rama Ranganathan
- Department of Medical Oncology (Pediatric Oncology Division) and Biostatistics, Cancer Institute (WIA), Adyar, Chennai, Tamilnadu, India
| | - Parathan Karunakaran
- Department of Medical Oncology (Pediatric Oncology Division) and Biostatistics, Cancer Institute (WIA), Adyar, Chennai, Tamilnadu, India
| | - Tenali G Sagar
- Department of Medical Oncology (Pediatric Oncology Division) and Biostatistics, Cancer Institute (WIA), Adyar, Chennai, Tamilnadu, India
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Ames WA, Machovec K. An update on the management of PONV in a pediatric patient. Best Pract Res Clin Anaesthesiol 2020; 34:749-758. [PMID: 33288124 DOI: 10.1016/j.bpa.2020.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/22/2020] [Accepted: 05/29/2020] [Indexed: 11/27/2022]
Abstract
Postoperative nausea and vomiting (PONV) is a major cause of patient dissatisfaction following anesthesia. The difficulty in diagnosing nausea in much of the pediatric population has led to an emphasis on anti-emetic prophylaxis for all. Assessment scores and prognostic tools enable the anesthesiologist to identify patients who are at a greater risk and appropriately apply more aggressive prophylactic, multi-drug strategies. New antiemetics emerging from other medical disciplines, particularly oncology, may have potential use in prophylaxis and treatment of nausea and vomiting in the pediatric surgical population. New agents, many of which have a long duration of action, will augment the anesthesiologist's ability to adequately prevent PONV, and to treat persistent nausea and vomiting that extend beyond the immediate post-operative period.
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Affiliation(s)
- Warwick Aubrey Ames
- Department of Anesthesiology, Duke University Medical Center, 2301 Erwin Rd, Durham, NC, 27710, USA.
| | - Kelly Machovec
- Department of Anesthesiology, Duke University Medical Center, 2301 Erwin Rd, Durham, NC, 27710, USA.
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13
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[Prevention and treatment of antineoplastic drug-induced nausea and vomiting in pediatric onco-hematology: An update]. Bull Cancer 2020; 107:800-812. [PMID: 32418660 DOI: 10.1016/j.bulcan.2020.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 03/25/2020] [Accepted: 03/29/2020] [Indexed: 11/21/2022]
Abstract
Antineoplastic drug induced nausea and vomiting are common adverse events in cancer care of paediatric patients ; therefore, prevention and management of these adverse events is a major concern for healthcare professionals. There are common features between paediatric and adult patients in terms of the emetogenic level depending on antineoplastic agents or about available medicines. However, there are also specificities for paediatric population including individual risk factors of emesis or nausea assessment for example. Knowledge relative to available medicines is also limited in the paediatric population, especially for recent medicines. This review aims to provide a comprehensive overview about antiemetics in paediatric oncology to clinicians and other healthcare professionals involved in paediatric cancer care. First of all, we describe physiopathological paediatric specificity, risk factors and clinical assessment of antineoplastic drug induced nausea and vomiting. Secondly, we focus on available medicines and also address the issue of complementary and alternative medicines.
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The Use, Safety, and Efficacy of Olanzapine in a Level I Pediatric Trauma Center Emergency Department Over a 10-Year Period. Pediatr Emerg Care 2020; 36:70-76. [PMID: 28697164 DOI: 10.1097/pec.0000000000001231] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Olanzapine is a second-generation antipsychotic increasingly used in emergency medicine for many indications. Literature on its use in children is sparse. Our objectives were to describe the use, safety, and efficacy of olanzapine in pediatric emergency patients. METHODS A structured chart review was performed of patients 18 years old or younger receiving olanzapine from 2007 to 2016 in the emergency department of a pediatric level I trauma center. RESULTS A total of 285 children received olanzapine. Mean age was 16.4 years (range, 9-18 years); 121 were male (42.8%). Primary indications for olanzapine included agitation (n = 166, 58.3%), headache (n = 58, 20.4%), nausea/vomiting/abdominal pain (n = 37, 12.5%), unspecified pain (n = 20, 7%), and other (n = 4, 1.4%). Route of olanzapine administration was intramuscular (n = 160, 56%; median dose, 10 mg; range, 2.5-20), intravenous (n = 101, 36%; median dose, 5 mg; range, 1.25-5), and oral (n = 24, 8%; median dose, 10 mg; range, 5-10). For agitated patients, 28 (17%) received another sedative within 1 hour. For headache patients, 5 (8.6%) received another analgesic. For gastrointestinal complaints, 5 patients (13.5%) received another analgesic/antiemetic. Adverse respiratory events were hypoxia (pulse oximetry reading, in percentage, <92%; n = 7, 2.4%), supplemental oxygen placement (n = 9, 3.2%), and intubation (n = 2, 0.7%). No patient died or had a dysrhythmia. One patient experienced dystonia. CONCLUSIONS Olanzapine seems safe when used for a variety of conditions in pediatric emergency patients. It may be effective for acute agitation, primary headache, and gastrointestinal complaints.
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15
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Duffy EA, Dias N, Hendricks-Ferguson V, Hellsten M, Skeens-Borland M, Thornton C, Linder LA. Perspectives on Cancer Pain Assessment and Management in Children. Semin Oncol Nurs 2019; 35:261-273. [PMID: 31078340 DOI: 10.1016/j.soncn.2019.04.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To report evidence regarding pain assessment and management for children and adolescents receiving treatment for cancer. DATA SOURCES Published research and clinical guidelines. CONCLUSION Children and adolescents experience multiple sources of pain across the cancer continuum. They require developmentally relevant approaches when assessing and managing pain. This review suggests that consideration of the developmental stage and age of the child are essential in both pain assessment and pain management. IMPLICATIONS FOR NURSING PRACTICE Pediatric oncology nurses play a key role in developmentally appropriate pain assessment, identification of potential strategies to manage pain, and delivery of pharmacologic and nonpharmacologic therapies.
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Affiliation(s)
| | - Nancy Dias
- East Carolina University College of Nursing, Greenville, NC
| | | | - Melody Hellsten
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | | | - Cliff Thornton
- Herman & Walter Samuelson Children's Hospital of Sinai, Division of Pediatric Hematology/Oncology, Johns Hopkins School of Nursing, Baltimore, MD
| | - Lauri A Linder
- University of Utah, College of Nursing, Salt Lake City, UT; Primary Children's Hospital, Salt Lake City, UT
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16
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Abstract
Vomiting is not only unpleasant for both children and families, but can lead to frequent hospital admission. The persistent vomiting hampers oral intake and increases the risk of dehydration, so the proper use of antiemetic drugs can be useful. The pharmacological treatment of vomiting in children remains a challenge for the pediatrician because several antiemetics are prescribed as "off-label," outside their authorized drug label. Domperidone and ondansetron are the most commonly known antiemetic drugs. A single oral dose of ondansetron has been shown to reduce the risk of recurrent vomiting, the need for intravenous fluids, and hospital admissions in children with acute gastroenteritis. There is enough evidence to support ondansetron administration in children, so the clinical use can be defined as "off-label/on evidence." This review aims to provide an overview of therapeutic use, safety, and main pharmacological properties of antiemetic drugs in children. A comprehensive search of published literature using the PubMed MEDLINE database was carried out to identify all articles published in English from 1998 to February 2018. At present time, the "off-label/on-evidence" use of some antiemetics could improve the success rate of oral rehydration therapy in pediatric emergency settings and to change the management of vomiting with the prevention of the complications.
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McKinnon K, Jupp J, Ghosh S, Digout C, Eason S, Romanick M. Adherence to pediatric acute chemotherapy-induced nausea and vomiting guidelines in Canadian hospitals. Pediatr Blood Cancer 2019; 66:e27488. [PMID: 30318842 DOI: 10.1002/pbc.27488] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 08/31/2018] [Accepted: 09/06/2018] [Indexed: 11/12/2022]
Abstract
BACKGROUND Chemotherapy-induced nausea and vomiting (CINV) impacts quality of life for patients. Guidelines for emetogenicity classification and prevention of CINV in children were recently published and endorsed by pediatric oncology organizations. PROCEDURE A multicenter chart review was performed at four Canadian pediatric oncology centers examining rates of prescribing adherence to CINV guidelines between January 2012 and December 2015. Eligible patients received their first chemotherapy course of highly emetogenic chemotherapy (HEC) or moderately emetogenic chemotherapy (MEC). RESULTS Guideline adherence was described in 204 patients as antiemetic-only guideline adherence (AGA; examined medication/class prescribed only) and complete guideline adherence (CGA; examined medication/class, dose, frequency, and duration prescribed). Adherence was 29% (HEC 30%, MEC 19%, P = 0.1) and 2% for AGA and CGA patients, respectively. Vomiting in the first 24 h was experienced by 24% of AGA and 34% of non-AGA patients (P = 0.13), with mean breakthrough medication doses similar between AGA and non-AGA groups (HEC 1.8 vs 1.5, P = 0.45; MEC 3 vs 1.42, P = 0.35). In the first 24 h, HEC AGA patients achieved a complete control rate of 37% vs 45% for non-AGA patients (P = 0.31), while patients receiving AGA therapy for MEC achieved a complete control rate of 80% vs 24% for non-AGA patients (P = 0.02). CONCLUSIONS Adherence to guidelines was low across all four pediatric institutions. Each center used different approaches to implement pediatric CINV guidelines. Complete CINV control was low, with reports of emesis high, indicating that patients are not receiving optimal treatment.
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Affiliation(s)
- Krista McKinnon
- Pharmacy Services, Alberta Children's Hospital, Alberta Health Services, Calgary, Canada
| | - Jennifer Jupp
- Pharmacy Services, Alberta Children's Hospital, Alberta Health Services, Calgary, Canada
| | - Sunita Ghosh
- Cross Cancer Institute, Alberta Health Services, Edmonton, Canada
| | | | - Stephanie Eason
- Janeway Children's Health & Rehabilitation Center, St. John's, Canada
| | - Marcel Romanick
- Stollery Children's Hospital, Alberta Health Services, Edmonton, Canada
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Dupuis LL, Flank J, Schechter T, Dvorak CC, Sung L, Spettigue W. Comment on: Olanzapine for chemotherapy-induced nausea: Lessons learned from child and adolescent psychiatry. Pediatr Blood Cancer 2019; 66:e27456. [PMID: 30207056 DOI: 10.1002/pbc.27456] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 08/20/2018] [Indexed: 11/10/2022]
Affiliation(s)
- L Lee Dupuis
- Research Institute and Department of Pharmacy, The Hospital for Sick Children and Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Jacqueline Flank
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Canada
| | - Tal Schechter
- Department of Medicine, Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Christopher C Dvorak
- Department of Medicine, Division of Pediatric Allergy, Immunology & Bone Marrow Transplantation, Benioff Children's Hospital, University of California San Francisco, San Francisco, California
| | - Lillian Sung
- Department of Medicine, Division of Haematology/Oncology and Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Wendy Spettigue
- Department of Medicine, Hospital-based Psychiatry, Children's Hospital of Eastern Ontario, Ottawa, Canada
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Samsel C, Kearney J, Meadows AL, Abrams A, Hirst JM, Muriel AC. Olanzapine for chemotherapy-induced nausea: Lessons learned from child and adolescent psychiatry. Pediatr Blood Cancer 2018; 65:e27289. [PMID: 29932280 DOI: 10.1002/pbc.27289] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 05/21/2018] [Accepted: 05/24/2018] [Indexed: 11/07/2022]
Affiliation(s)
- Chase Samsel
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Psychiatry, Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Julia Kearney
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Amy L Meadows
- Department of Psychiatry and Pediatrics, University of Kentucky College of Medicine, Lexington, Kentucky
- Kentucky Children's Hospital, Lexington, Kentucky
| | - Annah Abrams
- Harvard Medical School, Boston, Massachusetts
- Department of Pediatric Psychosocial Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jeremy M Hirst
- Department of Psychiatry and Palliative Care, University of California San Diego School of Medicine, San Diego, California
| | - Anna C Muriel
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Psychiatry, Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Sutherland A, Naessens K, Plugge E, Ware L, Head K, Burton MJ, Wee B. Olanzapine for the prevention and treatment of cancer-related nausea and vomiting in adults. Cochrane Database Syst Rev 2018; 9:CD012555. [PMID: 30246876 PMCID: PMC6513437 DOI: 10.1002/14651858.cd012555.pub2] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Olanzapine as an antiemetic represents a new use of an antipsychotic drug. People with cancer may experience nausea and vomiting whilst receiving chemotherapy or radiotherapy, or whilst in the palliative phase of illness. OBJECTIVES To assess the efficacy and safety of olanzapine when used as an antiemetic in the prevention and treatment of nausea and vomiting related to cancer in adults. SEARCH METHODS We searched CENTRAL, MEDLINE and Embase for published data on 20th September 2017, as well as ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform for unpublished trials. We checked reference lists, and contacted experts in the field and study authors. SELECTION CRITERIA We included randomised controlled trials (RCTs) of olanzapine versus any comparator with or without adjunct therapies for the prevention or treatment, or both, of nausea or vomiting in people with cancer aged 18 years or older, in any setting, of any duration, with at least 10 participants per treatment arm. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodology. We used GRADE to assess quality of evidence for each main outcome. We extracted data for absence of nausea or vomiting and frequency of serious adverse events as primary outcomes. We extracted data for patient perception of treatment, other adverse events, somnolence and fatigue, attrition, nausea or vomiting severity, breakthrough nausea and vomiting, rescue antiemetic use, and nausea and vomiting as secondary outcomes at specified time points. MAIN RESULTS We included 14 RCTs (1917 participants) from high-, middle- and low-income countries, representing over 24 different cancers. Thirteen studies were in chemotherapy-induced nausea and vomiting. Oral olanzapine was administered during highly emetogenic (HEC) or moderately emetogenic (MEC) chemotherapy (12 studies); chemoradiotherapy (one study); or palliation (one study). Eight studies await classification and 13 are ongoing.The main comparison was olanzapine versus placebo/no treatment. Other comparisons were olanzapine versus NK1 antagonist, prokinetic, 5-HT3 antagonist or dexamethasone.We assessed all but one study as having one or more domains that were at high risk of bias. Eight RCTs with fewer than 50 participants per treatment arm, and 10 RCTs with issues related to blinding, were at high risk of bias. We downgraded GRADE assessments due to imprecision, inconsistency and study limitations.Olanzapine versus placebo/no treatmentPrimary outcomesOlanzapine probably doubles the likelihood of no nausea or vomiting during chemotherapy from 25% to 50% (risk ratio (RR) 1.98, 95% confidence interval (CI) 1.59 to 2.47; 561 participants; 3 studies; solid tumours; HEC or MEC therapy; moderate-quality evidence) when added to standard therapy. Number needed to treat for additional beneficial outcome (NNTB) was 5 (95% CI 3.3 - 6.6).It is uncertain if olanzapine increases the risk of serious adverse events (absolute risk difference 0.7% more, 95% CI 0.2 to 5.2) (RR 2.46, 95% CI 0.48 to 12.55; 7 studies, 889 participants, low-quality evidence).Secondary outcomesFour studies reported patient perception of treatment. One study (48 participants) reported no difference in patient preference. Four reported quality of life but data were insufficient for meta-analysis.Olanzapine may increase other adverse events (RR 1.71, 95% CI 0.99 to 2.96; 332 participants; 4 studies; low-quality evidence) and probably increases somnolence and fatigue compared to no treatment or placebo (RR 2.33, 95% CI 1.30 to 4.18; anticipated absolute risk 8.2% more, 95% CI 1.9 to 18.8; 464 participants; 5 studies; moderate-quality evidence). Olanzapine probably does not affect all-cause attrition (RR 0.99, 95% CI 0.57 to 1.73; 943 participants; 8 studies; I² = 0%). We are uncertain if olanzapine increases attrition due to adverse events (RR 3.00, 95% CI 0.13 to 70.16; 422 participants; 6 studies). No participants withdrew due to lack of efficacy.We are uncertain if olanzapine reduces breakthrough nausea and vomiting (RR 0.38, 95% CI 0.10 to 1.47; 501 participants; 2 studies; I² = 54%) compared to placebo or no treatment. No studies reported 50% reduction in severity of nausea or vomiting, use of rescue antiemetics, or attrition.We are uncertain of olanzapine's efficacy in reducing acute nausea or vomiting. Olanzapine probably reduces delayed nausea (RR 1.71, 95% CI 1.40 to 2.09; 585 participants; 3 studies) and vomiting (RR 1.28, 95% CI 1.14 to 1.42; 702 participants; 5 studies).Subgroup analysis: 5 mg versus 10 mgPlanned subgroup analyses found that it is unclear if 5 mg is as effective an antiemetic as 10 mg. There is insufficient evidence to exclude the possibility that 5 mg may confer a lower risk of somnolence and fatigue than 10 mg.Other comparisonsOne study (20 participants) compared olanzapine versus NK1 antagonists. We observed no difference in any reported outcomes.One study (112 participants) compared olanzapine versus a prokinetic (metoclopramide), reporting that olanzapine may increase freedom from overall nausea (RR 2.95, 95% CI 1.73 to 5.02) and overall vomiting (RR 3.03, 95% CI 1.78 to 5.14).One study (62 participants) examined olanzapine versus 5-HT3 antagonists, reporting olanzapine may increase the likelihood of 50% or greater reduction in nausea or vomiting at 48 hours (RR 1.82, 95% CI 1.11 to 2.97) and 24 hours (RR 1.36, 95% CI 0.80 to 2.34).One study (229 participants) compared olanzapine versus dexamethasone, reporting that olanzapine may reduce overall nausea (RR 1.73, 95% CI 1.37 to 2.18), overall vomiting (RR 1.27, 95% CI 1.10 to 1.48), delayed nausea (RR 1.66, 95% CI 1.33 to 2.08) and delayed vomiting (RR 1.25, 95% CI 1.07 to 1.45). AUTHORS' CONCLUSIONS There is moderate-quality evidence that oral olanzapine probably increases the likelihood of not being nauseous or vomiting during chemotherapy from 25% to 50% in adults with solid tumours, in addition to standard therapy, compared to placebo or no treatment. There is uncertainty whether it increases serious adverse events. It may increase the likelihood of other adverse events, probably increasing somnolence and fatigue. There is uncertainty about relative benefits and harms of 5 mg versus 10 mg.We identified only RCTs describing oral administration. The findings of this review cannot be extrapolated to provide evidence about the efficacy and safety of any injectable form (intravenous, intramuscular or subcutaneous) of olanzapine.
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Affiliation(s)
- Anna Sutherland
- Katharine House HospiceMandeville RoadAynho Road, AdderburyBanburyUKOX17 3NL
- Cochrane Fellowship, Cochrane UKOxfordUK
| | - Katrien Naessens
- Oxford Radcliffe Trust/Health Education Thames ValleyPalliative CareOxfordUK
| | - Emma Plugge
- Cochrane UKSummertown Pavilion18 ‐ 24 Middle WayOxfordUKOX2 7LG
| | - Lynda Ware
- Cochrane UKSummertown Pavilion18 ‐ 24 Middle WayOxfordUKOX2 7LG
| | - Karen Head
- Nuffield Department of Surgical Sciences, University of OxfordCochrane ENTUK Cochrane Centre, Summertown Pavilion18 ‐ 24 Middle WayOxfordUK
| | - Martin J Burton
- Cochrane UKSummertown Pavilion18 ‐ 24 Middle WayOxfordUKOX2 7LG
| | - Bee Wee
- Churchill HospitalNuffield Department of Medicine and Sir Michael Sobell HouseOld RoadHeadingtonOxfordUKOX3 7LJ
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Wang W, Lou G, Zhang Y. Olanzapine with ondansetron and dexamethasone for the prevention of cisplatin-based chemotherapy-induced nausea and vomiting in lung cancer. Medicine (Baltimore) 2018; 97:e12331. [PMID: 30212982 PMCID: PMC6156067 DOI: 10.1097/md.0000000000012331] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Olanzapine is an atypical antipsychotic that has shown efficacy for the treatment of nausea, anxiety, and insomnia. This study was conducted to evaluate the efficacy of olanzapine (5 mg) combined with 5-HT3 receptor antagonists and dexamethasone for the prevention of chemotherapy-induced nausea and vomiting (CINV) in lung patients receiving cisplatin-based (25 mg/m2 d1-3) highly emetogenic chemotherapy (HEC).Olanzapine (5 mg) was administered a day prior to cisplatin administration and continued on days 1 to 5. We evaluated complete response (CR) rate and rates of no nausea and no vomiting in 3 periods. In addition, Self-Rating Anxiety Scale (SAS), Self-rating Depression Scale (SDS), and The Functional Living Index-Emesis (FLIE) questionnaire were also assessed.A total of 40 lung cancer patients were included. CR for acute, delayed, and over all phases were 82.5%, 75.0%, and 70.0%, respectively. The rate of no nausea in the acute phase was 70.0% and 62.5% in delayed phase. The rate of no vomiting in the acute phase was 85.0%, and 77.5% in delayed phase. The rate of no nausea and no vomiting in the overall phase were 57.5% and 75.0%, respectively. The median SAS and SDS score were 37.9 and 41.6 in pre-chemotherapy, respectively. Up to day 6 after chemotherapy treatment, the median SAS and SDS score were 36.9 and 42.0, respectively. The median FLIE score was 111.7. The main side effects were grade 1 somnolence (35.0%) and mild constipation (52.5%).Around 5 mg olanzapine may be used as a potential, safe, and cost-beneficial alternative to prevent nausea and vomiting for HEC, particular for multiday chemotherapy regimen.
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Kishimoto K, Kawasaki K, Saito A, Kozaki A, Ishida T, Hasegawa D, Kosaka Y. Prevention of chemotherapy-induced vomiting in children receiving multiple-day cisplatin chemotherapy: A hospital-based, retrospective cohort study. Pediatr Blood Cancer 2017; 64. [PMID: 28205315 DOI: 10.1002/pbc.26485] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 01/11/2017] [Accepted: 01/12/2017] [Indexed: 11/08/2022]
Abstract
BACKGROUND Optimal prevention of chemotherapy-induced vomiting (CIV) has not been established for patients receiving cisplatin in divided doses. The aim of this study was to describe the incidence and risk factors of CIV in children who received multiple-day cisplatin chemotherapy. PROCEDURE A total of 24 consecutive pediatric patients (age 0-19 years) who received multiple-day cisplatin chemotherapy in our hospital were enrolled. Patients with relapsed disease or primary intracranial tumor and those who received concurrent radiation therapy were excluded. The number of chemotherapy cycles reviewed was 107, with a median of five per patient. All patients received granisetron. Dexamethasone and NK-1 receptor antagonists (NK1RA) were used as additional antiemetics for prophylaxis of CIV. RESULTS CIV was observed in 22 of 24 (92%) patients, and 61 of 107 (57%) cycles. Patients who developed CIV had a higher incidence of other chemotherapy-related adverse events (87 vs. 41%, P < 0.001). The incidence of CIV was lower in patients administered with NK1RA than those without (32 vs. 68%, P < 0.001). Multivariate logistic regression identified age less than or equal to 2 years (odds ratio [OR] = 0.25, 95% confidence interval [CI] = 0.10-0.63) and administration of NK1RA (OR = 0.16, 95% CI = 0.06-0.43) as independent factors for CIV. CONCLUSIONS These results suggest that NK1RA is crucial to reduce CIV in children who receive multiple-day cisplatin chemotherapy.
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Affiliation(s)
- Kenji Kishimoto
- Department of Hematology and Oncology, Children's Cancer Center, Kobe Children's Hospital, Kobe, Japan
| | - Keiichiro Kawasaki
- Department of Hematology and Oncology, Children's Cancer Center, Kobe Children's Hospital, Kobe, Japan
| | - Atsuro Saito
- Department of Hematology and Oncology, Children's Cancer Center, Kobe Children's Hospital, Kobe, Japan
| | - Aiko Kozaki
- Department of Hematology and Oncology, Children's Cancer Center, Kobe Children's Hospital, Kobe, Japan
| | - Toshiaki Ishida
- Department of Hematology and Oncology, Children's Cancer Center, Kobe Children's Hospital, Kobe, Japan
| | - Daiichiro Hasegawa
- Department of Hematology and Oncology, Children's Cancer Center, Kobe Children's Hospital, Kobe, Japan
| | - Yoshiyuki Kosaka
- Department of Hematology and Oncology, Children's Cancer Center, Kobe Children's Hospital, Kobe, Japan
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Abstract
Chemotherapy-induced nausea and vomiting (CINV) is associated with a significant deterioration in quality of life and is perceived by patients as a major adverse effect of the treatment. This review summarizes the safety and efficacy of current antiemetic agents for the prevention of CINV in children. Information on antiemetic prophylaxis for CINV in children was obtained from a literature review of current peer-reviewed articles and recent international guidelines. The literature review and the international antiemetic guidelines provide recommendations for use of specific antiemetics in children based on the emetogenicity of the chemotherapy. 5-Hydroxytryptamine-3 (5-HT3) receptor antagonists have been safe and effective in the prevention of acute emesis with a few patients experiencing mild headache. No adequate studies have been conducted to date for specific recommendations for the prevention of delayed nausea and vomiting in children. The neurokinin (NK)-1 receptor antagonist aprepitant has been approved by the US FDA for use in children of a specific age and weight. No studies for the NK1 receptor antagonists netupitant and rolapitant in children have been conducted. Olanzapine, an antipsychotic, has been shown to be safe and effective in preventing nausea and emesis in adult patients receiving chemotherapy. Its use in children has been limited to children with poor control of CINV; more studies are necessary in this population. In conclusion, practitioners should follow international antiemetic guidelines to provide patients with the specific antiemetics in the recommended dose for the highest possible quality of care.
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Chelkeba L, Gidey K, Mamo A, Yohannes B, Matso T, Melaku T. Olanzapine for chemotherapy-induced nausea and vomiting: systematic review and meta-analysis. Pharm Pract (Granada) 2017; 15:877. [PMID: 28503222 PMCID: PMC5386623 DOI: 10.18549/pharmpract.2017.01.877] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 03/07/2017] [Indexed: 11/29/2022] Open
Abstract
Background: Chemotherapy induced nausea and vomiting (CINV) remains the most distressing event in patients receiving highly emetogenic chemotherapy (HEC) or moderately emetogenic chemotherapy (MEC). Objective: Therefore, this meta-analysis was conducted to evaluate the efficacy of olanzapine containing regimen in preventing acute, delayed and overall phases of CINV. Methods: PubMed, EBSCO, and Cochrane central register of controlled trials electronic databases were searched to identify RCTs that compared the effects of olanzapine with non-olanzapine regimen in preventing CINV. Randomized clinical trials (RCTs) that compared olanzapine containing regimen with non-olanzapine regimen were included. The primary outcomes were the percentage of patients achieving no vomiting or no nausea in acute, delayed and overall phases. Results: 13 RCTs that enrolled 1686 participants were included in this meta-analysis. 852 patients were assigned to olanzapine and 834 patients were assigned to non-olanzapine regimen (other standard antiemetic regimen). The percentages of no emesis achieved were 87.5%, 76.2%, 73.6% in olanzapine versus 76.7%, 61.8%, and 56.4% in non-olanzapine regimen in acute, delayed and overall phases, respectively. The percentages of no nausea were 82%, 64.3%, 61.6% in olanzapine group versus 71.3%, 41.8%, and 40.6% in non-olanzapine group in acute, delayed and overall phases, respectively. In general, olanzapine containing regimen achieved statistical superiority to non-olanzapine regimen in no vomiting endpoint in acute phase (OR 2.16; 95%CI 1.60 to 2.91, p<0.00001; I-square=5%; p=0.40), delayed phase (OR 2.28; 95%CI 1.1.46 to 3.54, p=0.0003; I-square=65%; p=0.001) and overall phase (OR 2.48; 95%CI 1.59 to 3.86, p<0.0001; I-square=69%; p< 0.0001). Conclusion: The current meta-analysis showed that olanzapine was statistically and clinically superior to non-olanzapine regimen in preventing CINV in most domains of the parameters.
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Affiliation(s)
- Legese Chelkeba
- PhD. Department of clinical Pharmacy, College of Health Sciences, Jimma University. Jimma, (Ethiopia).
| | - Kidu Gidey
- MSc. Department of clinical Pharmacy, College of Health Sciences, Jimma University. Jimma, (Ethiopia).
| | - Ayele Mamo
- MSc. Department of clinical Pharmacy, College of Health Sciences, Jimma University. Jimma, (Ethiopia).
| | - Berhane Yohannes
- MSc. Department of clinical Pharmacy, College of Health Sciences, Jimma University. Jimma, (Ethiopia).
| | - Tsehay Matso
- MSc. Department of clinical Pharmacy, College of Health Sciences, Jimma University. Jimma, (Ethiopia).
| | - Tsegaye Melaku
- MSc. Department of clinical Pharmacy, College of Health Sciences, Jimma University. Jimma, (Ethiopia).
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25
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Prophylaxis and management of antineoplastic drug induced nausea and vomiting in children with cancer. PEDIATRIC HEMATOLOGY ONCOLOGY JOURNAL 2016. [DOI: 10.1016/j.phoj.2016.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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26
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Dupuis LL, Sung L, Molassiotis A, Orsey AD, Tissing W, van de Wetering M. 2016 updated MASCC/ESMO consensus recommendations: Prevention of acute chemotherapy-induced nausea and vomiting in children. Support Care Cancer 2016; 25:323-331. [PMID: 27565788 DOI: 10.1007/s00520-016-3384-y] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 08/16/2016] [Indexed: 11/25/2022]
Abstract
PURPOSE To update the 2009 recommendations for the prevention of acute chemotherapy-induced emesis in children. METHODS We updated the original systematic literature search. Randomized studies were included in the evidence to support this guideline if they were primary studies fully published in full text in English or French; included only children less than 18 years old or, for mixed studies of adults and children, reported the pediatric results separately or the median or mean age was no more than 13 years; evaluated acute chemotherapy-induced nausea and vomiting (CINV) prophylaxis; provided sufficient information to permit determination of the emetogenicity of the antineoplastic therapy administered or the study investigators stated the emetogenicity of the chemotherapy administered; included an implicit or explicit definition of complete acute CINV response; described the antiemetic regimen in full; and reported the complete acute CINV response rate as a proportion. RESULTS Twenty-five randomized studies, including eight published since 2009, met the criteria for inclusion in this systematic review. Prophylaxis with a 5-HT3 antagonist (granisetron or ondansetron or palonosetron or tropisetron) ± dexamethasone ± aprepitant is recommended for children receiving highly or moderately emetogenic chemotherapy. For children receiving chemotherapy of low emetogenicity, a 5-HT3 antagonist is recommended. CONCLUSIONS The findings of several randomized trials were used to update recommendations for the prevention of acute CINV. However, significant research gaps remain and must be addressed before CINV control in children can be optimized.
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Affiliation(s)
- L Lee Dupuis
- Department of Pharmacy and Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada.
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada.
| | - Lillian Sung
- Department of Pediatrics and Research Institute, The Hospital for Sick Children, Toronto, Canada
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Alexander Molassiotis
- School of Nursing and WHO Collaborating Centre for Community Health Services, The Hong Kong Polytechnic University, Hong Kong, China
| | - Andrea D Orsey
- Division of Pediatric Hematology/Oncology, Connecticut Children's Medical Center, Hartford, CT, USA
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Wim Tissing
- Department of Pediatric Oncology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Marianne van de Wetering
- Department of Paediatric Oncology, Emma Children's Hospital/Academic Medical Center, Amsterdam, Netherlands
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27
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Flank J, Robinson PD, Holdsworth M, Phillips R, Portwine C, Gibson P, Maan C, Stefin N, Sung L, Dupuis LL. Guideline for the Treatment of Breakthrough and the Prevention of Refractory Chemotherapy-Induced Nausea and Vomiting in Children With Cancer. Pediatr Blood Cancer 2016; 63:1144-51. [PMID: 26960036 DOI: 10.1002/pbc.25955] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 01/28/2016] [Indexed: 11/06/2022]
Abstract
This clinical practice guideline provides an approach to the treatment of breakthrough chemotherapy-induced nausea and vomiting (CINV) and the prevention of refractory CINV in children. It was developed by an international, interprofessional panel and is based on systematic literature reviews. Evidence-based interventions for the treatment of breakthrough and prophylaxis of refractory CINV are recommended. Gaps in the evidence used to support the recommendations made in this clinical practice guideline were identified. The contribution of these recommendations to breakthrough and refractory CINV control in children requires prospective evaluation.
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Affiliation(s)
- Jacqueline Flank
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | | | - Mark Holdsworth
- College of Pharmacy, University of New Mexico, Albuquerque, New Mexico
| | - Robert Phillips
- Regional Department of Haematology and Oncology, Leeds Children's Hospital, Leeds, United Kingdom.,Centre for Reviews and Dissemination, University of York, York, United Kingdom
| | - Carol Portwine
- Division of Hematology/Oncology, Department of Pediatrics, McMaster University, Hamilton, Canada
| | - Paul Gibson
- Pediatric Hematology/Oncology, Children's Hospital, London Health Sciences Centre, London, Canada
| | - Cathy Maan
- Pediatric Hematology/Oncology, Children's Hospital, London Health Sciences Centre, London, Canada
| | - Nancy Stefin
- Division of Hematology/Oncology, Department of Pediatrics, McMaster University, Hamilton, Canada
| | - Lillian Sung
- Department of Paediatrics, Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada.,Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - L Lee Dupuis
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada.,Research Institute, The Hospital for Sick Children, Toronto, Canada
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28
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Meng Q, Chen GH, Guo PM. Olanzapine combined with normal antiemetic drugs in patients on solid tumor chemotherapy: Antiemetic effect and impact on quality of life. Shijie Huaren Xiaohua Zazhi 2016; 24:1117-1123. [DOI: 10.11569/wcjd.v24.i7.1117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the efficacy and safety of olanzapine for prevention of chemotherapy-induced nausea and vomiting (CINV) in patients receiving highly or moderately emetogenic chemotherapy (HEC or MEC), and to evaluate the impact of olanzapine on quality of life (QOL) in cancer patients on chemotherapy.
METHODS: One hundred and twenty patients receiving highly or moderately emetogenic chemotherapy were randomly assigned to a study group and a control group, with 60 cases in each group. Routine antiemetics were used in the control group, and olanzapine (2.5 mg, bid, p.o) was add in the study group. All patients were asked to fill the observation form of CINV once a day, and they were also instructed to fill the EORTC QLQ-C30 questionnaire during the period of chemotherapy. Primary endpoints were complete response (CR) and effective response (ER) in the acute and delayed periods. Secondary endpoints were QOL during chemotherapy, drug safety and toxicity.
RESULTS: Complete response rates for acute nausea and vomiting in patients with highly and moderately emetogenic chemotherapy were improved by 10.6% (48.5% vs 37.9%, P = 0.01) and 17.8% (63.0% vs 45.2%, P = 0.008), respectively. Effective response rates for acute nausea and vomiting in patients with highly and moderately emetogenic chemotherapy were improved by 22.0% (90.9% vs 68.9%, P = 0.00) and 24.9% (92.6% vs 67.7%, P = 0.001), respectively. Complete response rates for delayed nausea and vomiting in patients with highly and moderately emetogenic chemotherapy were improved by 14.8% (35.5% vs 20.7%, P = 0.04) and 14.4% (37.0% vs 22.6 %, P = 0.02), respectively. Effective response rates for delayed nausea and vomiting in patients with highly and moderately emetogenic chemotherapy were improved by 29.6% (84.8% vs 55.2%, P = 0.001) and 29.8% (81.4% vs 51.6%, P = 0.002), respectively. All patients were evaluable for QOL. When comparing the study group with the control group in QOL, significant differences were seen in global health status, emotional functioning, social functioning, nausea and vomiting, insomnia and appetite loss in favour of the study group. Both treatments were well tolerated.
CONCLUSION: Olanzapine can improve the complete response and effective response for nausea and vomiting in patients receiving highly or moderately emetogenic chemotherapy compared with the standard antiemesis therapy, as well as improve the QOL of cancer patients on chemotherapy. Olanzapine is a safe and efficient drug for prevention of CINV.
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29
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DeRemer DL, Clemmons AB, Orr J, Clark SM, Gandhi AS. Emerging Role of Olanzapine for Prevention and Treatment of Chemotherapy-Induced Nausea and Vomiting. Pharmacotherapy 2016; 36:218-29. [DOI: 10.1002/phar.1703] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- David L. DeRemer
- Department of Clinical and Administrative Pharmacy; University of Georgia, College of Pharmacy; Augusta Georgia
- Georgia Regents Cancer Center; Augusta Georgia
| | - Amber B. Clemmons
- Department of Clinical and Administrative Pharmacy; University of Georgia, College of Pharmacy; Augusta Georgia
- Georgia Regents Cancer Center; Augusta Georgia
- Department of Pharmacy; Georgia Regents Medical Center; Augusta Georgia
| | - Julianne Orr
- Department of Clinical and Administrative Pharmacy; University of Georgia, College of Pharmacy; Augusta Georgia
- Department of Pharmacy; Georgia Regents Medical Center; Augusta Georgia
| | - Stephen Michael Clark
- Department of Clinical and Administrative Pharmacy; University of Georgia, College of Pharmacy; Augusta Georgia
- Georgia Regents Cancer Center; Augusta Georgia
- Department of Pharmacy; Georgia Regents Medical Center; Augusta Georgia
| | - Arpita Shah Gandhi
- Department of Clinical and Administrative Pharmacy; University of Georgia, College of Pharmacy; Augusta Georgia
- Georgia Regents Cancer Center; Augusta Georgia
- Department of Pharmacy; Georgia Regents Medical Center; Augusta Georgia
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