The Management of Nausea and Vomiting Not Related to Anticancer Therapy in Patients with Cancer

Development of a simultaneous LC-MS/MS analytical method for plasma: 16 antipsychotics approved in Japan and 4 drug metabolites

The increased risk of adverse drug reactions due to the concomitant use of antipsychotics is problematic in the treatment of schizophrenia. Therefore, the simultaneous analysis of their plasma concentrations is required. In this study, we developed a simultaneous liquid chromatography/tandem mass spectrometry (LC-MS/MS) method for analyzing plasma antipsychotics approved in Japan for therapeutic drug monitoring (TDM) applications. First, we counted the prescriptions for 16 antipsychotics and concomitant drugs used at the Tohoku University Hospital. LC-MS/MS was used for the simultaneous analysis of 16 antipsychotics and four drug metabolites. This analysis was conducted using a combination of selected reaction monitoring mode and reversed-phase chromatography. Following the examination of the MS/MS and LC conditions, an analytical method validation test was conducted. The developed method was used to analyze plasma antipsychotic levels in patients with schizophrenia. One-third of the patients received treatment with multiple antipsychotics. Under LC-MS/MS conditions, LC separation was performed using a combination of a C18 column and ammonium formate-based mobile phases with a gradient flow. The calibration curves were optimized by adjusting the ion abundance, and 11 compounds met the criteria for intra- and inter-day reproducibility tests. Some stability test results did not meet these criteria; therefore, further investigation is required. The developed method permitted the measurement of all the plasma parameters, including concentrations above the therapeutic range. Therefore, this method may be useful in the daily TDM practice of antipsychotics.

Gastro-Intestinal Symptoms in Palliative Care Patients

This review of the palliation of various gastro-intestinal (GI) symptoms encountered in cancer patients is by no means exhaustive. Frequent symptoms such as constipation, nausea and vomiting, bowel obstructions, ascites and bleeds will be discussed, focusing on their assessment and most importantly, how to control the associated symptoms. All of these symptoms and GI complications can significantly impact patients' quality of life (QOL) and should be treated as quickly and aggressively as possible.

Cyclizine pharmacovigilance in hospice/palliative care: net effects for nausea or vomiting

OBJECTIVES

To describe the contemporary real-world use of cyclizine for nausea or vomiting, and the associated benefits and harms.

METHODS

This was a prospective, consecutive case series of routine clinical use of cyclizine for nausea or vomiting in palliative care conducted across 19 sites in Australia, Aotearoa/New Zealand and the UK. Clinical outcomes were graded using the National Cancer Institute Common Terminology Criteria for Adverse Events at baseline and 72 hours after initiation of cyclizine. Ad hoc safety reporting continued for 2 weeks.

RESULTS

Data were collected from 101 patients between May 2018 and December 2020. Cyclizine was mostly used in combination with another antiemetic. Overall, 79 patients benefited and 32 experienced harm (56 had benefit without harm; 9 had harm without benefit). The most common harms were constipation (13%), somnolence (9%) and confusion (7%), adding to the already high rates of these symptoms at baseline. For the four patients with serious harms (grade ≥3), these were exacerbations of existing symptoms. Nine patients stopped cyclizine at 72 hours and a further 20 patients within 2 weeks. The most common reasons for stopping were lack of benefit and symptom resolution; none stopped because of harms.

CONCLUSIONS

When used as described in a palliative care setting, cyclizine benefits about three-quarters of patients, with about one-third experiencing tolerable harms.

Do Patients Benefit from a Trial of Corticosteroids at the End of Life?

OPINION STATEMENT

Patients with advanced cancer in the last 6 months of their lives have a higher frequency of distressing and debilitating physical and psychosocial symptoms such as cancer pain, cancer-related fatigue (CRF), anorexia, shortness of breath, poor sleep, anxiety, and depression. Often these symptoms significantly impact the patients' quality of life, and therefore require prompt assessment and effective treatment. There are specific treatments for certain distressing cancer-related symptoms (e.g., opioids for pain), but for the other symptoms such as CRF, anorexia-cachexia, and shortness of breath, there are limited or no evidence-based treatments. Also, in the management of cancer pain in this population, many patients are refractory to opioids. Hence, corticosteroids are one of the most common adjuvant medications prescribed for the management of this distressing symptom. However, there is limited evidence in regard to the effectiveness of corticosteroids in the improvement of the symptoms, side-effect profile, most optimal duration of use, dose, type of steroid, and most recently, the use with immunotherapy in advanced cancer patients at the end of life. These factors significantly limit the use of this important medication in terminally ill cancer patients. Further research is therefore critical to provide the optimal prescription of corticosteroids in this highly distressed population.