Management of Chemotherapy-Induced Nausea and Vomiting in Pediatric Patients

Trial Sequential Analysis and Meta-Analysis of Olanzapine in Pediatric Patients for Chemotherapy-Induced Nausea and Vomiting (CINV)

Background and Objective: Olanzapine (OLZ) containing regimens are approved in adults for chemotherapy-induced nausea and vomiting (CINV) receiving highly emetogenic chemotherapy (HEC) or moderately emetogenic chemotherapy (MEC), and the same has not been approved in the pediatric population. In order to generate data regarding the efficacy and safety of OLZ as an adjunct to the standard of care (SoC) for CINV in pediatric patients receiving HEC/MEC, the review authors performed this systematic review and meta-analysis. Methods: A systematic literature search was performed through the databases Cochrane Library, Pub Med, and clinicaltrials.gov, from inception to September 2023, using keywords: "chemotherapy" and "olanzapine," "nausea" and "vomiting." Randomized clinical trials published in English that analyzed the efficacy and safety of olanzapine as an adjunct to SoC were included. The essential outcomes included in this study were the proportion of patients with no emesis in the acute and delayed phase, patients with no nausea in the acute and delayed phase, the proportion of patients requiring rescue medication, and the proportion of patients with reduced CNS arousal. Results: In the OLZ group, a greater number of patients had no emesis both in the acute and delayed phase (RR = 1.22; 95% CI = 1.09-1.37; P = .0004); and (RR = 1.23; 95% CI = 0.92-1.63; P = .16) respectively. Similarly, a higher number of patients showed no nausea both in the acute and delayed phase (RR = 1.08; 95% CI = 0.78-1.48; P = .66) and (RR = 1.12; 95% CI = 0.79-1.61; P = .52) respectively. The use of rescue medication was significantly less in the OLZ group (RR = 0.62; 95% CI = 0.42-0.91; P = .01). More patients experienced reduced CNS arousal in the OLZ group (RR = 2.97; 95% CI = 2.02-4.38; P < .0001). Conclusions: Olanzapine as an adjunct to the SoC may be effective in acute emesis, which may also reduce the use of rescue medication. Reduced CNS alertness was the significant adverse effect observed. For other endpoints, more studies are required to substantiate its role in CINV.

Outcome of antiemetic prophylaxis among pediatric cancer patients receiving moderate to highly emetogenic chemotherapy at pediatric hemato-oncology ward of Tikur Anbessa specialized hospital: A prospective observational study

INTRODUCTION

Chemotherapy-induced nausea and vomiting (CINV) is a major issue for chemotherapy pediatric patients, especially in developing countries due to limited access to essential antiemetics. This study aimed to assess antiemetic prophylaxis outcomes in pediatric cancer patients at Tikur Anbessa Specialized Hospital in Addis Ababa, Ethiopia.

METHODS

A longitudinal prospective observational study design was conducted among 201 pediatric cancer patients followed up to 120 h post-chemotherapy.

RESULTS

The majority of patients (75.1%) received combination prophylactic antiemetics in the acute phase. Complete response (CR) was the highest in the acute phase (71.1%). Emesis episodes occurred most frequently on the first day of treatment (28.4%) and gradually decreased over time. History of motion sickness, platinum-based chemotherapy, and prior chemotherapy-induced vomiting (CIV) were associated with emesis during the acute phase whereas multiple-day chemotherapy, prior CIV, receipt of antiemetics, and a history of motion sickness in the delayed phase. However, the odds of CIV were reduced with steroid presence in the chemotherapy regimen.

CONCLUSIONS

A considerable number of participants could not achieve a CR. It is important for clinicians to be cognizant of risk factors that influence the outcome of antiemetic prophylaxis to achieve better control of CINV among pediatric cancer patients.

Translation and Psychometric Evaluation of the Hindi Language Version of the Pediatric Nausea Assessment Tool (PeNAT) in the Indian Population

OBJECTIVES

To translate the Pediatric Nausea Assessment Tool (PeNAT) into Hindi and validate it in Indian pediatric cancer patients and survivors.

METHODS

The PeNAT-Hindi was finalized by forward and backward translations, and pilot testing. The PeNAT-Hindi was administered to 200 Hindi-speaking pediatric (4-18 y) cancer patients/survivors, in three groups. These included pediatric cancer patients who had recently received chemotherapy (n = 150); who received no chemotherapy within 5 d (n = 25) and survivors (n = 25). Construct validity was tested by comparing scores among the three groups. Test-retest reliability and criterion validity were estimated by the correlation of the first PeNAT score with the second (taken 1 h later) PeNAT score and the number of vomiting/retching episodes, respectively. Convergent validity and discriminant validity were estimated by correlating PeNAT scores with parent-assessed nausea severity, and pain, respectively. The responsiveness was tested by comparing second PeNAT scores with subsequent divergent PeNAT scores among patients reporting subjective change (improvement and worsening, respectively) in nausea severity.

RESULTS

Test-retest reliability of PeNAT-Hindi was good (intraclass correlation = 0.791). The initial PeNAT score had moderate correlation with the number of vomiting/retching episodes (Spearman ρ = 0.401). Median PeNAT scores in group 1 versus groups 2 and 3 were significantly different (p < 0.001). Initial PeNAT scores showed a moderate correlation with parent-assessed nausea (Spearman ρ = 0.657) and a weak correlation with parent-assessed pain (Spearman ρ = 0.319). The responsiveness (standardized response mean) of PeNAT-Hindi to the change in nausea severity was -1.79 (improvement) and 2.19 (worsening), respectively.

CONCLUSION

PeNAT-Hindi showed good reliability and acceptable validity. It may be used among Hindi-speaking children for measuring nausea. The responsiveness of PeNAT-Hindi needs further evaluation.

Age of Pediatric Patients Affects Delayed Chemotherapy-Induced Vomiting

The purpose of this study was to investigate the risk factors for delayed chemotherapy-induced vomiting (DCIV) in pediatric oncology patients. We collected data on pediatric patients from a tertiary care pediatric hospital in an Asian urban center. We analyzed the risk factors for DCIV in patients by univariate analysis and logistic regression. Patients were grouped according to age by the Youden index, and differences in clinical features between the high-risk and low-risk groups were calculated. In the univariate analysis, the number of chemotherapy days, pH, and blood glucose levels were significantly associated with DCIV. In the logistic regression analysis, patient age was an independent risk factor (odds ratio [OR] = 1.013, 95% confidence interval [CI] = 1.005-1.021, P = .002). Children in the high-risk group had a higher grade of vomiting (P < .05). Age is an important risk factor for DCIV in pediatric patients, with older children tending to experience more frequent and more severe vomiting.

Combination of thalidomide and Clostridium butyricum relieves chemotherapy-induced nausea and vomiting via gut microbiota and vagus nerve activity modulation

Nausea and vomiting (CINV) are distressful and widespread side effects of chemotherapy, and additional efficient regimens to alleviate CINV are urgently needed. In the present study, colorectal cancer (CRC) mice model induced by Azoxymethane (AOM)/Dextran Sodium Sulfate (DSS) was employed to evaluate the cancer suppression and CINV amelioration effect of the combination of thalidomide (THD) and Clostridium butyricum. Our results suggested that the combination of THD and C. butyricum abundantly enhanced the anticancer effect of cisplatin via activating the caspase-3 apoptosis pathway, and also ameliorated CINV via inhibiting the neurotransmitter (e.g., 5-HT and tachykinin 1) and its receptor (e.g., 5-HT₃R and NK-1R) in brain and colon. Additionally, the combination of THD and C. butyricum reversed the gut dysbacteriosis in CRC mice by increasing the abundance of Clostridium, Lactobacillus, Bifidobacterium, and Ruminococcus at the genus level, and also led to increased expression of occludin and Trek1 in the colon, while decreased expression of TLR4, MyD88, NF-κB, and HDAC1, as well as the mRNA level of IL-6, IL-1β, and TNF-α. In all, these results suggest that the combination of THD and C. butyricum had good efficacy in enhancing cancer treatments and ameliorating CINV, which thus provides a more effective strategy for the treatment of CRC.

The emerging role of olanzapine in paediatric CINV control: A review

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.

The Effects of Acupressure in the Prevention of Nausea and Vomiting Related to Chemotherapy in Children: A Randomized Double-Blinded Placebo-Controlled Study

Background: Acupressure is known to be a nursing intervention used to prevent chemotherapy-induced nausea and vomiting in children. Methods: This study was conducted to evaluate and compare the effectiveness of manual and wristband acupressure in the prevention of chemotherapy-induced nausea and vomiting in children. This double-blinded and placebo-controlled study was conducted with 44 children aged between 5 and 18 years receiving chemotherapy in a university hospital's pediatric oncology clinic. Children were randomized into groups using a 2 × 2 factorial design: (a) The child who was given manual acupressure before the first chemotherapy was given placebo manual acupressure before the next chemotherapy; (b) the same child who was administered wristband acupressure before the first chemotherapy was administered placebo wristband acupressure before the next chemotherapy. After all interventions, the severity and number of episodes of nausea and vomiting and additional antiemetic needs in the children were monitored for 24 h. Results: In both groups, the severity and number of nausea and vomiting were lower according to their own placebo groups. Manual and wristband acupressure were effective in reducing the severity and number of nausea and vomiting, but manual acupressure was more effective in reducing the severity and number of nausea and vomiting in comparison to wristband acupressure (p < .05). No statistically significant difference was found between the groups regarding additional antiemetic drug use. Discussion: In this study, manual and wristband acupressure were determined to be effective in reducing the severity and number of nausea and vomiting related to chemotherapy.

Optimizing antiemetic therapy for children undergoing chemotherapy

Chemotherapy-induced nausea and vomiting (CINV) is a common side effect of most chemotherapy agents. Suboptimal management of CINV impacts quality of life, nutrition, gastrointestinal (GI) integrity, and adherence to chemotherapy treatment plans. This article reviews the principles of CINV management, planning and implementation of antiemetic regimens, and pharmacology of the antiemetics currently available in the United States appropriate for pediatric use. With the advent of more targeted therapies, increased use of immunotherapy, and the effects of radiotherapy to the brain, spine, and abdomen, treatment of CINV now has a broader application than just for chemotherapeutics alone.

Tapping into 5-HT3 Receptors to Modify Metabolic and Immune Responses

5-hydroxytryptamine type 3 (5-HT₃) receptors are ligand gated ion channels, which clearly distinguish their mode of action from the other G-protein coupled 5-HT or serotonin receptors. 5-HT₃ receptors are well established targets for emesis and gastrointestinal mobility and are used as adjunct targets in treating schizophrenia. However, the distribution of these receptors is wider than the nervous system and there is potential that these additional sites can be targeted to modulate inflammatory and/or metabolic conditions. Recent progress in structural biology and pharmacology of 5-HT₃ receptors have provided profound insights into mechanisms of their action. These advances, combined with insights into clinical relevance of mutations in genes encoding 5-HT₃ subunits and increasing understanding of their implications in patient's predisposition to diseases and response to the treatment, open new avenues for personalized precision medicine. In this review, we recap on the current status of 5-HT₃ receptor-based therapies using a biochemical and physiological perspective. We assess the potential for targeting 5-HT₃ receptors in conditions involving metabolic or inflammatory disorders based on recent findings, underscoring the challenges and limitations of this approach.

Comparing the effect of acupressure and ginger on chemotherapy gastrointestinal side-effects in children with leukemia

The biosocial data of 90 children with acute lymphoblastic leukemia, were collected along with assessment of gastrointestinal side-effects of chemotherapy using visual analogue scale. Ginger lozenges has more effect than acupressure in alleviating nausea and vomiting. Acupressure alleviate the nausea best in the group aged 13-15 years. Ginger helped more the other two groups (7-12 years, 69 % of the group didn't suffer from nausea), versus 50 % aged 13-15). Both acupressure and ginger affected girls more than boys in alleviating nausea. The acupressure effect on vomiting incidence didn't differ in both males and males, whilst ginger helped the males more.

Phase III study of palonosetron for prevention of chemotherapy-induced nausea and vomiting in pediatric patients

BACKGROUND

Palonosetron has demonstrated non-inferiority to ondansetron for prevention of chemotherapy-induced nausea and vomiting in pediatric patients in the United States and Europe. We conducted a single-arm registration study to evaluate the efficacy, safety and pharmacokinetics of palonosetron in pediatric patients in Japan.

METHODS

Key inclusion criteria were age of 28 days to 18 years and malignant disease for which initial highly emetogenic chemotherapy or moderately emetogenic chemotherapy was planned. Patients received palonosetron at 20 μg/kg over at least 30 s intravenously before the start of highly emetogenic chemotherapy or moderately emetogenic chemotherapy and received dexamethasone on Days 1-3. The primary endpoint was the proportion of patients achieving a complete response in the overall phase (0-120 h) in Course 1, and its threshold was set at 30%.

RESULTS

From December 2016 to June 2019, 60 patients were enrolled, and 58 received at least one dose of palonosetron. The proportion of patients achieving a complete response during the overall phase was 58.6% (95% confidence interval, 44.9%-71.4%), showing the primary endpoint was met (P < 0.0001). Treatment-related adverse events occurred in two patients (3.4%). Regarding the pharmacokinetics of palonosetron, neither the plasma concentration immediately after administration nor the area under the plasma concentration-time curve from time 0 to infinity differed significantly among the age groups.

CONCLUSION

We demonstrated the efficacy of palonosetron in pediatric patients receiving highly emetogenic chemotherapy or moderately emetogenic chemotherapy and confirmed the appropriateness of the 20 μg/kg dose, regardless of age, considering the safety and pharmacokinetic profiles.

TRIAL REGISTRATION

JapicCTI-163305, registered 6 June 2016.

Data Quality of Chemotherapy-Induced Nausea and Vomiting Documentation

OBJECTIVE

The objective of the study was to characterize the completeness and concordance of the electronic health record (EHR) documentation of cancer symptoms among multidisciplinary health care professionals.

METHODS

We examined the EHRs of children, adolescents, and young adults who received highly emetogenic chemotherapy and characterized the completeness and concordance of chemotherapy-induced nausea and vomiting (CINV) documentation by clinician type and by the International Classification of Diseases 10th Revision (ICD-10) coding choice.

RESULTS

The EHRs of 127 patients, comprising 870 patient notes, were abstracted and reviewed. A CINV assessment was documented by prescribers in 75% of patients, and by nurses in 58% of patients. Of the 60 encounters where both prescribers and nurses documented, 72% agreed on the presence/absence of CINV.

CONCLUSION

Most patients receiving highly emetogenic chemotherapy had a documented assessment of CINV; however, many had incomplete or discordant documentation of CINV from different providers by role, implying the importance of incorporating pragmatic knowledge of EHR documentation patterns among multidisciplinary health professionals for EHR phenotyping and clinical decision support systems directed toward cancer-related symptom management.

Efficacy and Safety of Thalidomide for Chemotherapy-induced Nausea and Vomiting

Purpose: A substantial number of cancer patients discontinue chemotherapy due to severe chemotherapy-induced nausea and vomiting (CINV). This study aimed to evaluate the efficacy and safety of thalidomide (THD) in CINV. Methods: We searched different databases to identify related studies that investigated the efficacy and safety of THD in CINV. The primary outcomes were CINV in the acute (0-24 h), delayed (24-120 h), and overall (0-120 h) phases, respectively. The secondary outcomes were the safety of THD and the patients' quality of life (QOL). Results: Fourteen randomized control trials (RCTs) including 1744 patients (42% male) reported the risk ratio (RR) and 95%CI of the THD group versus control group in reducing nausea and vomiting. Meta-analysis showed that THD statistically enhanced the complete response rate of nausea and vomiting in the delayed (nausea: RR = 1.69, 95%CI: 1.47-1.94; vomiting: RR = 1.38, 95%CI: 1.26-1.51) and overall phases (nausea: RR = 1.54, 95%CI: 1.31-1.81; vomiting: RR = 1.31, 95%CI: 1.18-1.46). Furthermore, subgroup analysis based on THD dosage (100 vs 200 mg/day) demonstrated no statistical significance with respect to overlapping 95%CI. Thirty studies monitored the adverse events (AEs) of THD, all under grade 3 based on the CTCAE criteria. We compared the eight most common AEs; sedation, constipation, and drowsiness/dizziness were slightly frequent compared with controls. Conclusion: THD is an effective adjuvant and a potential alternative in reducing delayed and overall CINV. Other regimens might be added for CINV during the acute phase.

Gingerol inhibits cisplatin-induced acute and delayed emesis in rats and minks by regulating the central and peripheral 5-HT, SP, and DA systems

Abstract

Gingerol, a biologically active component in ginger, has shown antiemetic properties. Our study aimed to explore the underlying mechanisms of gingerol on protecting rats and minks from chemotherapy-induced nausea and vomiting. The preventive impact of gingerol was evaluated in the pica model of rats and the vomiting model of minks induced by cisplatin at every 6 h continuously for a duration of 72 h. Animals were arbitrarily separated into blank control group, simple gingerol control group, cisplatin control group, cisplatin + metoclopramide group, cisplatin + three different doses gingerol group (low-dose; middle-dose; high-dose). The area postrema as well as ileum damage were assessed using H&E stain. The levels of 5-TH, 5-HT₃ receptor, TPH, SERT, SP, NK₁ receptor, PPT, NEP, DA, D2R, TH, and DAT were determined using immunohistochemistry or qRT-PCR in rats and minks. All indicators were measured in the area postrema along with ileum. The kaolin intake by rats and the incidence of CINV of minks were significantly decreased after pretreatment with gingerol in a dosage-dependent way for the duration of 0–24-h and 24–72-h. Gingerol markedly decreased the levels of 5-TH, 5-HT₃ receptor, TPH, SP, NK₁ receptor, PPT, DA, D2R, TH, alleviated area postrema as well as ileum damage, and increased the accumulation of SERT, NEP, DAT in the area postrema along with ileum of rats and minks. Gingerol alleviates cisplatin-induced kaolin intake of rats and emesis of minks possibly by regulating central and peripheral 5-HT system, SP system and DA system.

Graphic abstract

Efficacy, safety and feasibility of fosaprepitant for the prevention of chemotherapy-induced nausea and vomiting in pediatric patients receiving moderately and highly emetogenic chemotherapy - results of a non-interventional observation study

BACKGROUND

Chemotherapy-induced nausea and vomiting (CINV) belong among the most burdensome side effects in hemato-oncology. Mostly, a combination of ondansetron and dexamethasone is used as antiemetic prophylaxis in pediatric patients undergoing emetogenic chemotherapy. However, dexamethasone is prohibited in different pediatric chemotherapy protocols. Currently, data on the use of ondansetron with the new antiemetic agent fosaprepitant without dexamethasone is not available for pediatric patients.

METHODS

In this non-interventional observation study, 79 pediatric patients with a median age of 8.0 years (range 0.5-17.9 years) who received a CINV prophylaxis regimen with either fosaprepitant (4 mg/kg; maximum 150 mg) and ondansetron (as 24-h continuous infusion) (n = 40; fosaprepitant group/FG) or ondansetron only (n = 39; control group/CG) during moderately or highly emetogenic chemotherapy were analyzed. The groups were analyzed and compared for frequency of vomiting, administered doses of on-demand antiemetic dimenhydrinate and adverse events during the acute (0-24 h after chemotherapy administration) and delayed (> 24 h-120 h) CINV phases.

RESULTS

A total of 112 and 116 chemotherapy blocks were analyzed in the fosaprepitant and the control group, respectively. The emetogenic potential of the administered chemotherapy did not significantly differ (p = 0.8812) between the two cohorts. In the acute CINV phase, the percentage of patients experiencing vomiting (n = 26 patients) and the vomiting events were significantly higher (p = 0.0005 and p < 0.0001, respectively) in the CG (n = 26 patients (66.7%); 88 events) compared with the FG (n = 10 patients (25.0%); 37 events). In the delayed CINV phase, the percentage of patients experiencing vomiting and the vomiting events were also significantly higher (p = 0.0017 and p < 0.0001, respectively) in the CG (n = 31 patients (79.5%); 164 events) compared with the FG (n = 17 patients (42.5%); 103 events). Additionally, significantly more dimenhydrinate doses were administered in the CG compared with the FG patients (n = 322/n = 198; p < 0.0001). The occurrence of adverse events did not significantly differ between the two groups (p > 0.05).

CONCLUSION

Fosaprepitant (4.0 mg/kg) in addition to ondansetron, without application of dexamethasone, was well tolerated, safe, effective and superior to ondansetron only as CINV prophylaxis in pediatric patients during moderately and highly emetogenic chemotherapy.

Systematic review of the effectiveness of complementary and alternative medicine on nausea and vomiting in children with cancer: a study protocol

INTRODUCTION

Nausea and vomiting are two most common symptoms reported by children with cancer when they undergo active treatment. However, pharmacological treatment is not sufficient to manage these two symptoms, with over 40% of children still experience nausea and vomiting after receiving antiemetics. There has been an exponential growth of studies to demonstrate the effectiveness of different complementary complementary medicine (CAM) to control nausea and vomiting during cancer treatment. Appropriate application of CAM enhances the effectiveness of antiemetics, thus reducing the symptom burden on children as well as improving their general condition and quality of life during cancer treatment. Nevertheless, it remains unclear which CAM is the best approach to help children to prevent or reduce nausea and vomiting during and after cancer treatment. This paper describes a protocol for identifying, analysing and synthesising research evidence on the effectiveness of CAM on nausea and vomiting in children with cancer.

METHODS AND ANALYSIS

A total of 10 databases will be searched to identify appropriate literature: MEDLINE, the Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, CINAHL, PsycINFO, LILACS, OpenSIGLE, the Chinese Biomedical Literature Database, the Chinese Medical Current Contents and the Chinese National Knowledge Infrastructure. All randomised controlled trials which meet the inclusion criteria will be included. The primary outcome is the changes in nausea and vomiting either assessed by self-reported and/or objective measures. Review Manager 5.3 will be used to synthesise the data, calculate the treatment effects, perform any subgroup analysis and assess the risk of bias.

ETHICAL AND DISSEMINATION

The results will be presented at international conferences and published in peer-reviewed journals. As no individual data will be involved in this review, ethical approval is not required.

PROSPERO REGISTRATION NUMBER

CRD42019135404.

Intravenous fosaprepitant for the prevention of chemotherapy-induced vomiting in children: A double-blind, placebo-controlled, phase III randomized trial

BACKGROUND

Fosaprepitant is a neurokinin-1 receptor antagonist, approved for the prevention of chemotherapy-induced nausea and vomiting. The data on the use of fosaprepitant in children are limited and therefore we conducted a phase III randomized controlled trial.

PROCEDURE

Children aged 1-12 years scheduled to receive moderately or highly emetogenic chemotherapy were randomly assigned to arm-A (fosaprepitant) or arm-B (placebo). Children recruited to arm-A received intravenous ondansetron plus dexamethasone followed by fosaprepitant infusion. Children recruited to arm-B received the same drugs as those given to children in arm-A, except that fosaprepitant was substituted with a placebo. Ondansetron and dexamethasone were continued for 48 hours after completion of chemotherapy. The primary end point of the study was to determine the proportion of patients who achieved a complete response (CR), defined as no vomiting, no retching, and no use of rescue medication, during the 24-120 hours (delayed phase) after administration of the last dose of chemotherapy. Secondary end points were the proportion of patients who achieved a CR during the acute phase (0-24 hours) and overall after administration of the last dose of chemotherapy.

RESULTS

One-hundred-sixty-three patients were analyzed (81 in the fosaprepitant arm and 82 in the placebo arm). CR rates were significantly higher in the fosaprepitant arm compared to those in the placebo arm during the acute phase (86% vs 60%, P < 0.001), delayed phase (79% vs 51%, P < 0.001), and overall phase (70% vs 41%, P < 0.001). Three (4%) patients in the fosaprepitant arm and sixteen (20%) in the placebo arm required rescue anti-emetics (P = 0.0017).

CONCLUSION

Addition of fosaprepitant to ondansetron and dexamethasone improved chemotherapy-induced vomiting control in children treated with moderately or highly emetogenic chemotherapy.

A Review of Patient-Reported Outcomes Labeling for Oncology Drugs Approved by the FDA and the EMA (2012-2016)

OBJECTIVES

To compare US Food and Drug Administration (FDA) and European Medicines Agency (EMA) labeling for evidence based on patient-reported outcomes (PROs) of new oncology treatments approved by both agencies.

METHODS

Oncology drugs and indications approved between 2012 and 2016 by both the FDA and the EMA were identified. PRO-related language and analysis reported in US product labels and drug approval packages and EMA summaries of product characteristics were compared for each indication.

RESULTS

In total, 49 oncology drugs were approved for a total of 64 indications. Of the 64 indications, 45 (70.3%) included PRO data in either regulatory submission. No FDA PRO labeling was identified. PRO language was included in the summary of product characteristics for 21 (46.7%) of 45 indications. European Organisation for Research and Treatment of Cancer and Functional Assessment of Cancer Therapy measures were used frequently in submissions. FDA's comments suggest that aspects of study design (eg, open labels) or the validity of PRO measures was the primary reason for the lack of labeling based on PRO endpoints. Both agencies identified missing PRO data as problematic for interpretation.

CONCLUSIONS

During this time period, the FDA and the EMA used different evidentiary standards to assess PRO data from oncology studies, with the EMA more likely to accept data from open-label studies and broad concepts such as health-related quality of life. An understanding of the key differences between the agencies may guide sponsor PRO strategy when pursuing labeling. Patient-focused proximal concepts are more likely than distal concepts to receive positive reviews.

Drug review: Fosaprepitant

Chemotherapy-induced nausea and vomiting (CINV) is a significant contributor to the treatment morbidity experienced by patients with cancer. With effective prophylactic anti-emetics given prior to administration of moderately or highly emetogenic chemotherapy (MEC or HEC) it is expected that 70-80% of patients will have no CINV. Fosaprepitant is an intravenous prodrug of aprepitant that acts as an anti-emetic by blocking the neurokinin (NK-1) receptor. Fosaprepitant in combination with dexamethasone and 5-HT3 antagonist like ondansetron has been shown to be effective in preventing CINV in patients receiving MEC or HEC. The current review discusses the pharmacology and clinical indications for the use of fosaprepitant. The evidence for the effectiveness of fosaprepitant in the prevention of CINV and the commonly observed adverse events with its administration is discussed in this review.

Multi-Component Herbal Products in the Prevention and Treatment of Chemotherapy-Associated Toxicity and Side Effects: A Review on Experimental and Clinical Evidences

Chemotherapy is nowadays the main treatment of human cancers. Chemotherapeutic agents target rapidly dividing cancer cells to suppress tumor progression, however, their non-specific cytotoxicity often leads to significant side effects that might be intolerable to cancer patients. Multi-component herbal products have been used for thousands of years for the treatment of multiple human diseases. This study aims to systematically summarize and evaluate the experimental and clinical evidences of the efficacy of multi-component herbal products in improving chemotherapy-induced side effect. Literature was retrieved from PubMed database and evaluated based on the side effects described. Multi-component herbal products were found to be effective in ameliorating the neurotoxicity, gastrointestinal toxicity, hematological toxicity, cardiotoxicity, hepatotoxicity and nephrotoxicity. Both experimental and clinical evidences were found, indicating the potential of applying multicomponent herbal products in the clinical treatment of chemotherapy-induced side effects. However, the lack of mechanistic and pharmacokinetic studies, inconsistency in product quality, as well as insufficient clinical evidence suggested that more investigations are urgently necessary. In all, our review shed light on the potential of using multi-component herbal products in the clinical management of chemotherapy-induced toxicity and side effects. We also discussed the potential threats of natural products for cancer treatment and compared the advantages of using herbs to conventional chemical drugs.

Acute chemotherapy-induced nausea and vomiting in children with cancer: Still waiting for a common consensus on treatment

Chemotherapy-induced nausea and vomiting (CINV) is one of the most common treatment side-effects, and remains a significant concern, in children undergoing chemotherapy. Although adult patients receive chemotherapy regimens combined with appropriate standardized antiemetic treatment, children can receive markedly varying antiemetic treatments. A narrative review of CINV was performed regarding CINV definition, scoring system, prevention and treatment, specifically focussing on studies conducted with paediatric oncology patients. The review highlighted a lack of rigorously developed CINV scoring systems and standardized CINV pharmacological treatment for paediatric oncology patients. Different scoring systems were found to identify potential risk factors for CINV associated with the use of several different antiemetic drugs, however, few studies have been performed in children undergoing chemotherapy. Thus, CINV remains a distressing and partially controlled side-effect in the paediatric patient population. To reduce emesis and improve quality of life in paediatric oncology patients, standardized antiemetic treatment may be preferred, using a unique CINV scoring system that accounts for the emetogenic level of the chemotherapy regimen adopted and the children's clinical characteristics.

Ginger Extract and [6]-Gingerol Inhibit Contraction of Rat Entire Small Intestine

This study aims to investigate the effect of oral administration and the direct action of ginger extract or [6]-gingerol on small intestinal contractility. The direct effect of 10 minutes preincubation of ginger ethanolic extract (10, 100 and 300 μg/mL) or [6]-gingerol (1, 30, and 100 μM) on 0.01 to 30 μM ACh-induced contractions of all parts of the small intestine isolated from normal rats was investigated using the organ bath technique. For in vivo study, the rats were orally administered with extract (10, 20, and 100 mg/kg/d) or [6]-gingerol (2 mg/kg/d) for 7 days, followed by determining the contractile responses to ACh of rat isolated duodenum, jejunum, and ileum and their histology were assessed. Direct application of the extract or [6]-gingerol attenuated ACh-induced contractions in each small intestinal segment, E_max was reduced by 40% to 80%, while EC₅₀ increased 3- to 8-fold from control. Similarly, in the in vivo study ACh-induced contractions were reduced in all parts of the small intestine isolated from rats orally treated with ginger extract (20 and 100 mg/kg/d) or [6]-gingerol (2 mg/kg/d). E_max decreased 15% to 30%, while EC₅₀ increased 1- to 3-fold compared to control. No discernable changes in the histology of intestinal segments were detectable. Thus, the results support the clinical application of ginger for disorders of gastrointestinal motility.