Intravenous lorazepam to prevent nausea and vomiting associated with cancer chemotherapy

Physiology of chemotherapy-induced emesis and antiemetic therapy. Predictive models for evaluation of new compounds

The physiology of emesis has been studied for several hundred years, focusing on the different centres involved and the mechanics of expulsion. The vomiting centre receives inputs from various emetic detectors such as the gut, the vestibular labyrinths and the chemoreceptor trigger zone. Emesis is a common disabling effect in motion sickness, postoperative conditions and in radio- and chemotherapy. Our current understanding of the mechanisms has been provided mainly by the recent introduction of serotonin 5-HT3 receptor antagonists into therapeutic use. Nevertheless, despite the considerable advances made in the understanding of the different pathways involved in emesis, there are number of areas that still require experimental investigation. Different animal and human models are available to study the physiology of emesis and to evaluate the antiemetic activity of new compounds, but they need to be predictors of clinical situations.

Efficacy of Ondansetron and Lorazepam in controlling emesis associated with cytotoxic chemotherapy

A phase II study using a combination of Ondansetron and Lorazepam to treat patients receiving either highly or moderately emetogenic chemotherapy regimens has recently been completed. A total of 56 patients were enrolled and data from 53 is amenable to analysis. The overall response rates were 100% and 91% for the highly and moderately emetogenic regimens respectively, with 16 out of 20 patients (80%) and 18 out of 33 patients (54.5%) achieving a complete or major response respectively. Toxicity was mild and no dose modifications were necessary.

Enhancing the effectiveness of the specific serotonin antagonists. Combination antiemetic therapy with dexamethasone

Combinations of drugs have become standard therapy for the prevention of vomiting caused by anticancer drugs like cisplatin. Recently, a new class of antiemetic agents, the potent and specific 5-HT3 receptor antagonists such as ondansetron, granisetron, and tropisetron, have been shown to be more effective and better tolerated than metoclopramide. This report describes the rationale for combination antiemetic therapy, details the testing of metoclopramide-based regimens as a model for combination therapy development, reviews completed trials of ondansetron plus dexamethasone, and offers strategies to further alleviate vomiting during anticancer chemotherapy. The reported trials testing metoclopramide-based combinations were reviewed and that experience was applied to the ongoing studies of ondansetron when used with dexamethasone and other agents. Combinations of metoclopramide, dexamethasone, and lorazepam prevented acute emesis caused by high-dose cisplatin in 63% of patients, lessened side effects, and were convenient enough to administer to outpatients. Completed trials of ondansetron and dexamethasone demonstrated improved vomiting control over ondansetron alone while using less cumbersome schedules. Attempts to improve ondansetron-based antiemetic regimens by developing optimal drug doses and schedules and adding adjuvant and different classes of antiemetic agents are now in clinical testing. Based on previous experience and current results, combinations of a specific serotonin agonist and dexamethasone are the best treatment for prevention of vomiting induced by chemotherapy. Future clinical research should aim to refine antiemetic regimens and improve emetic control through the use of new antiemetic and adjuvant agents.

Midazolam in patients receiving anticancer chemotherapy and antiemetics

Benzodiazepines lessen anxiety and improve comfort in cancer patients. Midazolam is an effective benzodiazepine with a rapid onset and short duration of action, properties that could permit its use in outpatient areas or in short but stressful situations. Two consecutive trials were undertaken to study midazolam as an adjunct in patients receiving anticancer chemotherapy. Each studied midazolam given as a short infusion 30 min prior to chemotherapy at dose levels ranging from 0.01 to 0.05 mg/kg. Trial I determined the safety, sedation, and dose of midazolam in patients receiving chemotherapy of low to moderate emetic potential. Twenty-two patients were entered. No significant respiratory depression or oxygen desaturation was observed. At the optimal dose level (0.04 mg/kg), sedation began a median of 3 min following administration and continued for a median of 38 min. Sixty-four percent of patients experienced mild sedation. Trial II studied the same doses of midazolam when used in combination with intravenous metoclopramide and dexamethasone in patients receiving cisplatin > or = 100 mg/m2. Nineteen patients were entered; 79% experienced mild sedation. At the 0.04-mg/kg dose level, sedation began a median of 18 min following administration and continued for a median of 170 min. Midazolam can be given safely to patients receiving chemotherapy with and without concomitant antiemetics. The predictability and duration of its sedative effects suggest it can be used in outpatients.

Antiemetic regimens in outpatients receiving cisplatin and non-cisplatin chemotherapy. A randomized trial comparing high-dose metoclopramide plus methylprednisolone with and without lorazepam

Results of a randomized trial on antiemesis for cisplatin (CDDP) and non-CDDP chemotherapy-induced vomiting are reported. One hundred and sixty-three outpatients received 282 chemotherapy courses (141 with CDDP and 141 without CDDP). Patients were randomly assigned to receive either high-dose metoclopramide plus methylprednisolone (arm A) or the same drugs plus lorazepam (arm B). In both arms a high protection rate for vomiting was obtained, on the whole without statistically significant differences. Patients who received lorazepam had, however, significantly fewer nausea episodes during first day post-chemotherapy (p less than 0.05). Arm B was also superior in anxiety control during the first day of chemotherapy (p less than 0.01). Both regimens were significantly more effective in patients who had not been given chemotherapy previously (p less than 0.01). No differences in antiemetic protection were found between CDDP and non-CDDP courses. No significant differences were found in premonitory vomiting control between the two arms of the trial. Toxicity was very mild with both regimens, although sedation was significantly higher in arm B (p less than 0.001). We conclude that high-dose metoclopramide plus methylprednisolone is a highly effective combination for chemotherapy-induced nausea and vomiting, and that it is quite suitable for outpatient use. Lorazepam did not significantly increase the antiemetic potency of the combination, nor did it improve premonitory vomiting control, although it gave a better control of acute nausea and anxiety.

Anticipatory nausea and vomiting: a form of chemotherapy phobia?

This paper proposes that the phenomenon of anticipatory nausea and/or vomiting is a component of a phobic response to chemotherapy. Two cases are presented to highlight the clinical aspects of chemotherapy phobia. The evidence confirming such a diagnosis is put forth as it relates to anticipatory anxiety, phobic response, avoidance behaviour and treatment.

The role of metoclopramide in acute and delayed chemotherapy induced emesis: a randomised double blind trial

High dose metoclopramide is an effective anti-emetic for use with cisplatin containing chemotherapy regimens but can cause extrapyramidal reactions. Lorazepam and dexamethasone are increasingly being used to alleviate chemotherapy induced emesis. This trial has assessed the contribution of high dose metoclopramide to anti-emetic control when given with dexamethasone and lorazepam. Eight-one patients receiving chemotherapy, mainly for gynaecological malignancy, entered a randomised double blind cross-over trial comparing dexamethasone and lorazepam with or without a 24 h metoclopramide infusion. This was followed by oral dexamethasone with or without oral metoclopramide for three further days depending on the initial randomisation. Sixty-one patients were fully evaluable. Fifty-five received cisplatin containing regimens and six non-cisplatin regimens. There was a significant reduction in the number of episodes of vomiting during the first 24 h in patients receiving the metoclopramide combination (P = 0.0001). On first exposure to chemotherapy 45% of patients receiving dexamethasone, lorazepam and high dose metoclopramide had no vomiting while 67% had two episodes or less ('major control'). This compared to 11% total control and 25% major control in those receiving dexamethasone, lorazepam and placebo. The control of nausea in the first 24 h was also improved (P = 0.0001). There was no difference in the degree of nausea or vomiting during the following three weeks between those receiving oral dexamethasone alone and those receiving dexamethasone and metoclopramide. Both groups showed a significant increase in nausea in the three weeks following the second course of treatment when compared to the first (P = 0.0007). Extrapyramidal reactions were recorded in 11.5% of patients receiving metoclopramide. More patients stated a preference for the metoclopramide combination although this was not statistically significant (chi 2(1) = 0.29, P = 0.59). In conclusion the combination of dexamethasone and lorazepam can give major control of emesis in 25% of patients receiving very emetogenic chemotherapy. The addition of metoclopramide increases this to 67% on first exposure to chemotherapy, but at the expense of extrapyramidal reactions in 11.5%.

Contributions of benzodiazepines to cancer therapy

We have reviewed the therapeutic effects of benzodiazepines employed as adjuncts to cancer treatment. These agents have been used primarily for alleviating or attenuating situational anxiety, insomnia, chemotherapy-induced nausea and vomiting, and anticipatory nausea and vomiting. Situational anxiety not corrected by psychosocial support, symptom control, or time may be successfully treated with benzodiazepines. Procedure-related anxiety, for example, that related to bone marrow biopsy, venipuncture, intrathecal therapy, and the insertion of subclavian and femoral catheters, is a serious problem that may be alleviated by the use of benzodiazepines. Insomnia not caused by a depression serious enough to warrant treatment with a tricyclic antidepressant also may be successfully treated with benzodiazepines. Many clinicians have found benzodiazepines to be useful adjuncts to a cancer chemotherapy regimen because of their anxiolytic, sedative, and amnesic properties and also because of their suspected antiemetic properties when these drugs are used in conjunction with known antiemetic agents. The ability of lorazepam to induce antegrade amnesia has proved particularly useful in alleviating anticipatory nausea and vomiting connected with repeated courses of cytotoxic chemotherapy. Furthermore, since benzodiazepines are relatively safe drugs, their continued and probably expanded uses as cancer therapy adjuncts can be anticipated.

Antiemetic control and prevention of side effects of anti-cancer therapy with lorazepam or diphenhydramine when used in combination with metoclopramide plus dexamethasone. A double-blind, randomized trial

Combinations of metoclopramide and dexamethasone given intravenously control vomiting caused by high doses of cisplatin. Lorazepam and diphenhydramine are useful adjuncts to antiemetics. In a double-blind trial, 120 patients receiving high-dose cisplatin (120 mg/m2) for the first time were randomly assigned to receive either lorazepam (1.5 mg/m2) or diphenhydramine (50 mg) intravenously, 45 minutes prior to cisplatin. In addition, all patients received intravenous dexamethasone (20 mg) 40 minutes prior to chemotherapy along with metoclopramide (3 mg/kg) 30 minutes before and 90 minutes after cisplatin. Patients were directly observed in the hospital after cisplatin administration and completed a subjective assessment questionnaire. Overall, 60% of patients experienced no vomiting, and 83% had two or fewer emetic episodes during the study. There were no significant differences in objective antiemetic control between the two regimens. Only 3% of patients receiving lorazepam experienced treatment-related restlessness as opposed to 19% given diphenhydramine (P = 0.007). Less recall of chemotherapy administration (P less than 0.001), more sedation (P = 0.003), and transient enuresis while sedated (P = 0.0002) were characteristic of patients receiving lorazepam. Patient-generated ratings revealed less anxiety (P = 0.0001) for those individuals given the lorazepam-containing combination. Both regimens were well accepted, with 89% of patients receiving the lorazepam combination and 83% of those given the diphenhydramine regimen wishing to receive the same drugs in the future. Some degree of delayed vomiting occurred in 85% of patients during the 4-day period following this study. During the time that patients are at the greatest risk for emesis, the 24 hours immediately following cisplatin, three drug antiemetic combinations of either lorazepam or diphenhydramine with metoclopramide plus dexamethasone stopped cisplatin-induced emesis for the majority of patients and lessen other treatment-related side effects. Less restlessness and anxiety were observed among individuals receiving the lorazepam-containing combination.

Optimum management of nausea and vomiting in cancer chemotherapy

Nausea and vomiting continue to be critical problems in cancer chemotherapy, although considerable progress has been made toward understanding the neuropharmacological mechanisms of vomiting and how chemotherapeutic agents and antiemetics affect these mechanisms. The principles of behavioural psychology have also been applied in an effort to understand and effectively manage these complications which have potentially serious consequences. For example, there is now some degree of rationality to our use of metoclopramide for cisplatin-induced nausea and vomiting, the use of combination antiemetic regimens, and use of lorazepam for the prevention (albeit unproven) of anticipatory nausea and vomiting. It must be admitted, however, that our approach is for the most part still empirical. Selecting an antiemetic programme is not a simple task. The emetogenic potential of the chemotherapy being used, the presence of coexisting diseases, the potential toxicity of the antiemetic drug and whether antiemetic therapy is to take place in the hospital or in an outpatient setting, the familiarity of the clinician with the various antiemetic therapies, and cost are all factors which need to be considered. Although phenothiazines remain the standard treatment, they are of little value against chemotherapy programmes that produce moderate or severe problems. Newer pharmacological approaches including butyrophenones, cannabinoids, metoclopramide, high-dose corticosteroids, and benzodiazepines have shown increased antiemetic efficacy, as have combinations of these agents which are directed against multiple sites of emetogenic activity. The role of behavioural therapies, which have been shown to be effective particularly in children and in anticipatory nausea and vomiting, needs to be more firmly established. Rather than recommending a given antiemetic programme for any particular chemotherapy, it is preferable to think in terms of initial approaches and how they can be modified. No one antiemetic programme is effective or safe in all situations.

Mechanisms and management of chemotherapy-induced nausea and vomiting

Only in recent years has serious attention been given to the control of chemotherapy-induced emesis (CIE) which is to the patient a most obnoxious side-effect. Important advances in the understanding of the mechanisms of CIE have led to the scientific appraisal of potential anti-emetics whilst additional, useful anti-emetics have appeared by serendipity. CIE has largely been studied in trials separating either cis-platinum (severely emetic) or non-cis-platinum(moderately emetic)-induced emesis. In the evolution of these trials the difficulty and importance of accurate evaluation of emesis has been revealed and the whole area of psychogenic emesis opened to investigation and treatment. Phenothiazines and butyrophenones have a definite modest anti-emetic role against moderately emetogenic chemotherapy but increasingly corticosteroids, benzodiazepines, high dose metoclopramide and cannabinoids are being used with great effect even with severely emetic drugs. Combination anti-emesis has further improved control rates and new schedules of currently available anti-emetics are now proving their worth. Major advances in anti-emetic control have been achieved recently and every patient at risk of CIE should have good control, if not total abolition, of emesis with appropriate use of anti-emetics.

The antiemetic efficacy of secobarbital and chlorpromazine compared to metoclopramide, diphenhydramine, and dexamethasone. A randomized trial

The efficacy of secobarbital sodium plus chlorpromazine (SC) in the prevention of cisplatin induced emesis was compared to the combination of metoclopramide, diphenhydramine, and dexamethasone (MDD). Twenty-three patients were entered onto protocol. Eighteen were evaluable. Good to excellent antiemetic prophylaxis was obtained in 72% with MDD versus 17% with SC (P less than 0.01). Sedation and anticholinergic side effects were more common with SC. Extrapyramidal reactions were more commonly seen with MDD. Significantly more patients preferred the combination of metoclopramide, diphenhydramine, and dexamethasone (P less than 0.05).

The control of cancer chemotherapy-induced nausea and vomiting

The incidence and consequences of the nausea and vomiting induced by many cancer chemotherapeutic regimes are explored and the emetogenic potential of the commonly used cytotoxic drugs evaluated. The physiology and pharmacology of chemotherapy-induced vomiting is largely unresolved but the postulated mechanisms are described and related to known properties of anti-emetic agents. The difficulties associated with the design and evaluation of trials assessing the effectiveness of single agent or combination therapy for this indication are discussed. After identifying general principles of anti-emetic prophylaxis, a critical evaluation is made of the effectiveness of the following drugs or classes of drugs, based on the available data: antihistamines, anticholinergics, phenothiazines, butyrophenones, domperidone, metoclopramide, cannabinoids, corticosteroids and benzodiazepines. Although there are still insufficient data to allow absolute recommendations to be made regarding the choice of anti-emetic therapy, considerations which should govern drug choice are listed and an algorithm presented as an aid to decision making. The contributions that can be made by a pharmacist in this area of drug use are noted.

A pilot study of lorazepam-induced amnesia with cis-platinum-containing chemotherapy

Eighteen patients with advanced epithelial ovarian cancer were given 36 courses of cis-platinum-containing chemotherapy at Cedars-Sinai Medical Center. Patients were given lorazepam (Ativan) prior to chemotherapy. Amnesia for the day of chemotherapy was reported in 29 courses. Lack of recall for the chemotherapy infusion and the subsequent 8 hr or greater was reported in 33 of the 36 courses. In two courses, no amnesia effects were noted. No serious side effects of lorazepam therapy occurred and all patients believed that the amnesic effect was beneficial during chemotherapy. Lorazepam (Ativan) appears to be a safe medication to induce amnesia for cis-platinum chemotherapy and deserves further study to determine its effect on anticipatory vomiting, nausea and vomiting, and patient compliance with continued chemotherapy.

Lorazepam as an adjunct to antiemetic therapy with haloperidol in patients receiving cytotoxic chemotherapy

Twenty-seven consecutive patients were treated with 3 mg oral lorazepam and 2.5 mg intravenous haloperidol in an effort to improve patient tolerance of cytotoxic chemotherapy and decrease nausea and vomiting. Antiemetic efficacy and side-effects were assessed using a patient questionnaire. Vomiting either did not occur, or was considered to be of only moderate intensity in 22 patients (81%) and usually ceased within 24 hours of commencing chemotherapy. Similarly, nausea was either absent or of only moderate severity, lasting less than 48 hours in the majority of patients. Eight of 11 patients who had received similar previous cytotoxic treatment with antiemetic agents but not lorazepam considered that lorazepam and haloperidol had considerably improved their tolerance of chemotherapy. The side-effects of haloperidol and lorazepam were mild and well tolerated.