Optimising antiemetic therapy: what are the problems and how can they be overcome?

Overview of premedication prescription and intake in an oncology day hospital: What do we need to change to improve patient management?

BACKGROUND

Premedication of cancer therapy against nausea and vomiting (NV) and hypersensitivity reaction (HS) is essential for good patient management. However, this prescription is not always optimal. Today, as a large part of cancer therapies are administered in day hospitals (DH), premedication taken on the day of the cancer treatment is injected as a 30-min infusion.

OBJECTIVE

To assess compliance with recommendations for premedication prescription and intake; to analyse patient attitude about switching to exclusively oral forms taken at home.

METHOD

The study is conducted in the medical oncology DH of a French Hospital from 17 January to 25 February 2022. The data collection is carried out as an individual interview, associated with the distribution of two questionnaires. Data are coupled with the premedication set up on our software and the last medical report. Intakes are considered optimal when recommendations, tolerance, background, and adherence of the patient are taken into account.

RESULTS

Seventy patients were included for interviews. Regarding software prescriptions, our configuration was consistent with recommendations in 100% of cases for HS and 37% for NV. Intakes were compliant in 51.4% of cases, non-compliant in 17.1% and debatable in 31.5%. Disparities between the practices of different physicians were identified. Regarding the feasibility of oral substitution, it could concern 63.5% of patients.

CONCLUSION

This work makes it possible to improve the management of all patients and to make the operation of the care unit more fluid.

SEOM clinical guideline emesis (2021)

Among the side effects of anticancer treatment, chemotherapy-induced nausea and vomiting (CINV) is one of the most feared given its high prevalence, affecting up to 40% of patients. It can impair patient’s quality of life and provoke low adherence to cancer treatment or chemotherapy dose reductions that can comprise treatment efficacy. Suffering CINV depends on factors related to the intrinsic emetogenicity of antineoplastic drugs and on patient characteristics. CINV can appear at different times regarding the administration of antitumor treatment and the variability of risk according to the different antitumor regimens has, as a consequence, the need for a different and adapted antiemetic treatment prophylaxis to achieve the desired objective of complete protection of the patient in the acute phase, in the late phase and in the global phase of emesis. As a basis for the recommendations, the level of emetogenicity of anticancer treatment is considered and they are classified as high, moderate, low and minimal emetogenicity and these recommendations are based on the use of antiemetic drugs with a high therapeutic index: anti 5-HT, anti-NK and steroids. Despite having highly effective treatments, clinical reality shows that they are not applied enough, so evidence-based recommendations are needed to show the best options and help in decision-making. To cover all the antiemetic prophylaxis options, we have also included recommendations for oral treatments, multiday regimens and radiation-induced emesis prevention.

Pharmacogenetic and clinical predictors of ondansetron failure in a diverse pediatric oncology population

PURPOSE

Chemotherapy-induced nausea and vomiting (CINV) is a frequently seen burdensome adverse event of cancer therapy. The 5-HT3 receptor antagonist ondansetron has improved the rates of CINV but, unfortunately, up to 30% of patients do not obtain satisfactory control. This study examined whether genetic variations in a relevant drug-metabolizing enzyme (CYP2D6), transporter (ABCB1), or receptor (5-HT3) were associated with ondansetron failure.

METHODS

DNA was extracted from blood and used to genotype: ABCB1 (3435C > T (rs1045642) and G2677A/T (rs2032582)), 5-HT3RB (rs3758987 T > C and rs45460698 (delAAG/dupAAG)), and CYP2D6 variants. Ondansetron failure was determined by review of the medical records and by patient-reported outcomes (PROs).

RESULTS

One hundred twenty-nine patients were approached; 103 consented. Participants were less than 1 to 33 years (mean 6.85). A total of 39.8% was female, 58.3% was White (22.3% Black, 19.4% other), and 24.3% was Hispanic. A majority had leukemia or lymphoma, and 41 (39.8%) met the definition of ondansetron failure. Of variants tested, rs45460698 independently showed a significant difference in risk of ondansetron failure between a mutant (any deletion) and normal allele (p = 0.0281, OR 2.67). Age and BMI were both predictive of ondansetron failure (age > 12 (OR 1.12, p = 0.0012) and higher BMI (OR 1.13, p = 0.0119)). In multivariate analysis, age > 12 was highly predictive of ondansetron failure (OR 7.108, p = 0.0008). rs45460698 was predictive when combined with an increased nausea phenotype variant of rs1045642 (OR 3.45, p = 0.0426).

CONCLUSION

Select phenotypes of 5-HT3RB and ABCB1, age, and potentially BMI can help predict increased risk for CINV in a diverse pediatric oncology population.

Effect of increase in duration of aprepitant consumption from 3 to 6 days on the prevention of nausea and vomiting in women receiving combination of anthracycline/cyclophosphamide chemotherapy: A randomized, crossover, clinical trial

BACKGROUND

Aprepitant is one of the effective antiemetic drugs that usually used for a period of 3 days for prevention of anthracycline/cyclophosphamide (AC) induced nausea and vomiting. However, many patients still experience nausea and vomiting on days 3-5. The aim of this study was to evaluate the effect of an increase in duration of aprepitant consumption from 3 to 6 days on the prevention of nausea and vomiting in women receiving AC chemotherapy.

MATERIALS AND METHODS

It was a randomized, crossover, controlled clinical trial. Women with breast cancer and scheduled to receive AC regimens were enrolled in this study. Enrolled patients were randomized into two groups. Group I received 3 days regimen of aprepitant in the first course of AC regimen chemotherapy and 6 days regimen of aprepitant in the second course; Group II received 6 days regimen followed by 3 days regimen. For nausea and vomiting assessment, we used Eastern Cooperative Oncology Group questionnaire.

RESULTS

Forty-nine patients were enrolled in this study. Sixty-three percent achieved a complete response with 6 days aprepitant regimen compared with 39% with 3 days regimen (P < 0.001). Ten percent had at least one vomiting episode during the 6 days regimen versus 15% with 3 days regimen (P = 0.034). Nausea was significantly more severe in 3 days regimen of aprepitant than in 6 days regimen.

CONCLUSION

Increase in the duration of aprepitant consumption through 6 days resulted in significantly better prevention of nausea and vomiting than 3 days consumption for women receiving AC chemotherapy.

Concomitant drugs with low risks of drug-drug interactions for use in oncology clinical trials

BACKGROUND

Drug-drug interactions (DDIs) may occur with investigational drugs and affect patient safety, trial outcomes, and drug development. A list of preferred drugs with minimal risks of DDIs for treatment of symptoms or comorbidities frequently encountered by cancer patients would be helpful.

METHODS

We reviewed the literature to assess DDIs reported for the main drugs available for treatment of symptoms/comorbidities frequently encountered by cancer patients. Reviews and relevant original articles cited were retrieved and analyzed, and the following data were collected and double-checked: pharmacological properties; effects, if any, of drugs on CYP enzymes, membrane transporters, and QT interval; and involvement in significant DDIs.

RESULTS

A list of preferred drugs with minimal risks of DDIs was compiled.

CONCLUSION

Acknowledging for heterogeneity in data sources, prevention of unexpected DDIs during clinical trials may be improved by using this list of preferred drugs for the management of study patient's symptoms.

Overshadowing as prevention of anticipatory nausea and vomiting in pediatric cancer patients: study protocol for a randomized controlled trial

BACKGROUND

Emesis and nausea are side effects induced by chemotherapy. These effects lead to enormous stress and strain on cancer patients. Further consequences may include restrictions in quality of life, cachexia or therapy avoidance. Evidence suggests that cancer patients develop the side effects of nausea and vomiting in anticipation of chemotherapy. Contextual cues such as smell, sounds or even the sight of the clinic may evoke anticipatory nausea and vomiting prior to infusion. Anticipatory nausea and vomiting are problems that cannot be solved by administration of antiemetica alone.The purpose of the proposed randomized placebo-controlled trial is to use an overshadowing technique to prevent anticipatory nausea and vomiting and to decrease the intensity and duration of post-treatment nausea and vomiting. Furthermore, the effect on anxiety, adherence and quality of life will be evaluated.

METHODS/DESIGN

Fifty-two pediatric cancer patients will be evenly assigned to two groups: an experimental group and a control group. The participants, hospital staff and data analysts will be kept blinded towards group allocation. The experimental group will receive during three chemotherapy cycles a salient piece of candy prior to every infusion, whereas the control group will receive flavorless placebo tablets.

DISCUSSION

If an effectiveness of the overshadowing technique is proven, implementation of this treatment into the hospitals' daily routine will follow. The use of this efficient and economic procedure should aid a reduced need for antiemetics.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN30242271/

Palonosetron plus single-dose dexamethasone for the prevention of nausea and vomiting in women receiving anthracycline/cyclophosphamide-containing chemotherapy: meta-analysis of individual patient data examining the effect of age on outcome in two phase III trials

Purpose

Data from two randomized trials, evaluating a single-day regimen of palonosetron plus dexamethasone against emesis due to moderately emetogenic chemotherapy, were assessed for the impact of age on outcome in a pooled sample of women receiving anthracycline and/or cyclophosphamide (AC)-containing chemotherapy.

Methods

Chemo-naïve breast cancer patients randomized to receive palonosetron (0.25 mg) plus dexamethasone (8 mg IV) on day 1 of chemotherapy (n = 200), or the same regimen followed by oral dexamethasone (8 mg) on days 2 and 3 (n = 205), were included in the analysis. The primary endpoint was complete response (CR: no vomiting and no rescue anti-emetics) in the 5-day study period. The effect of the 1-day regimen and age (<50 and ≥50 years) was investigated by a meta-analysis of individual patient data.

Results

Younger patients comprised 43 % and 49 % of the 1-day and 3-day regimen groups, respectively; 94 % of the pooled sample received the AC combination. There were no between-treatment differences in CR rate according to age during all observation periods. In the 1-day regimen group, 55.2 % of younger patients achieved overall CR compared with 54 % of older patients. In the 3-day regimen group, 51.5 % of younger patients achieved overall CR compared with 58.7 % of older patients. In the adjusted analysis, younger age was not associated with overall CR to treatment (risk difference, −3.1 %; 95 % CI, −13.0 to 6.7 %; P = 0.533).

Conclusions

These results provide evidence that, irrespective of age, the dexamethasone-sparing regimen is not associated with a significant loss in overall anti-emetic protection in women undergoing AC-containing chemotherapy.

Cardiovascular events in cancer patients treated with highly or moderately emetogenic chemotherapy: results from a population-based study

Studies on cardiovascular safety in cancer patients treated with highly or moderately emetogenic chemotherapy (HEC or MEC), who may have taken the antiemetic, aprepitant, have been limited to clinical trials and postmarketing spontaneous reports. Our study explored background rates of cardiovascular disease (CVD) events among HEC- or MEC-treated cancer patients in a population-based setting to contextualize events seen in a new drug development program and to determine at a high level whether rates differed by aprepitant usage. Medical and pharmacy claims data from the 2005–2007 IMPACT National Benchmark Database were classified into emetogenic chemotherapy categories and CVD outcomes. Among 5827 HEC/MEC-treated patients, frequencies were highest for hypertension (16–21%) and composites of venous (7–12%) and arterial thromboembolic events (4–7%). Aprepitant users generally did not experience higher frequencies of events compared to nonusers. Our study serves as a useful benchmark of background CVD event rates in a population-based setting of cancer patients.

Supportive care treatment guidelines: value, limitations, and opportunities

Evidence-based guidelines in clinical oncology practice are now prominent, with emphasis on clinical, health outcome and economic perspectives. Given the complexity of cancer management, a multidisciplinary approach is essential. Evidence-based guidelines to address supportive cancer care have merged expert opinion, systematic evaluation of clinical and research data, and meta-analyses of clinical trials. Production of supportive care guidelines by the interdisciplinary team is dependent on sufficient high-quality research studies. Once published, it is essential they be customized at institutional and national levels. Implementation in clinical practice is perhaps the greatest challenge. Optimal management occurs through integration of country-specific issues, including care access, healthcare resources, information technology, and national coordination of healthcare practices. The purpose of this article is to: (1) provide an overview of interdisciplinary cancer management using evidence-based guidelines; (2) delineate the theory and practice of guideline dissemination, utilization and outcome assessment; and (3) recommend future research strategies to maximize guidelines use in clinical practice.

Clinical and economic burden of chemotherapy-induced nausea and vomiting among patients with cancer in a hospital outpatient setting in the United States

OBJECTIVE

This study evaluated the overall burden of illness of chemotherapy-induced nausea and vomiting (CINV) and associated all-cause costs from a hospital's perspective (costs to the hospital) in patients with cancer treated with chemotherapy (CT) in the US hospital outpatient setting.

METHODS

Patients with a cancer diagnosis aged ≥18 years initiating CT in a hospital outpatient setting for the first time between April 1 2007 and March 31 2009 were extracted from the Premier Perspective Database. Patients were followed through eight CT cycles or 6 months post-index date, whichever occurred first. Within each CT cycle, the follow-up time for CINV event estimation was from day 1 (except rescue medication use that was identified from day 2) to cycle end. A multivariate regression model was developed to predict the CINV event rate per CT cycle in the study follow-up period. Associated total all-cause costs of managing CINV from a hospital's perspective were analyzed descriptively. Event rate and associated costs were estimated in the entire hospital setting (outpatient, inpatient, and emergency room). All-cause costs included inpatient, hospital outpatient, and ER visit costs (identified through a primary or secondary diagnosis code for nausea, vomiting, and/or volume depletion) and pharmacy cost (rescue medications for CINV treatment). All physician costs and non CINV-related treatment (pharmacy) costs were excluded from the analyses.

RESULTS

Among 11,495 study patients, 8,806 patients (76.6%) received prophylaxis for all cycles in the follow-up period. The overall base population had an average age of 63.3 years, was 51.0% female, and 72.7% White. The distribution of emetogenicity for cycle 1 CT cycle was 26.0% HEC, 46.1% MEC, and 26.4% LEC/MinEC combined. In the follow-up period, a total of 47,988 CINV events with an associated total all-cause treatment cost of $89 million were observed. Average daily treatment cost for all care settings was $1854.7. The regression model predicted a 20% CINV event rate per CT cycle in the follow-up period. Study limitations include potential lack of generalizibility, absence of data on certain confounders including alcohol consumption and prior history of motion sickness, lack of a control analysis group to estimate incremental use of resource utilization and associated costs, and a potential for cost under-estimation.

CONCLUSION

In the current study analysis, a 20% CINV event rate per CT cycle per patient was predicted with an associated all-cause average daily total cost of approximately $1850. Further studies on early and appropriate antiemetic prophylaxis on CINV rates and economic outcomes are warranted.

Grundlagen der systemischen Therapie

Die Einführung sog. »zielgerichteter Medikamente« hat einen Paradigmenwechsel in der Systemtherapic maligner Erkrankungen ausgelöst. Voraussetzung hierfür waren die in den letzten 25 Jahren gesammelten Erkenntnisse der molekularbiologischen, molekulargenetischen und immunologischen Grundlagenforschung, die ein besseres Verständnis der pathogenetischen Prozesse im Rahmen der malignen Transformation und Tumorprogression sowie die Identifikation strategischer Zielstrukturen (»Targets«) ermöglichen. Auf diese Weise wurde ein neuer Ansatz der Entwicklung antineoplastischer Therapeutika angestoßen, der auf die Wirkung an spezifischen Molekülaktivitäten und nicht primär auf zelluläre Endpunkte (Wachstumshemmung, Zelltod) ausgerichtet ist.

Symptom management in geriatric oncology: practical treatment considerations and current challenges

OPINION STATEMENT

Symptom management of the actively treated elderly cancer patient represents an undertreated and disproportionately understudied cohort in oncology. There is a dearth of specific recommendations or guidelines regarding drug selection, dosing, and side effects which account for changes in aging physiology, pharmacokinetics, and idiosynchratic reactions. In treating cardinal symptoms and clusters of symptoms including pain, constipation, fatigue/weakness, nausea/vomiting, mucositis/xerostomia, and nutritional depletion syndromes such as malabsorption and anorexia/cachexia, most clinicians base their therapeutic decisions on individual experience. Depending on relative interest and level of competency, symptom management is often narrow in scope, frequently ineffective, and not based on evidence. We discuss these issues in a practical format, by surveying and comparing available core literature to the extent that it readily exists and by incorporating our own experiences.

Evaluation of opioid induced nausea and vomiting in sickle cell disease

A common side effect of opioids is nausea and vomiting; however, the incidence in hospitalized patients receiving opioids for acute pain is unknown. We performed a retrospective study in adult patients with sickle cell disease admitted for an acute pain crisis during a six-month period to evaluate the incidence of nausea and vomiting and characterize the prescribing of antiemetics. Eligibility included normal hepatic and renal function. Thirty-four subjects with a total of 97 admissions were evaluated. As expected, opioids were prescribed during all admissions. Fifty percent of the subjects experienced nausea or vomiting during the study period and these same patients accounted for the majority of the admissions, 17 subjects with 71 admissions (Group I). Nausea was reported in 18 (25%) of these admissions and vomiting was reported in 24 (34%) of these admissions. The most common antiemetics prescribed were: prochlorperazine, metoclopramide, and promethazine and antiemetics were ordered during 22 (23%) separate admissions for all subjects included in the study. The clinical benefit of these medications is limited due to uneven documentation. In conclusion, many of our patients experienced nausea or vomiting with antiemetics infrequently prescribed on an as needed basis. This suggests a need for better approaches to manage nausea and vomiting in patients receiving opioids.

The effect of cannabidiol and URB597 on conditioned gaping (a model of nausea) elicited by a lithium-paired context in the rat

RATIONALE

Anticipatory nausea (AN) experienced by chemotherapy patients is resistant to current anti-nausea treatments. In this study, the effect of manipulation of the endocannabinoid (EC) system on a rat model of nausea (conditioned gaping) was determined.

OBJECTIVE

The potential of cannabidiol (CBD) and the fatty acid amide hydrolase (FAAH) inhibitor, URB597 (URB) to reduce conditioned gaping in rats were evaluated.

MATERIALS AND METHODS

In each experiment, rats received four conditioning trials in which they were injected with lithium chloride immediately before placement in a distinctive odor-laced context. During testing, in experiment 1, rats were injected with vehicle (VEH), 1, 5 or 10 mg/kg CBD 30 min before placement in the context previously paired with nausea and in experiment 2, rats were injected with VEH, 0.1 or 0.3 mg/kg URB 2 h before placement in the context. Additional groups evaluated the ability of the CB(1) antagonist/inverse agonist, SR141716A, to reverse the suppressive effects of URB. Experiment 3 measured the potential of URB to interfere with the establishment of conditioned gaping.

RESULTS

When administered before testing, CBD (1 and 5, but not 10 mg/kg) and URB (0.3, but not 0.1 mg/kg) suppressed conditioned gaping. The effect of URB was reversed by pre-treatment with the CB(1) antagonist/inverse agonist, SR141716A. When administered before conditioning, URB also interfered with the establishment of conditioned gaping.

CONCLUSIONS

Manipulations of the EC system may have therapeutic potential in the treatment of AN.

Antiemetic placebo: Reduce adverse drug interactions between chemotherapeutic agents and antiemetic drugs in cancer patients

Cancer patients receiving chemotherapy often require a wide range of drugs to manage symptoms of their cancer. The adverse drug interactions are common in the field of medical oncology. Chemotherapy-induced nausea and vomiting (CINV) continues to have a considerable effect on the physical and psychological well-being of patients with cancer, despite significant advances in antiemetic drugs since the 1990s. Fortunately, evidence-based interventions suggested that to a certain extent antiemetic effects can be achieved by use of placebo appropriately. Placebo effect can be reinforced by conferring much meaning. Thus physician can replace antiemetic drugs with reinforced meaningful antiemetic placebo to get better prevention and treatment efficacy for CINV while reduce the unnecessary adverse drug interactions induced by antiemetic drugs and chemotherapeutic agents.

Exposure to a context previously associated with nausea elicits conditioned gaping in rats: a model of anticipatory nausea

Following one or more chemotherapy treatments, many patients report that they experience anticipatory nausea. This phase of nausea has been interpreted as a classically conditioned response where a conditional association develops between the contextual clinic cues and the nausea and/or vomiting that developed following treatment. Although rats do not vomit, they display a distinctive gaping reaction when exposed a flavored solution previously paired with a toxin. Here we report that, even in the absence of a flavored solution, rats display conditioned gaping reactions during exposure to a distinctive context previously paired with a high dose of lithium (Experiment 1 with a distinctive odor and Experiment 3 without a distinctive odor), a low dose of lithium (Experiment 2) or provocative vestibular stimulation (Experiment 2). These results suggest that the conditioned gaping reaction in rats is selectively elicited by nausea-paired contextual stimuli, as well as flavors. This rat model of anticipatory nausea may serve as a valuable preclinical tool to evaluate the effectiveness of anti-nausea treatments and the side effect of nausea produced by newly developed pharmaceutical compounds intended for other clinical treatments.

Patterns of fatigue during a course of chemotherapy: Results from a multi-centre study

Fatigue is a highly prevalent condition among patients with cancer affecting between 70% and 100% and patients describe their fatigue experiences as the most distressing of symptoms. However, the management of fatigue is complicated by our current lack of understanding of its pathophysiology. This study aimed to gain an insight into the longitudinal fatigue experiences of patients receiving chemotherapy. A convenience sample of patients receiving chemotherapy (n=249) were recruited and recorded their fatigue experiences using a paper questionnaire for 14 consecutive days following each cycle of chemotherapy. Fatigue was reported in 57% of all completed questionnaires. Patients report fatigue as a relatively constant presence following chemotherapy. Moreover, fatigue experiences increase over consecutive cycles of chemotherapy. This study supports the existing evidence illustrating fatigue as a significant problem for patients with cancer and provides new data demonstrating patterns of fatigue over the duration of a course of chemotherapy. Understanding this experience of fatigue should prompt health professionals providing care for this patient population to seek and test a range of management strategies to help patients maintain their quality of life during cancer treatment.

The endocannabinoid system as an emerging target of pharmacotherapy

The recent identification of cannabinoid receptors and their endogenous lipid ligands has triggered an exponential growth of studies exploring the endocannabinoid system and its regulatory functions in health and disease. Such studies have been greatly facilitated by the introduction of selective cannabinoid receptor antagonists and inhibitors of endocannabinoid metabolism and transport, as well as mice deficient in cannabinoid receptors or the endocannabinoid-degrading enzyme fatty acid amidohydrolase. In the past decade, the endocannabinoid system has been implicated in a growing number of physiological functions, both in the central and peripheral nervous systems and in peripheral organs. More importantly, modulating the activity of the endocannabinoid system turned out to hold therapeutic promise in a wide range of disparate diseases and pathological conditions, ranging from mood and anxiety disorders, movement disorders such as Parkinson's and Huntington's disease, neuropathic pain, multiple sclerosis and spinal cord injury, to cancer, atherosclerosis, myocardial infarction, stroke, hypertension, glaucoma, obesity/metabolic syndrome, and osteoporosis, to name just a few. An impediment to the development of cannabinoid medications has been the socially unacceptable psychoactive properties of plant-derived or synthetic agonists, mediated by CB(1) receptors. However, this problem does not arise when the therapeutic aim is achieved by treatment with a CB(1) receptor antagonist, such as in obesity, and may also be absent when the action of endocannabinoids is enhanced indirectly through blocking their metabolism or transport. The use of selective CB(2) receptor agonists, which lack psychoactive properties, could represent another promising avenue for certain conditions. The abuse potential of plant-derived cannabinoids may also be limited through the use of preparations with controlled composition and the careful selection of dose and route of administration. The growing number of preclinical studies and clinical trials with compounds that modulate the endocannabinoid system will probably result in novel therapeutic approaches in a number of diseases for which current treatments do not fully address the patients' need. Here, we provide a comprehensive overview on the current state of knowledge of the endocannabinoid system as a target of pharmacotherapy.

Update on the Management of Chemotherapy-induced Nausea and Vomiting

Chemotherapy is associated with a variety of side effects, and many of these can be dose-limiting. One of the most dreaded side effects for patients receiving chemotherapy is nausea and vomiting, however. Although in the last 2 decades there have been several advances in the development of new therapies for prevention of chemotherapy-induced nausea and vomiting (CINV), recent pharmacologic advances have significantly improved control of this feared side effect. Antiemetic guidelines help clinicians manage CINV and are updated frequently. Ongoing studies further define appropriate management of patients with CINV; of particular interest is delayed nausea and vomiting. With the addition of the long-acting serotonin antagonist, palonosetron, and the unique neurokinin-1 antagonist, aprepitant, control of CINV has improved considerably for those patients receiving chemotherapy. This article discusses CINV and recent pharmacologic advances in controlling this side effect. Guidelines for the management of CINV are reviewed.

Was muss ich praktisch bei der Umsetzung einer Chemotherapie beachten?

The patient stands at the center of a chemotherapy. The aim of the curative or palliative treatment is not only the death of the tumor cells, but also the maintenance or improvement of the patient's physical condition, especially the improvement of quality of life. Before starting the therapy, it is necessary to determine, for example, the patient's general condition and motivation, and to carry out a consultation. Examinations, for example, blood tests, audiograms, renal function and lung function should also be made. Thus, the patient's tolerance for even the most onerous chemotherapy can be investigated and patients can be individually prepared for the treatment.

Post hoc comparison of daily rates of nausea and vomiting with once- and twice-daily galantamine from a double-blind, placebo-controlled, parallel-group, 6-month study

BACKGROUND

A once-daily extended-release galantamine(GAL-ER) formulation has been designed to improve tolerability compared with twice-daily immediate-release galantamine (GAL-IR).

OBJECTIVE

The aim of this study was to conduct a post hoc analysis of the clinical presentation of nausea and vomiting with GAL-ER compared with GAL-IR in subjects with mild to moderate Alzheimer's disease (AD).

METHODS

This is the report of a post hoc analysis of a large, randomized, double-blind, placebo-controlled, multicenter trial of GAL-ER with GAL-IR as the active control in subjects with mild to moderate AD. Galantamine dose was titrated every 4 weeks by increments of 8 mg/d to a daily dose of 16 or 24 mg, based on tolerability. Daily rates of nausea and vomiting were compared for the GAL-ER and GAL-IR groups. AUCs of the daily percentage of subjects reporting nausea/vomiting during dose titration were calculated. Antiemetic use for nausea/vomiting was compared between GAL-ER and GAL-IR groups.

RESULTS

Demographic characteristics were similar between the GAL-ER, GAL-IR, and placebo groups. Nausea was reported by 16.9% (54/319) of GAL-ER, 13.8% (45/326) of GAL-IR, and 5.0% (16/320) of placebo patients; vomiting was reported for 6.6% (21/319) of GAL-ER, 8.6% (28/326) of GAL-IR, and 2.2% (7/320) of placebo patients. The mean (SD) daily rate of nausea in the total population was 3.1 (13.43%) in the GAL-ER group and 5.2% (22.07%) in the GAL-IR group (P = NS); the mean (SD) daily rate of vomiting for the total population was 0.6% (4.14%) in the GAL-ER group and 1.6% (14.50%) in the GAL-IR group (P = NS). The mean (SD) daily rate of nausea or vomiting in the total population was 1.2 (8.46) and 0.4 (5.44) in the placebo group, respectively. For subjects reporting nausea, the mean (SD, SE) percentage of days with nausea was lower with GAL-ER than with GAL-IR (18.4% [28.22%, 5.31%] vs 38.0% [48.23%, 6.04%]; P = 0.014). AUC of the daily percentage of subjects reporting nausea/vomiting during dose titration was significantly higher in the GAL-IR group compared with the placebo group (320.9 vs 102.9; P = 0.01); there was no statistical difference between the GAL-ER group and placebo (171.1 vs 102.9; P = NS). Antiemetic use by subjects reporting nausea or vomiting was significantly lower in the GAL-ER group than the GAL-IR group (33.3% vs 53.4%; P = 0.028).

CONCLUSIONS

In these subjects with AD, the daily percentage of subjects reporting nausea and vomiting, and the percentage of days with vomiting among subjects reporting vomiting, did not significantly differ between the GAL-ER and GAL-IR groups. However, GAL-ER was associated with a significantly lower percentage of days with nausea than GAL-IR among subjects reporting nausea. AUC of the daily percentage of subjects with nausea or vomiting during dose titration did not differ significantly between the GAL-ER and placebo groups but was significantly higher in the GAL-IR group than placebo. Subjects with nausea or vomiting who received GAL-ER reported significantly less antiemetic use than those treated with GAL-IR. These results suggest the need for additional studies to explore the potential differences in the tolerability of these formulations.