Skip to main content

Antipsychotics for chemotherapy induced nausea and vomiting



by: Eric Widera (@ewidera)

So yesterday I wrote about the rapid uptake of using antipsychotics for insomnia in the hospital setting and wondered “when did this become a thing?”   Today, I’ll like to talk about antipsychotics for nausea by first asking that same question.

When did antipsychotics for nausea become a thing?  A long time ago.  Haloperidol and other anti-dopaminergic agents like metaclopromide have a long history of use both in the hospice, palliative care, and oncology setting.  Now we have a little more evidence that at least one of these drugs, olanzapine, may help with the prevention of chemotherapy induced nausea and vomiting.

The Study

A double-blind, randomized control study published in the NEJM last week compared 10mg olanzapine with placebo for 4 days, in addition to usual care with dexamethasone, aprepitant or fosaprepitant, and a 5-HT3 receptor antagonist, in 380 patients with no previous chemotherapy who were receiving cisplatin or cyclophosphamide–doxorubicin (two highly emetic agents).  The primary outcome was nausea prevention.  Secondary outcomes including no emesis and no use of rescue medication.

What they found

Not shocking for those who have been doing this work for a while – adding an anti-dopenergic agent works.   The proportion of patients with no chemotherapy-induced nausea was significantly greater with olanzapine than with placebo for multiple time points:
  • 0 to 24 hours after chemotherapy: 74% vs. 45%
  • 25 to 120 hours after chemotherapy: 42% vs. 25%
  • Overall 120-hour period: 37% vs. 22%

The complete-response rate was also significantly increased with olanzapine compared to placebo during the three periods:
  • 0 to 24 hours after chemotherapy: 86% versus 65% 
  • 25 to 120 hours after chemotherapy: 67% versus 52% 
  • Overall 120-hour period: 64% versus 41%

The biggest adverse effect was sedation which was severe in 5% of patients at day 2, but nobody stopped the study because of sedation.

Take Home Point

While this is a study of a particular antipsychotic, olanzapine, one does have to wonder if there would have been similar findings if they used a tried and true hospice medication: haloperidol.  Nevertheless, it does serve as an important study addressing one of the most common symptoms we see in palliative care.


Comments

Whatever disease we suffer, we should be courageous to face it. Being bold will help us to get rid of the disease soon. This article has mentioned everything very correctly. It's very sad thinking about the chemotherapy.

Popular posts from this blog

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …

Length of Stay in Nursing Homes at the End of Life

One out of every four of us will die while residing in a nursing home. For most of us, that stay in a nursing home will be brief, although this may depend upon social and demographic variables like our gender, net worth, and marital status. These are the conclusions of an important new study published in JAGS by Kelly and colleagues (many of whom are geripal contributors, including Alex Smith and Ken Covinsky).

The study authors used data from the Health and Retirement Study (HRS) to describe the lengths of stay of older adults who resided in nursing homes at the end of life. What they found was that out of the 8,433 study participants who died between 1992 and 2006, 27.3% of resided in a nursing home prior to their death. Most of these patients (70%) actually died in the nursing home without being transferred to another setting like a hospital.

 The length of stay data were striking:

the median length of stay in a nursing home before death was 5 months the average length of stay was l…

Palliative Care in Nursing Homes: Discussion of a Multinational Trial with Lieve Van den Block

Nursing homes are a tough place to do palliative care.  There is extremely high staff turnover, physicians are often not present except for the occasional monthly visit, many residents die with untreated symptoms usually after multiple hospitalizations and burdensome life-prolonging treatments, and specialty palliative care - well that is nowhere to be found in most nursing homes outside of hospice.  So what can we do to improve the palliative care outlook in nursing homes?

On todays podcast we talk with Lieve Van den Block about her recent palliative care intervention that was published in JAMA IM this week.  Lieve led a multicomponent intervention to integrate basic nonspecialist palliative care in in 78 nursing homes located in 7 different European countries.  Just take a moment to grasp the size of this study - 7 counties, 78 nursing homes.  I struggle with just trying to improve palliative care in one site!

We discuss with Lieve the results of the study, her take on why they got…