Radiotherapy-induced nausea and vomiting: Prophylaxis and treatment
- Petra Feyer, MD
Petra Feyer, MD
- Head of Department, Radiation Oncology
- Vivantes Clinics Berlin Neukoelln
- Karin Jordan, MD
Karin Jordan, MD
- Associate Professor
- Universitätsklinikum der Martin-Luther-Universität Halle-Wittenberg
- Section Editors
- Paul J Hesketh, MD
Paul J Hesketh, MD
- Section Editor — Supportive Care
- Chair, Lahey Health Cancer Institute
- Director, Thoracic Oncology, Lahey Hospital and Medical Center
- Professor of Medicine, Tufts University School of Medicine
- Steven E Schild, MD
Steven E Schild, MD
- Section Editor — Radiation Therapy
- Professor of Radiation Oncology
- Mayo Clinic College of Medicine
Nausea and vomiting caused by radiotherapy (RT) are generally less severe than that caused by chemotherapy, but nausea and vomiting can last for a prolonged period in some cases. These side effects are clinically important and can be distressing for patients. Furthermore, RT-induced nausea and vomiting (RINV) can cause patients to delay or refuse further treatment.
The incidence, classification of risk, and management of RINV are discussed here. The approach to chemotherapy-induced nausea and vomiting is discussed separately. (See "Prevention and treatment of chemotherapy-induced nausea and vomiting in adults".)
The pathophysiology of radiotherapy (RT)-induced nausea and vomiting (RINV) is incompletely understood but is thought to be similar to that caused by chemotherapy. Progress in understanding the pathophysiology of chemotherapy-induced emesis led to the development of agents that form the basis for treatment of RINV. (See "Pathophysiology and prediction of chemotherapy-induced nausea and vomiting".)
Two prospective observational studies provide information on the frequency of radiotherapy (RT)-induced nausea and vomiting (RINV) and the extent to which this problem is treated:
●The Italian Group for Antiemetic Research in Radiotherapy (IGARR) analyzed the incidence of RINV in 1020 patients receiving various kinds of RT with or without concomitant chemotherapy . Overall, nausea and/or vomiting was reported by 28 percent. The median time to the first episode of vomiting was three days. Antiemetic drugs were administered to 17 percent of the patients, including 12 percent treated prophylactically and 5 percent given rescue therapy.
- Maranzano E, De Angelis V, Pergolizzi S, et al. A prospective observational trial on emesis in radiotherapy: analysis of 1020 patients recruited in 45 Italian radiation oncology centres. Radiother Oncol 2010; 94:36.
- Enblom A, Bergius Axelsson B, Steineck G, et al. One third of patients with radiotherapy-induced nausea consider their antiemetic treatment insufficient. Support Care Cancer 2009; 17:23.
- Poon M, Hwang J, Dennis K, et al. A novel prospective descriptive analysis of nausea and vomiting among patients receiving gastrointestinal radiation therapy. Support Care Cancer 2016; 24:1545.
- Basch E, Prestrud AA, Hesketh PJ, et al. Antiemetics: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 2011; 29:4189.
- Ruhlmann CH, Jahn F, Jordan K, et al. 2016 updated MASCC/ESMO consensus recommendations: prevention of radiotherapy-induced nausea and vomiting. Support Care Cancer 2017; 25:309.
- Roila F, Molassiotis A, Herrstedt J, et al. 2016 MASCC and ESMO guideline update for the prevention of chemotherapy- and radiotherapy-induced nausea and vomiting and of nausea and vomiting in advanced cancer patients. Ann Oncol 2016; 27:v119.
- Salvo N, Doble B, Khan L, et al. Prophylaxis of radiation-induced nausea and vomiting using 5-hydroxytryptamine-3 serotonin receptor antagonists: a systematic review of randomized trials. Int J Radiat Oncol Biol Phys 2012; 82:408.
- Aass N, Håtun DE, Thoresen M, Fosså SD. Prophylactic use of tropisetron or metoclopramide during adjuvant abdominal radiotherapy of seminoma stage I: a randomised, open trial in 23 patients. Radiother Oncol 1997; 45:125.
- Bey P, Wilkinson PM, Resbeut M, et al. A double-blind, placebo-controlled trial of i.v. dolasetron mesilate in the prevention of radiotherapy-induced nausea and vomiting in cancer patients. Support Care Cancer 1996; 4:378.
- Franzén L, Nyman J, Hagberg H, et al. A randomised placebo controlled study with ondansetron in patients undergoing fractionated radiotherapy. Ann Oncol 1996; 7:587.
- Lanciano R, Sherman DM, Michalski J, et al. The efficacy and safety of once-daily Kytril (granisetron hydrochloride) tablets in the prophylaxis of nausea and emesis following fractionated upper abdominal radiotherapy. Cancer Invest 2001; 19:763.
- Priestman TJ, Roberts JT, Lucraft H, et al. Results of a randomized, double-blind comparative study of ondansetron and metoclopramide in the prevention of nausea and vomiting following high-dose upper abdominal irradiation. Clin Oncol (R Coll Radiol) 1990; 2:71.
- Priestman TJ, Roberts JT, Upadhyaya BK. A prospective randomized double-blind trial comparing ondansetron versus prochlorperazine for the prevention of nausea and vomiting in patients undergoing fractionated radiotherapy. Clin Oncol (R Coll Radiol) 1993; 5:358.
- Prentice HG, Cunningham S, Gandhi L, et al. Granisetron in the prevention of irradiation-induced emesis. Bone Marrow Transplant 1995; 15:445.
- Spitzer TR, Bryson JC, Cirenza E, et al. Randomized double-blind, placebo-controlled evaluation of oral ondansetron in the prevention of nausea and vomiting associated with fractionated total-body irradiation. J Clin Oncol 1994; 12:2432.
- Spitzer TR, Friedman CJ, Bushnell W, et al. Double-blind, randomized, parallel-group study on the efficacy and safety of oral granisetron and oral ondansetron in the prophylaxis of nausea and vomiting in patients receiving hyperfractionated total body irradiation. Bone Marrow Transplant 2000; 26:203.
- Sykes AJ, Kiltie AE, Stewart AL. Ondansetron versus a chlorpromazine and dexamethasone combination for the prevention of nausea and vomiting: a prospective, randomised study to assess efficacy, cost effectiveness and quality of life following single-fraction radiotherapy. Support Care Cancer 1997; 5:500.
- Tiley C, Powles R, Catalano J, et al. Results of a double blind placebo controlled study of ondansetron as an antiemetic during total body irradiation in patients undergoing bone marrow transplantation. Leuk Lymphoma 1992; 7:317.
- Goodin S, Cunningham R. 5-HT(3)-receptor antagonists for the treatment of nausea and vomiting: a reappraisal of their side-effect profile. Oncologist 2002; 7:424.
- Jordan K, Schmoll HJ, Aapro MS. Comparative activity of antiemetic drugs. Crit Rev Oncol Hematol 2007; 61:162.
- Feyer PC, Stewart AL, Titlbach OJ. Aetiology and prevention of emesis induced by radiotherapy. Support Care Cancer 1998; 6:253.
- Ruhlmann CH, Belli C, Dahl T, Herrstedt J. Palonosetron and prednisolone for the prevention of nausea and emesis during fractionated radiotherapy and 5 cycles of concomitant weekly cisplatin-a phase II study. Support Care Cancer 2013; 21:3425.
- FDA safety communication available online at http://www.fda.gov/Drugs/DrugSafety/ucm237081.htm (Accessed on December 21, 2010).
- Kirkbride P, Bezjak A, Pater J, et al. Dexamethasone for the prophylaxis of radiation-induced emesis: a National Cancer Institute of Canada Clinical Trials Group phase III study. J Clin Oncol 2000; 18:1960.
- National Cancer Institute of Canada Clinical Trials Group (SC19), Wong RK, Paul N, et al. 5-hydroxytryptamine-3 receptor antagonist with or without short-course dexamethasone in the prophylaxis of radiation induced emesis: a placebo-controlled randomized trial of the National Cancer Institute of Canada Clinical Trials Group (SC19). J Clin Oncol 2006; 24:3458.
- American Society of Clinical Oncology, Kris MG, Hesketh PJ, et al. American Society of Clinical Oncology guideline for antiemetics in oncology: update 2006. J Clin Oncol 2006; 24:2932.
- Feyer PCh, Maranzano E, Molassiotis A, et al. Radiotherapy-induced nausea and vomiting (RINV): antiemetic guidelines. Support Care Cancer 2005; 13:122.
- Yamamoto K, Nohara K, Furuya T, Yamatodani A. Ondansetron, dexamethasone and an NK1 antagonist block radiation sickness in mice. Pharmacol Biochem Behav 2005; 82:24.
- Jahn F, Riesner A, Jahn P, et al. Addition of the Neurokinin-1-Receptor Antagonist (RA) Aprepitant to a 5-Hydroxytryptamine-RA and Dexamethasone in the Prophylaxis of Nausea and Vomiting Due to Radiation Therapy With Concomitant Cisplatin. Int J Radiat Oncol Biol Phys 2015; 92:1101.
- Ruhlmann CH, Christensen TB, Dohn LH, et al. Efficacy and safety of fosaprepitant for the prevention of nausea and emesis during 5 weeks of chemoradiotherapy for cervical cancer (the GAND-emesis study): a multinational, randomised, placebo-controlled, double-blind, phase 3 trial. Lancet Oncol 2016; 17:509.
- Roila F, Ciccarese G, Palladino MA, De Angelis V. Prevention of radiotherapy-induced emesis. Tumori 1998; 84:274.
- Navari RM, Nagy CK, Le-Rademacher J, Loprinzi CL. Olanzapine versus fosaprepitant for the prevention of concurrent chemotherapy radiotherapy-induced nausea and vomiting. J Community Support Oncol 2016; 14:141.
- Dennis K, Zhang L, Lutz S, et al. International patterns of practice in the management of radiation therapy-induced nausea and vomiting. Int J Radiat Oncol Biol Phys 2012; 84:e49.
- LeBourgeois JP, McKenna CJ, Coster B, et al. Efficacy of an ondansetron orally disintegrating tablet: a novel oral formulation of this 5-HT(3) receptor antagonist in the treatment of fractionated radiotherapy-induced nausea and emesis. Emesis Study Group for the Ondansetron Orally Disintegrating Tablet in Radiotherapy Treatment. Clin Oncol (R Coll Radiol) 1999; 11:340.
- Maranzano E, Feyer PCh, Molassiotis A, et al. Evidence-based recommendations for the use of antiemetics in radiotherapy. Radiother Oncol 2005; 76:227.
- Mystakidou K, Katsouda E, Linou A, et al. Prophylactic tropisetron versus rescue tropisetron in fractionated radiotherapy to moderate or high emetogenic areas: a prospective randomized open label study in cancer patients. Med Oncol 2006; 23:251.
- Navari RM, Nagy CK, Gray SE. The use of olanzapine versus metoclopramide for the treatment of breakthrough chemotherapy-induced nausea and vomiting in patients receiving highly emetogenic chemotherapy. Support Care Cancer 2013; 21:1655.
- Jordan K, Kinitz I, Voigt W, et al. Safety and efficacy of a triple antiemetic combination with the NK-1 antagonist aprepitant in highly and moderately emetogenic multiple-day chemotherapy. Eur J Cancer 2009; 45:1184.
- Maranzano E. Radiation-induced emesis: a problem with many open questions. Tumori 2001; 87:213.