Pathophysiology and prediction of chemotherapy-induced nausea and vomiting
- 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
Few side effects of cancer treatment are more feared by the patient than nausea and vomiting. Although nausea and emesis (vomiting and/or retching) can also result from surgery, opiates, or radiotherapy, chemotherapy-induced nausea and vomiting (CINV) is potentially the most severe and most distressing. Although significant progress has been made with the development of a number of effective and well-tolerated antiemetic treatments, CINV remains an important adverse effect of treatment.
The types of emesis, its pathophysiology, and factors predictive for the development of CINV will be reviewed here. The characteristics of the available antiemetic drugs, the management of CINV, and a general approach to the patient are discussed separately. (See "Prevention and treatment of chemotherapy-induced nausea and vomiting in adults" and "Characteristics of antiemetic drugs" and "Approach to the adult with nausea and vomiting".)
TYPES OF EMESIS
Three distinct types of CINV have been defined: acute, delayed, and anticipatory. Recognizing the differences between these types of CINV has important implications for both prevention and management.
Acute emesis — Acute emesis is defined as emesis occurring during the first 24 hours after chemotherapy. In the absence of effective prophylaxis, it most commonly begins within one to two hours of chemotherapy and usually peaks in the first four to six hours. Acute emesis is the most widely studied manifestation of CINV.
Delayed emesis — Emesis occurring more than 24 hours after chemotherapy is classified as delayed. It is best characterized following treatment with high-dose cisplatin. In the absence of antiemetic prophylaxis, delayed emesis after cisplatin peaks at approximately 48 to 72 hours after therapy, then gradually subsides over the next two to three days . While the frequency and number of episodes of emesis may be less during the delayed period compared with acute emesis, the delayed form is less well controlled with current antiemetic medications . Delayed emesis occurs most frequently after cisplatin but can also occur following other agents, including carboplatin, cyclophosphamide, anthracyclines, and oxaliplatin [2,3], and after combinations, such as cyclophosphamide plus an anthracycline.
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