Treatment of Nausea, Vomiting, and Retching in Patients with Cancer
 
   Nausea, vomiting, and retching (NVR) are a problem for 50-60% of patients with advanced cancer. These problems are more common in patients under 65 years old, in women, and in those with cancer of the stomach or breast. Nausea is the queasiness or feeling of "stomach upset" which may lead to the urge to vomit. Vomiting, or emesis, is the actual act of "throwing up." Patients rate nausea as a more unpleasant symptom than vomiting alone and consider it to be as distressing as pain. Retching, also called "dry heaves" may resemble an attempt to vomit that does not remove anything from the stomach. Although most people think that nausea or vomiting is secondary to chemotherapy or radiation, in most cases the cause of nausea, vomiting, or retching (NVR) is multifactorial, and when planning treatment, all contributing factors should be considered.  Other common causes of vomiting in patients with advanced cancer include side effects of medications, especially chemotherapy and opioids (during initial period of opioid treatment), radiation to pelvic or abdominal areas, gastritis or ulceration, constipation, renal failure, hypercalcemia, raised intracranial pressure, vestibular (balance) disturbance, anxiety, and cough. 
   Effective management of individual symptoms during initial and continued therapy profoundly influences symptom response throughout the course of cancer therapy. Unless the symptoms of NVR have been effectively prevented or managed during the first cycle of the first course of chemotherapy or radiation, the actual or perceived threat of the disease, its treatment, and discomforts relating to therapy, can arouse a variety of emotional and physiological responses.

   Neurotransmitters are chemicals in the body that transmit nervous impulses, such as dopamine, acetylcholine, histamine, and serotonin (5-HT). Antiemetic drugs are predominately neurotransmitter blocking agents which are effective at different receptor sites and therefore treat different causes of vomiting. For example, 5HT3 antagonists (e.g. ondansetron, tropisetron, granisetron, dolasetron) are effective for chemotherapy/radiation induced nausea and vomiting, but are not the first line of therapy for nausea and vomiting due to other causes, and their benefit is often reduced in the course of multiple cycles of chemotherapy. However, although the benzodiazepines (e.g., lorazepam and alprazolam) are only minimally effective as antiemetics, they can be particularly useful when anxiety is associated with nausea and vomiting. As there are often numerous causes of NVR in patients in the palliative care setting, 30% of patients require two or more antiemetics combined with other medications that help to eliminate nausea and spasms of the gastrointestinal tract. NVR can be treated with oral drugs, but alternative preparations such as transdermal or topical creams, oral lozenges, or suppositories may be preferable, especially  for patients with severe vomiting.

 Ask our pharmacist about the benefits of customized medications to meet specific patient needs.  For example, we can compound combinations of compatible medications into a single dosage form to simplify dosing regimens. When patients are unable to swallow, we can prepare medications as topical or transdermal dosage forms such as creams, gels, or lozenges, thereby avoiding the need for injections. Oral medications can be flavored to please each patient, from choices such as coffee, root beer, watermelon, and many more.

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