Preventing Vomiting Caused by Cancer Treatment

November 2, 2015

To help doctors give their patients the best possible care, the American Society of Clinical Oncology (ASCO) developed evidence-based recommendations on the use of drugs called antiemetics that prevent vomiting. This guideline was updated in 2015 to add a new combination drug. This guide for patients receiving any type of chemotherapy or radiation therapy is based on these updated ASCO recommendations.

Understanding nausea and vomiting from cancer treatment

Vomiting or throwing up is the act of expelling the contents of the stomach through the mouth. It may also be called emesis. Nausea is the urge to vomit. Nausea and vomiting may be caused by the cancer treatments listed below.

  • Radiation therapy, which is the use of high-energy x-rays or other particles to destroy cancer cells

  • Chemotherapy, which is the use of drugs to kill cancer cells

  • Targeted therapy, which is treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival

Not all patients who receive these treatments will have nausea and/or vomiting. Patients who often have motion sickness or have vomited after previous cancer treatments are more likely to experience nausea and vomiting.

Anticipatory emesis is vomiting that occurs before treatment in patients who have previously felt nauseated or vomited after treatment. The prevention and treatment of anticipatory vomiting depends on the patient. Tell your doctor if you have experienced vomiting with previous treatment. Your doctor may be able to recommend medication or behavioral therapy to help reduce vomiting.

The risk of nausea and vomiting from chemotherapy and targeted therapy

Some drugs used for cancer treatment are more likely to cause nausea and vomiting than other drugs. The table below lists the likelihood that a certain cancer drug will cause nausea and vomiting.

Nearly Always Causes Nausea and Vomiting
(High Risk)

Usually Causes Nausea and Vomiting
(Moderate Risk)

Sometimes Causes Nausea and Vomiting
(Low Risk)

Rarely Causes Nausea and Vomiting
(Minimal Risk)

Carmustine (BiCNU)

Alemtuzumab (Campath)

Bortezomib (Velcade)

Bevacizumab (Avastin)

Cisplatin (Platinol)

Azacitadine (Vidaza)

Cabazitaxel (Jevtana)

Bleomycin (Blenoxane)

Cyclophosphamide (Neosar) at higher doses

Bendamustine (Treanda)

Catumaxumab (Removab)

Busulfan (Busulfex, Myleran)

Dacarbazine (DTIC-Dome)

Carboplatin (Paraplatin)

Cytarabine at lower doses

Cetuximab (Erbitux)

Dactinomycin (Cosmegen)

Clofarabine (Clolar)

Docetaxel (Docefrez, Taxotere)

2-Chlorodeoxyadenosine (cladribine, Leustatin)

Daunorubicin (Cerubidine) when combined with cyclophosphamide

Cyclophosphamide at lower doses

Doxorubicin HCL liposome injection (Doxil)

Fludarabine (Fludara)

Doxorubicin (Adriamycin) when combined with cyclophosphamide

Cytarabine (Cytosar-U) at higher doses

Etoposide (Etopophus, Toposar, VePesid)

Pralatrexate (Folotyn)

Epirubicin (Ellence) when combined with cyclophosphamide

Daunorubicin

Fluorouracil (5-FU, Adrucil)

Rituximab (Rituxan)

Idarubicin (Idamycin) when combined with cyclophosphamide

Doxorubicin

Gemcitabine (Gemzar)

Vinblastine (Velban)

Mechlorethamine (Mustargen, Valchlor)

Epirubicin

Ixabepilone (Ixempra)

Vincristine (Vincasar PFS)

Streptozotocin (Zanosar)

Idarubicin

Methotrexate (multiple brand names)

Vinorelbine (Navelbine, Alocrest)

 

Ifosfamide (Ifex)

Mitomycin (Mitozytrex, Mutamycin)

 

 

Irinotecan (Camptosar)

Mitoxantrone (Novantrone)

 

 

Oxaliplatin (Eloxatin)

Paclitaxel (Taxol, Abraxane)

 

 

 

Panitumumab (Vectibix)

 

 

 

Pemetrexed (Alimta)

 

 

 

Temsirolimus (Torisel)

 

 

 

Topotecan (Hycamtin, Brakiva)

 

 

 

Trastuzumab (Herceptin)

 

Recommendations for preventing vomiting caused by chemotherapy and targeted therapy

The best way to manage nausea and vomiting caused by cancer treatment is to prevent it. Fortunately, many medications are available that can prevent vomiting. These medications may also prevent nausea. However, some patients may still have nausea even if they do not have vomiting. More research is needed to understand if these drugs prevent nausea.

Likelihood of Chemotherapy to Cause Nausea and Vomiting

Nearly Always Causes Nausea and Vomiting (High Risk)

Usually Causes Nausea and Vomiting (Moderate Risk)

Sometimes Causes Nausea and Vomiting (Low Risk)

Rarely Causes Nausea and Vomiting (Minimal Risk)

Recommended Treatment

Patients have two options that include:

A three-drug combination of the drugs listed below

1)      Aprepitant (Emend) on days 1 through 3 or fosaprepitant (Emend for Injection) on day 1

 

2)      Dolasetron (Anzemet; by mouth only), granisetron (Kytril, Sancuso), ondansetron (Zofran, Zuplenz), palonosetron (Aloxi), tropisetron (Navoban), or ramosetron (Nasea)

 

3)      Dexamethasone (multiple brand names) on days 1 through 3 or days 1 through 4

Or, a combination drug of netupitant and palonosetron (NEPA, Akynzeo) on day 1 plus dexamethasone on days 1 through 4

A two-drug combination of the following:

1) Palonosetron  (this is the preferred treatment, but granisetron or ondansetron may also be used)

2) Dexamethasone on days 1 through 3

Dexamethasone

No treatment required unless the patient has previously experienced vomiting with this treatment.

Recommendations for preventing vomiting caused by radiation therapy

The risk that radiation therapy will cause nausea and vomiting depends on where the radiation therapy is targeted and how much of the body is receiving treatment. The risks and recommended treatments of vomiting caused by radiation therapy are summarized in the table below.

Risk of Nausea and Vomiting From Radiation

Area of the Body Being Treated

Recommended Treatment

High

Total body irradiation (entire body) or total nodal (lymph node) irradiation

One of these drugs: granisetron or ondansetron (preferred) or dolasetron, tropisetron, or palonosetron before each dose and after the last, with dexamethasone before treatments 1 through 5

Moderate

Upper abdomen (trunk or stomach), upper body, or half of the body

One of these drugs: granisetron or ondansetron (preferred) or dolasetron, tropisetron, or palonosetron before each treatment with dexamethasone before treatments 1 through 5

Low

Lower thorax (chest)
Pelvis (lower abdomen)
Brain
Spinal cord (back)

Head and neck

One of these drugs: granisetron or ondansetron (preferred) or dolasetron, tropisetron, or palonosetron as needed

Minimal

Arms and legs
Breast

One of these drugs: granisetron or ondansetron (preferred) or dolasetron, tropisetron, or palonosetron  and metoclopramide (Reglan) or prochlorperazine (Compazine) as needed

What This Means for Patients

Vomiting can be prevented with the appropriate medications for most patients receiving cancer treatment. However, patients may still have nausea without vomiting. Medications to prevent vomiting should be taken as prescribed before treatment. And, they should be continued after treatment as directed by your doctor because the risk of vomiting may continue for several days after treatment.

If you have nausea and vomiting, even if you take your medication as prescribed, let your doctor know. Your doctor can recommend other medications to reduce nausea and vomiting and help prevent these symptoms during future cycles of chemotherapy. It is very important to call or see your doctor if you cannot keep food or water in your body because of severe nausea and vomiting. This can cause serious dehydration and electrolyte imbalance. It is also important to talk to your doctor if your symptoms worsen throughout treatment.

Questions to Ask Your Doctor

  • Does my treatment carry a high risk of nausea and vomiting?

  • What can be done to manage nausea?

  • What can be done to prevent vomiting?

  • Are some medications preferred over others? Why?

  • What are the instructions for taking these medications?

  • Do these medications have side effects that I should know about?

  • What are the costs of these medications?

  • If I’m worried about managing the costs related to my cancer care, who can help me with these concerns?

  • Where can I find more information?

Helpful Links

Read the entire clinical practice guideline published at www.asco.org/guidelines/antiemetics.

Nausea and Vomiting

Side Effects of Chemotherapy

Side Effects of Radiation Therapy

Targeted Treatments