Chemotherapy is ghastly so you might doubt my claim, but it use to be worse. One of the daily hardships of chemo is the constant nausea and vomiting. Prior to cancer, I had vomited at the most twice in my adult life, but shortly after my diagnosis I became a pro. I had some wonderful friends that regularly cooked for me, doing their best to boost my nutrition with wonderful healthy organic meals. Unfortunately, my compliments to the chef at that time was typically ‘’organic vomit is not really all that bad” and in truth it was tastier then hospital “seconds”. Hospital food typically provoked a pavlovian response, and I would vomit at the site of the pink plastic plate cover. As awful as this is, we are lucky compared to cancer patients a couple of generations earlier who had less options of anti-nausea medications. These meds make chemotherapy a bit more tolerable. In the past, cancer patients relied more on a nice light backrub from a nurse, doctor, or friend. I do find myself occasionally applying this technique as doctor.
When thinking about treating our chemotherapy induced nausea and vomiting there are some general principles to keep in mind: (i) medications work best if given BEFORE the onset of symptoms. This is why oncologists often give medications that ease nausea and vomiting just before infusing chemotherapy. (ii) In times when we have persistent nausea and vomiting scheduling (giving at routine times) a medication may help. This is often more effective then waiting for the symptoms to start when it becomes a difficult chase. (iii) A factor in chasing symptoms is that you can miss an opportunity where you may be up for a little bit of eating and drinking. Staying hydrated and having a little bit of food can also improve nausea and vomiting. An important part of our job as patients (and it is a full time job) is to make sure we do our part to get nutrition and stay active, despite the difficulty.
The nausea and vomiting that we experience during chemotherapy occurs because there are receptors in our brain, in an area called the central vomiting center, that are triggered by the chemotherapy circulating in our blood. The degree that different drugs are able to trigger this center accounts for the spectrum of symptoms with various medications. On the other hand, the medications that prevent nausea and vomiting, often work by blocking these receptors.
As a troll on a couple of cancer forums, I know advice for dealing with nausea and vomiting is a frequent question. Nausea and queasiness even without vomiting can be awful. It is important to let our doctors know about symptoms, so we can work together to improve how we are feeling. We should not feel rushed in the office and preparing for appointments with questions can ease this feeling. We have a lot to keep track of as patients plus we are taking lots of medications, so if you’re like me it is easy to forget questions. I found it helpful to keep a notebook nearby, to jot down questions as they arise in my mind. Writing down the responses can be helpful to keep records of changes that can be used later to help modify the action plan as needed. It is not unusual for it to take some time to find what works best. It took me awhile to find the right schedule of medications and home IV fluids before I had relief.
Below I list medications and other techniques to discuss with your doctor. It is not a comprehensive list, but it is a starting point that you can use to help guide questions so you can make a plan with your oncologist. I discuss my own experience and give a little extra information as an oncologist. Please do not make changes without the advice of your doctor. There are some combinations of medications that can and cannot be taken together. On one hand there are interactions that synergize the anti-nausea benefit whereas there are other interactions that can compound the side effects and are should not be used together. Your doctor will be best at helping to make sure that each medicine is used correctly.
Ondansetron (Zofran). Blocks serotonin receptors in the in the central vomiting center. Commonly this medication is used prior to procedures and chemotherapy. It is most effective at preventing nausea and vomiting and sometimes less effective at treating intractable symptoms already present. Scheduling this medication at routine times throughout the day can be effective at suppressing symptoms of nausea and vomiting. This medication does not typically cause much sleepiness or mental changes that are more common amongst the other anti-emetic medications. This drug can be recommended at different time intervals but there is a limit to the amount that that can be taken. (There are other medications that are in a similar class, one such med is Kytril)
Aprepitant. (Emend)- This is a new medication that works to block substance P in the central vomiting center. This medication was really helpful to me and made chemotherapy tolerable. When using emend, oncologists will need to consider if appropriate for the chemotherapy regimen that one is taking. This is because it may interfere with the effectiveness of certain chemotherapies. Sometimes, as in my case, a specialized chemotherapy pharmacist can work with your oncologist to determine if there is safe way to use. At some larger cancer hospitals oncologists will round with pharmacists. These specialists can be a good resource for you and your doctor if something is not working well. On a personal note, I found that this medication not only improved my nausea but seemed to give me a better sense of well being. I do not know if others have experienced this. This drug is only given once a day.
Lorazepam (Ativan). It also works on the central vomiting center. It can make you sleepy and can cause other behavioral changes. I found it effective when I took it scheduled (along with zofran). At first, the sleepiness (although sleeping through parts of chemo is not a bad thing!) made it hard to take, but like many other patients my body became tolerant and the side effects lessened whilst still effective at treating my nausea. Although this medication is also used to treat anxiety and helps with the anxiety of vomiting it has also has a broader anti-emetic effect. If you are hospitalized on a non-oncology hospital floor, you may need to explain to your nurses that you’re taking to treat nausea because more commonly outside of oncology, it is used for treating anxiety.
Promethazine (Phenegren). This drug also works on central vomiting center. This drug is not only preventative but can treat ongoing nausea and vomiting. This drug can NOT be given to children under the age of 2. This drug causes sleepiness. This drug has a rare side effect called dystonic reactions during which a muscle group can involuntarily tighten or twitch.
Dronabinol (Marinol). This medication is related to DTH which explains some of the side effects! I giggled so much in the hospital after getting this medication that my friend added a scale below zero of the pain scale for “Jessica on Marinol”, complete with a big goofy smiley face. This drug also works on central vomiting center to treat nausea and vomiting. It can cause sleepiness and behavioral changes. Personally, I could only take the side effects when in the hospital but since it is only an oral medication, many find it effective for home use. An added benefit, one that you may guess from the fact that it is a derivative of DTH, is that it gives the munchies. Because it helps with eating, it is also used to treat cancer related anorexia. With this one medication you can decrease nausea and stimulate appetite. (There are other medications used to treat chemo related anorexia that one can discuss with their doctor if this is a concern.)
Diphenhydramine (Benadryl). Although this common anti-histamine is mostly used to reverse or prevent allergies, some find that it has anti-nausea effect, especially in kids. It increases sleepiness which is not always a bad thing when you need to sleep in the hospital during chemotherapy. (Although do not sleep too much that your not doing your daily walks!).
Haloperidol (Haldol). Less frequently used in pediatric practice and I have personally have no experience prescribing. Although mostly thought of as an antipsychotic drug is also an effective antiemetic again because it works on the central brain vomiting center. Can have side effects such as extrpyramidal symptoms (named after the area of the brain thought to cause these symptoms) of involuntary muscle spasms. Also cause sleepiness and behavioral changes. This drug should be able to work on symptoms of nausea that are already present. (There are other drugs from the psychiatric class of medications that are effective in treating chemotherapy related nausea as well as chemotherapy related anorexia.)
Dexamethasone (Decadron). Decadron in a corticosteroid, an anti-inflammatory used to treat many conditions. It is also an anti-emetic. In some chemotherapy regimens it is given daily before chemotherapy begins. It is not used in all regimes or with all cancers. Some tumors get an anti-tumor effect from steroids and in those cases it is often important only to deliver steroids at specific times in specific situations to preserve the anti-tumor properties. Because of side effects, steroids for this indication are not typically used scheduled over a long period of time. Typically they are given more sparingly for a couple of days during intense cycles of chemotherapy. Like all steroid the symptoms of decadron worsen with increased doses given over a longer period of time. General side effects of steroids (this is not a comprehensive list): increased appetite and weight gain, change in body habitus, increased risk of infections, and temporary difficulty with sugar metabolism (diabetes), behavioral changes and acne.
Eating, vomiting, and then eating again (When to push and when to not). I was actually surprised how much this helped me. What motivated me to force myself to eat was not to make the nausea better but was to take an oral medication that needed to be taken with food. I was taking traditional chemotherapy but I wanted to be able to take a more biological oral agent at the same time. This meant that I needed to take an oral medication with food 4 times a day during my chemotherapy cycle. It was work (as a foodie I was surprised to experience how hard eating could be!) but I was highly motivated to try anything to cure this very difficult to cure cancer. So that if I vomited and still needed to take my meds I just ate again.
I love being a pediatrician but for little ones there is a limit to reasoning with them, so this is a less effective practice for younger kids. Many children will need some meal supplements during chemotherapy, so it does not need to be made into a battle, make you miserable, or make you feel that you are in anyway failing in your role. It is for the doctors and the nutritionists to figure out alternatives and to guide you. Having SMALL healthy and unhealthy snacks available is helpful because there are times when eating will naturally pick up. Normal portions can be a turn off food, because the sizes can be overwhelming. As I posted earlier, many parents think “my child is eating this means he/she is well.” As I posted earlier (http://chemotherapycheerleader.com/does-eating-mean-everything-is-okay-a-tip-for-parents-and-caregivers-of-cancer-patients/), I would try separating the two thoughts. Part of my normal speech to parents when their children are admitted for bone marrow transplant is that “today you have to find something else other then your child eating that will make you happy and signify a good day. The majority of children will not eat during transplant and will get their nutrition through the IV. It may not be as ideal as eating but in the short term can provide your child the protein and fats needed. But if it is only your child eating that will make you happy then it will be miserable month or two (and BMT is hard enough). So try to train yourself into thinking of a good day as a day that I heard my child laugh or they smiled or played.”
Oral and IV hydration. I think most of us have experienced nausea and vomiting at some point prior to chemotherapy, usually due to a GI illness. We have also probably noticed that as we get more dehydrated the nausea gets worse and there is a cycle downwards. This is because as the nausea worsens there is even less interest in drinking which worsens the dehydration and then further increases the nausea. Many of us, myself included, have found that we were doing okay in the hospital but soon after arriving home symptoms worsen. I had a great deal of delayed vomiting after chemotherapy, and in my first cycle was readmitted to the hospital in less then 24 hours. One of the reasons for this is stopping of IV hydration (although not the only reason). In an attempt to limit this effect, doctors will often give a goal for oral fluid intake. Sports drinks are a palatable source for oral hydration. Taking sips continuously throughout the day is a good tactic for staying hydrated. I personally did much better once I started getting home IV hydration overnight. This is not too difficult once you have a central line. They have very light electronic pumps that can deliver fluids. Unlike a hospital IV it can be on the bed or floor and still deliver and they do not “beep” as often. They come in little purses/sacs that can be carried around. It is not ideal for everyone but something worth discussing. I was put on IV hydration to prevent dehydration, but the added bonus is that it also helped me feel a lot better, reduced my nausea so that I could eat and drink more at home and needed less anti-nausea medications. Even as a doctor I was surprised at how much this helped me feel better. Having home IV fluids does require that your central line is accessed at home. This can increase chances of infection, so some thought from your medical team is needed to determine if this is an appropriate intervention.
Diet. Most of us know the BRATT (Banana’s, Rice, Apple sauce, Toast, and Tea.). Common sense typically guides us towards more bland foods in times of nausea and vomiting. As for tea, I recommend ginger tea since ginger has some anti-nausea properties and some folks will snack on crystallized ginger to aid with nausea. My gut always felt “destroyed” after taking cisplatin, at the peak of my GI symptoms there was almost nothing I could tolerate except, CONGEE. I had a South East Asian friend who made this for me each cycle, since it was the only thing that I could manage to eat after chemotherapy. Hopefully I will get a copy of the recipe so I can post in the future. The version she made was chicken. Basically it was a chicken broth (that she made with whole chickens not store broth, so it was tasty!) with rice that is cooked long and slow to a point where it disintegrates into the broth. It always felt like it gave my GI tract a smooth coating and the nutrients of the broth left me feeling better. So I recommend finding a nice Asian mom that makes a mean bowl of congee so that you too can sing the praises of congee!
Other. Just to reiterate that this is not a complete list of pharmacological or non-pharmacological interventions. There are other techniques that people pursue and claim to be helpful such as acupuncture. This is just meant to be a starting guide so that you have the language to discuss with your doctor. The most important point is that you should not suffer. If you are having symptoms there are interventions, so keep in open dialogue with your doctor.