anti emetic guidelines for the prevention and treatment

Clinical Guideline for the use of Anti- emetic for the Prevention and Treatment of Chemotherapy induced Emesis of 12

Clinical Guideline for the use of Anti- emetics for the Prevention and Treatment of Chemotherapy induced Emesis

1. Aim/Purpose of this Guideline 1.1. This Guideline aims to provide the best anti-emetic prophylaxis to all

patients receiving chemotherapy.

1.2. To reduce inappropriate prescribing of anti emetics.

1.3. To improve patients understanding and compliance with prophylactic

treatment, therefore improving its effectiveness.

1.4. To provided guidance in the prescribing of anti emetics to all medical staff

that prescribe chemotherapy

1.5. To provide all nursing staff working with chemotherapy the evidence and

guidance in the management of CINV.

2. The Guidance

2.1. Introduction

2.1.1. Chemotherapy induced nausea and vomiting (CINV) is a common adverse event associated with cancer treatment especially chemotherapy. 2.1.2. 70-80%of patients will experience some form of CINV

2.1.3. It can impact negatively on a patient’s quality of life.

2.1.4. Uncontrolled CINV can led to or prolong hospital admission.

2.1.5. There are 5 recognised different types of CINV:

Acute - occurs within first 24hrs of chemo administration. Is more common in people who are anxious, people who have little alcohol intake, women under 50 years and is more common in women who were nauseous in pregnancy. Acute CINV is also related to environment and the emetogenicity of the drug and dosing level it is given at.


Delayed - is more common and patients find it more distressing. It occurs 24 hours after administration of chemotherapy and it may persist. It is related to emetogenicity of drug

Anticipatory - CINV is fairly common and occurs in 10 – 44% of people. It can occurs prior to attending for chemotherapy and can be attributed to the adverse memory of CINV

Breakthrough - CINV is when nausea and vomiting is not controlled

well with anti-emetics use or when anti emetics are not given for the entire expected period of CINV. It requires ‘rescue’ anti-emetics

Refractory - occurs in subsequent cycles of chemotherapy, despite anti-emetic agents

2.1.6. Other causes of Nausea, such as constipation, uremia, vestibular disease should be considered in the assessment of a patient experiencing CINV and treated accordingly. 2.1.7. The chemotherapy prescriber should determine the emetic potential of each chemotherapy drug to be administered and prescribe the appropriate anti emetic according to the following guidelines.

2.2. Pathophysiology of CINV

2.2.1. The Vomiting Centre is located in the medulla. It is stimulated by neurotransmitters located in the Chemoreceptor trigger Zone (located in the Postrema near vomiting centre) and in the gastro-intestinal tract. 2.2.2. The Vomiting Centre contains muscarinic ,cholinergic and histamine receptors.

2.2.3. The Chemoreceptor trigger Zone is rich in dopamine D2 receptors.

2.2.4. Serotonin receptors, specifically 5HT3, exist in the central nervous system and the GI tract.

2.2.5. Substance P is a mammalian tachykinin that is found in vagal afferent neurons innervating the brainstem. Substance P is a ligand which binds to Neurokinin-1 receptors in the abdominal vagus and induces vomiting.

2.2.6. Medicines that block the neurotransmitter receptors involved in nausea and vomiting are used to control CINV


2.3. Emetogenic Risk of Chemotherapy

2.3.1. Each cytotoxic agent has a different emetic potential 2.3.2. The emetognic potential of minimal or low risk drugs can be

increased when given in combination. Consideration of this should be taken

when prescribing for combination regimens.

High - emesis risk,

>90% Moderate - risk,

30%–90% Low (emesis risk,

10%–30% Minimal (emesis

risk, <10%

Actinomycin -D Carboplatin Bortezomib Bleomycin

Carmustine Cyclophosphamide (<1,500 mg/m²)

Capecitabine Busulfan

Cisplatin Cytarabine ( >1g/m²)

Cetuximab Chlorambucil

Cyclophosphamide (>1,500 mg/m²)

Daunorubicin Cyclophosphamide (oral)

Cladribine

Dacarbazine Doxorubicin Cytarabine (>1g/m²) Fludarabine

Mustine Epirubicin Docetaxel Hydroxyurea

Streptozotocin

Doxorubicin – liposomal

Melphalan

Idarubicin Etoposide Methotrexate (<100 mg/m²)

Ifosfamide Gemcitabine Meracaptopurine

Irinotecan Methotrexate (>100 mg/m²)

Tioguanine

Mitomycin C Vinblastine

Melphalan Mitoxantrone Vincristine

Oxaliplatin Paclitaxel Vinorelbine

Trabectedin Procarbazine (oral)

Temozolomide Pemetrexed

Treosulfan Topotecan

Trastuzumab

5-Fluorouracil

Referenced from: Jordan K, Sippel C, Schmoll H, ( 2007) Guidelines for Antiemetic Treatment of Chemotherapy- induced

Nausea and vomiting: past, Present and Future recommendations. The Oncologist 12; 1143-1150


2.4. Anti emetics for CINV

2.4.1. Dopamine Antagonists

Metoclopramide – The UK MHRA (August 2013) has given new

guidance for the administration of oral metoclopramide. A review

confirmed the well know risks of neurological effects such as a short

term extrapyramidal disorders and tardive dyskinesia. The conclusion

was that the risks outweigh the benefits in long term and high dose

treatment. If patient is over 60kg dose should be 10mg TDS if under

60kg dose should be 500mcg per kg of body weight in three divided

doses.

Domperidone – The UK MHRA (May 2014) has given new

guidance for Domeridone to only be given for nausea and vomiting

at the lowest effective dose. Patients being prescribed this should

be considered if there are any contraindicated with cardiac

impairments.

2.4.2. 5-HT3 Receptor Antagonists

Granisetron – IV/PO routine. A patch is available for patients for

highly emotogenic chemotherapy regimens and would be considered

on an individual patient need for patients that would otherwise require

IM antiemetic’s in the community setting. Discussion required with

chemotherapy pharmacist before prescribing.

Ondansetron -The UK MHRA has given new guidance for the

administration of IV ondansetron based on further information on the

risk of dose-dependent QT interval prolongation, (first reported in

August 2012). The new advice is: patients aged 65 years or older, all

IV doses should be diluted in 50–100mL saline or other compatible

fluid and infused over at least 15 minutes. The maximum single IV

dose of ondansetron may be up to 16mg (maximum 8mg in patients

aged 75 years or older.


2.4.3. Corticosteroids

Dexamethasone

2.4.4. Benzodiazepines

Lorazepam

2.4.5. Neurokinin NK1 receptor antagonist

Aprepitant

2.5. Additional points

2.5.1. The suitability of the anti emetics outlined abelow should be assessed on an individual patient basis.

2.5.2. Patients must be educated regarding the risk of uncontrolled CINV (acute renal failure due to dehydration) and be given full clear instruction on how and when to contact the cancer units within RCHT.

2.5.3. The effectiveness of anti emetic cover for previous cycles of chemotherapy should be reviewed and subsequent cover modified accordingly.

2.5.4. For patients who are unable to tolerate oral anti emetics, other routes of administration can be considered, including suppositories, sub-cutaneous and patch. Advice regarding these can be sought from the cancer pharmacist or palliative care team.

2.5.5. Local joint formulary can be consulted for advice regarding the management of CINV and for the management of the side effects of anti emetics used.

2.5.6. Advice regarding refractory CINV not resolved by standard anti emetics can be sought from the palliative care team.


2.6. Recommended Aniti- emetic regimens for cytotoxic chemotherapy: Acute Delayed Second line

Highly

5-HT3 Antagonist - Orally/IV prior to each injection And/ or Dexamethasone – 20mg orally/IV starting on the day of chemotherapy, continuing for each day of chemotherapy. Note - Reduce dose to 8mg if using with Aprepitant. And/ or Aprepitant- Orally 125mg on day one, followed by 80mg for two days.

Dopamine Antagonists- normally either: Metoclopramide – dosed as above Domperidone – 10mg orally four times a day for 5days immediately after chemotherapy. And/or Dexamethasone – 4mg orally twice a day usually for 2-5 days. And/or 5-HT3 Antagonist - Orally/IV continuing twice a day for three days post and then as required by patient.

Aprepitant- Orally 125mg on day one, followed by 80mg for two days. Lorazepam – 1mg orally, sublingual or IV up to 8hrly. or Cyclizine – 50mg three times a day or 150mg daily by S/C infusion. or Dexamethasone- 4mg twice a day for up to one week Haloperidol - 1.5-3mg bd or Levomepromazine 6.25mg nocte/bd (or by syringe driver 6.25-25mg over 24 hours) Granisetron Patch – see notes above

Moderate 5-HT3 Antagonist - Orally/IV prior to each injection of chemotherapy And/or Dexamethasone – 8mg orally/IV starting on the day of chemotherapy.

Dopamine Antagonists- normally either: Metoclopramide – dosed as above Domperidone - 10mg orally four times a day for 5days immediately after chemotherapy. And/or Dexamethasone – 4mg orally twice a day usually for 2-5 days. And/or 5-HT3 Antagonist - Orally/IV continuing twice a day for three days post and then as required by patient.

Aprepitant- Orally 125mg on day one, followed by 80mg for two days. Lorazepam – 1mg orally, sublingual or IV up to 8hrly. or Cyclizine – 50mg three times a day or 150mg daily by S/C infusion. or Dexamethasone- 4mg twice a day for up to one week Haloperidol - 1.5-3mg bd or Levomepromazine 6.25mg nocte/bd (or by syringe driver 6.25-25mg over 24 hours)

Low No routine prohylaxis required Or Dopamine Antagonists- normally either: Metoclopramide – 10-20mg orally three times a day or Domperidone - 10-20mg orally four times a day Both for 4-5days and then as required by patient.

Dopamine Antagonists- normally either: Metoclopramide – dosed as above Domperidone - 10mg orally four times a day for 5days immediately after chemotherapy.


3. Monitoring compliance and effectiveness

Element to be monitored

Good prescribing of antiemetic’s for CINV

Lead Chemotherapy MDT

Tool ARIA – chemotherapy prescribing system.

Frequency As required/ongoing

Reporting arrangements

Chemotherapy MDT

Acting on recommendations and Lead(s)

Chemotherapy MDT

Change in practice and lessons to be shared

Required changes to practice will be identified and actioned within

3 months. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all

the relevant stakeholders

4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website.

4.2. Equality Impact Assessment

The Initial Equality Impact Assessment Screening Form is at Appendix 2.

http://www.rcht.nhs.uk/GET/d10268876

http://www.rcht.nhs.uk/GET/d10268876

http://www.rcht.nhs.uk/RoyalCornwallHospitalsTrust/OurOrganisation/EqualityAndDiversity/HumanRightsEqualityAndInclusion.aspx


Appendix 1. Governance Information

Document Title CLINICAL GUIDELINE FOR the use of Anti- emetic for the Prevention and Treatment of Chemotherapy induced Emesis

Date Issued/Approved: March 2015

Date Valid From: March 2015

Date Valid To: March 2018

Directorate / Department responsible (author/owner):

Chemotherapy Clinic Nurse Specialists

Contact details: 01872258347

Brief summary of contents Guidance on the prescribing of antiemetic’s for CINV

Suggested Keywords: Nausea, vomiting, chemotherapy

Target Audience RCHT PCH CFT KCCG

Executive Director responsible for Policy:

Nursing Executive

Date revised: March 2015

This document replaces (exact title of previous version):

Anti- emetic Guidelines for the Prevention and Treatment of Chemotherapy induced Emesis V2

Approval route (names of committees)/consultation:

Chemotherapy MDT (04.03.15) CSSC Governance DMB (14.04.15)

Divisional Manager confirming approval processes

Sally Rowe, Divisional Director CSSC

Name and Post Title of additional signatories

Janet Gardner, Governance Lead CSSC

Signature of Executive Director giving approval

{Original Copy Signed}

Publication Location (refer to Policy on Policies – Approvals and Ratification):

Internet & Intranet Intranet Only

Document Library Folder/Sub Folder Clinical / Cancer services

Links to key external standards N/A

Related Documents: National comprehensive cancer network


(2011).NCCN Practice guidelines in oncology (v.3.2011). Antiemesis. Retrieved 21/03/2011 from http://www.nccn.org/professionals Flemm L A, (2004). Aprepitant for chemotherapy induced nausea and vomiting. Clinical journal of oncology nursing. Vol 8, no 3. 303 – 306. Dando T M, Perry C M. (2004). Aprepitant. A review of its use in the prevention of chemotherapy-induced nausea and vomiting. Adis Data information; 64(7).778 – 794. Navari R M (2009). Antiemetic control:toward a new standard of care for emetogenic chemotherapy. Expert Opinion. 10(4);629-644 Jordan K, Sippel C, Schmoll H, ( 2007) Guidelines for Antiemetic Treatment of Chemotherapy- induced Nausea and vomiting: past, Present and Future recommendations. The Oncologist 12; 1143-1150 Joint Formulary Committee (2010) British National Formulary 60 September. BMJ publishing group Ltd and RPS Publishing London. Joint Formulary for Royal Cornwall Hospitals Trust (2010) Cornwall Partnership & IoS Community Health Services and GP’s, Nurses and other non-medical prescrbers within Cornwall and Isle of Silly MRHA

Training Need Identified? No


Version Control Table

Date Version No

Summary of Changes Changes Made by

(Name and Job Title)

2006 1 New policy Not known

2011 2 Revised, new trust format

Lisa Nicholls Chemotherapy CNS

2015 3 MRHA alerts, new template, Lisa Nicholls and Caroline Tonkin Chemotherapy CNS

All or part of this document can be released under the Freedom of Information Act 2000

This document is to be retained for 10 years from the date of expiry.

This document is only valid on the day of printing

Controlled Document

This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the

express permission of the author or their Line Manager.


Appendix 2. Initial Equality Impact Assessment Form

Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Rationale for Assessment / Existing Evidence

Age

Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to as policy) (Provide brief description): CLINICAL GUIDELINE FOR the use of Anti- emetic for the Prevention and Treatment of Chemotherapy induced Emesis

Directorate and service area: CSSC, Cancer Services

Is this a new or existing Policy? Existing

Name of individual completing assessment: Lisa Nicholls

Telephone: 01872258347

1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at?

To provide guidance in the prescribing of CINV

2. Policy Objectives*

To provide good antiemetic cover for chemotherapy patients

3. Policy – intended Outcomes*

To provide good antiemetic cover for chemotherapy patients

4. *How will you measure the outcome?

Good control of CINV in patients receiving chemotherapy

5. Who is intended to benefit from the policy?

Patients receiving chemotherapy

6a) Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? b) If yes, have these *groups been consulted? C). Please list any groups who have been consulted about this procedure.

Yes Yes Chemotherapy MDT

7. The Impact Please complete the following table.


Sex (male, female, trans-

gender / gender reassignment)

Race / Ethnic communities /groups

Disability - learning disability, physical disability, sensory impairment and mental health problems

Religion / other beliefs

Marriage and civil partnership

Pregnancy and maternity

Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian

You will need to continue to a full Equality Impact Assessment if the following have been highlighted:

You have ticked “Yes” in any column above and

No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or

Major service redesign or development

8. Please indicate if a full equality analysis is recommended. No

9. If you are not recommending a Full Impact assessment please explain why.

Signature of policy developer / lead manager / director Date of completion and submission

Names and signatures of members carrying out the Screening Assessment

1. Lisa Nicholls 2.

Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD A summary of the results will be published on the Trust’s web site. Signed _______________ Date ________________