Welcome to Mayo Clinic podcast. Our topic today is managing nausea and vomiting during chemotherapy. I'm your host, Rich Dietman.

In today's podcast we're talking about managing nausea and vomiting, two of the most common side effects of chemotherapy, which is used to treat many forms of cancer. My guest is Mayo Clinic cancer specialist, Dr. Charles Loprinzi. Dr. Loprinzi practices in the department of medical oncology at Mayo, and he's also medical editor of the book "Mayo Clinic Guide to Women's Cancers." Dr. Loprinzi, thanks for being with us.

Dr. Loprinzi: It's a pleasure.

Rich Dietman: Whether it's a valid fear or not, one of the first questions that many people have when they hear the word "chemotherapy" is, "Will I be sick, will I throw up?" How valid a concern is that for someone about to begin the chemotherapy?

Dr. Loprinzi: It is a very valid concern. It's much less of a concern now than it was 20 years ago because we have more effective nausea and vomiting medications. However, it still is quite a big concern.

Rich Dietman: Are there different classifications of nausea and vomiting related to chemotherapy?

Dr. Loprinzi: There are different classifications. Oncologists have put together three different classifications that we talk about in terms of nausea and vomiting related to chemotherapy. First is acute, which refers to nausea and vomiting which happens in the first 24 hours after chemotherapy is given; delayed is the second category, which is nausea and vomiting that happens from two days to five days after a dose of chemotherapy; and then there's another third classification called anticipatory nausea and vomiting, and that's nausea and vomiting that happens before a subsequent cycle of chemotherapy related to thoughts regarding the first cycles of chemotherapy.

Rich Dietman: Are there things that can predict who will get nausea and vomiting from chemotherapy and who won't be affected?

Dr. Loprinzi: Yes, oncologists use a number of things to help predict who will get chemotherapy-induced nausea and vomiting. First is the chemotherapy regimen that a person gets. There are some chemotherapy regimens that we use — drugs or combinations of drugs — which really don't cause nausea and vomiting very often at all. That's called grade 1 emetogenic potential. And then there are types of chemotherapy that will cause nausea and vomiting in greater than 90 percent of patients who receive that chemotherapy; and that gets up to what we call grade 4 emetogenic potential — "emesis" being the medical word for vomiting, so that there's grade 1, 2, 3 and 4.

Rich Dietman: So if I'm your patient and I have a particular kind of cancer and you're discussing with me a particular chemotherapy set of drugs, you probably can tell me with some certainty whether or not I'm going to have nausea and vomiting; maybe not absolute, but sounds like, depending on the chemotherapy regimen, you can tell me what I might expect.

Dr. Loprinzi: That's correct, there are some regimens that less than 10 percent of people will have vomiting, and others greater than 90 percent will. It doesn't guarantee it for any one person. Now, in addition to the chemotherapy regimen, there are differences between different people. There are some things that will predict patients who will get more trouble with nausea and vomiting. Nothing's absolute, but as a rule, women have more trouble than do men. Young people have more trouble with chemotherapy than do older people, in terms of nausea and vomiting. People who get motion sickness can get more trouble with nausea and vomiting. If a person's had previous chemotherapy and had nausea and vomiting from that chemotherapy, it will predict troubles on subsequent chemotherapy regimens. And also an interesting thing is people who drink a lot of alcohol tend to have less trouble with nausea and vomiting than people who don't.

Rich Dietman: Are there medications that can ease acute and delayed nausea and vomiting related to chemotherapy? And talk too a little bit about when those drugs are given. 

Dr. Loprinzi: Yes, there are medications and this has been an advance over the last 20 years in this area. The most common medications we call are the trons. There's ondansetron, granisetron, dolasetron and palonosetron — drugs that are helpful for preventing nausea and vomiting. The brand names for those, respectively, are Zofran, Kytril, Anzemet and Aloxi, and those will decrease nausea and vomiting quite a bit. In addition to those medications, there are corticosteroid medications — dexamethasone would be the most common one, is also helpful in decreasing nausea and vomiting. And then there's a third classification that's come about more recently, called NK1 receptor antagonists. The one that's around now is called aprepitant, or the brand name for that is Emend. So for example if we have people with grade 4 nausea and vomiting potential from chemotherapy — and 90 percent of people will have — only 10 percent of people will not have vomiting if you give those without any drugs. If you give one of the tron medications, that probably improves up to about 50 percent of people with no nausea and vomiting. If you add dexamethasone to that, that improves up to about 60 percent; and if you add aprepitant or Emend to that, that improves it to about 70 percent. All of the drugs have some side effects and some costs associated with them also. The drugs are given either intravenously or oral. A lot of people used to think it's better to get it IV (intravenously), but it turns out that some of the drugs actually work on the bowel, so it might be beneficial to give it to them orally.

Rich Dietman: And when can a person expect, generally, to get those drugs — at the same time they get their chemotherapy or day before? I suppose it may depend upon the drug.

Dr. Loprinzi: It does a little bit, but as a rule they're given a little bit before the time of chemotherapy, either orally or intravenously, and some of the drugs are given on the second and third day also.

Rich Dietman: What if they don't work, for a particular person, the anti-nausea drugs, what does a person do then? What can a person do instead of the drugs, or if they don't work, are there other alternatives to reducing nausea and vomiting?

Dr. Loprinzi: If the drugs don't work and you've already given the chemotherapy, people are having trouble with nausea and vomiting in the day or two or three or four afterwards, there are medications that we can try to give to try to decrease that nausea and vomiting. They're not great drugs, in all. The next thing to think about is when you're going to give the next cycle of chemotherapy, what will you do then to try to prevent the nausea and vomiting that the patient had on the first cycle. And again, we try to tailor the kind of drugs we give — based on the potential for the person to get the nausea and vomiting, based on their chemotherapy regimen and their personal characteristics — so we may modify that. There are several drugs there; and some drugs work for some people and not the others, and you won't know that for sure. So we can modify the drugs occasionally to try to better our improvement for giving this. We can give another medication, Ativan, or lorazepam, which is a drug like the old Valium, which will help people who are having trouble with nausea and vomiting. It mainly makes them drowsy, and then the nausea and vomiting experience isn't quite so bad. Other things people have looked at — hypnosis, there's some information that might be helpful. People aren't very well equipped to do that oftentimes, at the time when it's needed. There's some information that acupuncture also could be helpful. It's not utilized very much because it's a bit clumsy to be able to get that while the person is getting the chemotherapy.

Rich Dietman: So some of these might actually be applied while the person is getting the chemo.

Dr. Loprinzi: When acupuncture has been studied, that's where it was applied and seemed to be a little bit helpful — improved things by 5 percentage of patients who are not having nausea and vomiting or something to that range; however, it's somewhat clumsy to arrange while the person's getting chemotherapy to get the acupuncturist there at the same time. We're in a busy room, so it's not used that often.

Rich Dietman: Talk about food for a minute. Specifically, for someone who has an appetite, is getting chemotherapy, is having some nausea and vomiting, are there certain kinds of foods, or groups of foods that a person might want to think about eating more of, and others to stay away from?

Dr. Loprinzi: When a person's getting chemotherapy, I'm often asked what they should eat or shouldn't eat, and I generally recommend that they should not eat a big, fatty meal prior to getting their chemotherapy. They should eat the sort of thing that they would eat if they were having the flu. Bland soup, bland sandwich, that sort of thing, not something fatty. After people get the trouble with nausea and vomiting, there are some people — like with morning sickness associated with pregnancy — where they find that eating crackers, putting a little bit of something in their stomach, would be helpful in decreasing that nausea and vomiting.

Rich Dietman: How do you treat anticipatory nausea that you talked about earlier?

Dr. Loprinzi: So anticipatory nausea is the type that is related to the old story that people know of Pavlov's dog and back from high school science, people know that whenever they were about to give a dog some food, they would ring a bell and the dog would salivate, and after a while just ringing the bell would cause salivation. So this occurs with chemotherapy-induced nausea and vomiting, where a person comes back to the chemotherapy suite, and they get that nausea and vomiting experience. Interestingly enough, some people just driving by the hospital will get the trouble, or if they see their chemotherapy nurse in the grocery store, can get the same sort of trouble. The things that can be helpful for that are the benzodiazepine medications, this is the Valium-type medications, or lorazepam (Ativan) can be a bit helpful; and hypnosis also can be helpful in that situation.

Rich Dietman: Thanks very much, Dr. Loprinzi. We've been talking about managing nausea and vomiting during chemotherapy with Dr. Charles Loprinzi, a cancer specialist at Mayo Clinic, and editor of "Mayo Clinic Guide to Women's Cancers." You've been listening to Mayo Clinic podcast. I'm Rich Dietman.

PODCAST HELP

If the podcast does not play, you may need to download and install the latest version of the Windows Media Player. For additional troubleshooting tips, browse the Multimedia FAQ.