How to Manage Your Chemo Induced Nausea and Vomiting (CINV)

What Causes Chemotherapy Induced Nausea and Vomiting (CINV)?

You just received chemotherapy or cancer directed therapy and you are feeling nauseous.  Let me tell you why.  There is a gut brain connection that causes nausea and vomiting. Vomiting is controlled by the “emetic” center in the brainstem and receives input from 3 sources: the periphery, the cortex, and the chemoreceptor trigger zone. The peripheral pathways are mediated by serotonin (5HT3) and Neurokinin (NK) while the cortex is associated with anticipatory nausea and mediated by serotonin and histamine. Lastly, the chemoreceptor zone is a group of neurons at the base of the brain and is exposed to the body’s general circulation.

Overall, 70 percent of people report nausea associated  with chemotherapy and or cancer directed therapy so you're not alone.  Furthermore,  many of these chemotherapy drugs are considered highly emetogenic  or moderately emetogenic  which means they have a high likelihood of causing nausea and vomiting. Highly emetogenic means that greater  than 90% of  patients develop chemotherapy induced nausea and/or vomiting while moderately emetogenic induces nausea and/or vomiting in 30%-90% of all  patients. 

What type of nausea do you most associate with?

Anticipatory nausea: You  associate your treatment with a smell,  a color, or a place and you get nauseous before you've even received chemotherapy. 

Acute nausea: Happens within minutes to hours after the administration of chemotherapy and generally resolves within 24-48 hours

Delayed nausea: Occurs 24-48 hours after the onset of chemotherapy. 

Breakthrough nausea: Nausea occurs despite taking proper prophylactic medication post chemotherapy. Requires rescue medications to resolve. 

How do you manage the different types of nausea?

So what can you do to combat this nausea? There are several medications available to you via prescription at the pharmacy  or in the infusion center that are ordered by your medical oncology team. Your medical oncologist or Nurse practitioner will order “home” medications to be taken as needed or on a schedule pre or post chemotherapy. He/She should review in detail with you. Home medications are administered orally or via a transdermal patch. Infusion center medications can be either oral or intravenous (given through a vein or a port). Typically the medications ordered as pre-medications in the infusion center are based on the emetogenicity of your chemotherapy regimen. 

Anticipatory nausea: Breathing exercises, meditation, hypnosis, and discussion with a social worker or therapist are good ways to initially work on anticipatory nausea. If these remedies don’t work, I often recommend a shorter acting benzodiazepine, like Ativan (lorazepam) 0.5-1 mg dose or Xanax (alprazolam) 1 mg,  30 minutes prior to arriving at the cancer center. 

Acute nausea: Ideally you received a good pre-medication regimen prior to chemotherapy administration. Your oncology team and oncology pharmacist should review the proper premedications. Please note, these can always be adjusted and changed throughout your course of chemotherapy. Despite these measures, nausea will occur.  My favorite go-tos are ondansetron (zofran) and prochlorperazine (compazine). Compazine is a 10 mg tablet administered orally  every 6 hours as needed. It can be given around the clock if necessary. Zofran is an 8 mg tablet  administered orally every 8 hours and can be given around the clock as well as alternated with compazine. 

Delayed Nausea: Generally delayed nausea can be tackled with stronger IV pre-medications. The most commonly used drug is fosaprepitant (AKA emend or cinivanti). This is a 30 minute IV infusion that must be given prior to chemotherapy. Dexamethasone (decadron)  is a steroid that can be given both intravenously and orally. It should be used intravenously in combination with the emend prior to chemotherapy administration. Decadron, 4 mg, can be given twice daily for the first 3 days post chemotherapy to help offset the delayed nausea. 

Breakthrough Nausea: This may occur despite a great IV premedication regimen and around the clock compazine, zofran, and dexamethasone. Olanzapine (zyprexa) has been on the market for a long time as an antipsychotic medication, but in more recent years, has been used for highly emetogenic chemotherapy regimens and breakthrough nausea. Zyprexa dosing is either 2.5 mg or 5 mg given at bedtime. Bedtime is preferred because this medication is known to cause drowsiness and dizziness. Other rescue medications include Reglan (metoclopramide) which is a GI motility agent. Usual dosing is 5-10 mg given up to 4 times per day and ativan 0.5-1 mg given every 6 hours. 

Natural remedies to combat CINV

I often get asked about non-pharmacologic options to help combat nausea/vomiting.

1. Ginger: can be used to brew tea, in a smoothie, or taken as an oral supplement
2. Acupressure:  A kind of massage. It is based on the traditional Chinese medicine practice of acupuncture. With acupressure, you put pressure on certain places on your body. These places are called acupoints 
3. Acupuncture: Acupuncture can stimulate the body to release natural endogenous opioids (endorphins) and neurotransmitters or neurohormones, which can change the uncomfortable experience such as CINV and pain. I always recommend receiving acupuncture within 1-2 days post chemotherapy. Some people have a session prior to chemo to help prepare for the side effects. 
4. Hypnosis: work with a practitioner or use self guided hypnosis recording. A study in the Journal of developmental and behavioral pediatrics in 1994 showed that hypnosis was helpful in reducing the incidence of  anticipatory nausea. 
5. Meditation: use a self guided app or work with a practitioner to help alleviate symptoms. It can specifically target anxiety which helps people relax and focus less on bothersome symptoms. 
6. Hydration: Drinking adequate fluids throughout treatment helps combat nausea. Aim for ½ body weight in ounces of water. I recommend LMNT electrolyte packets that contain magnesium, potassium, and sodium in them. Mix in 24-32 ounces of water and drink 1-2 times daily. They can be found at Thrive market, LMNT website, and amazon. Whole Foods Market  carries NUUN and ultima electrolyte packets.  I prefer that patients avoid gatorade and pedialyte as they are full of sugar and other chemicals. You can always call your oncology office and request IV hydration. A liter bag of saline can have a significant impact on nausea. 
7. Protein: Focus on a healthy protein and fat source at every meal or snack. This will help with nausea. Pick foods that are easy to digest such as  eggs, protein smoothies, greek yogurt, lentils, and cottage cheese. Avoid spicy and acidic foods as well as consuming large meals.