Substance P Antagonists NK
10.2.4.5 Cannabinoids The plant Cannabis contains more than 60 differ-
ent types of cannabinoids which have physiologic activity. There are two FDA-approved products for CINV: dronabinol a synthetic isomer, - trans - Δ 9 - tetrahydrocannabinol and nabilone. Cannabinoids likely exert antiemetic effects by targeting cannabinoid-1 CB-1 and CB-2 recep- tors in the CNS Abrahamov et al. 1995 ; Tramer et al. 2001 . These agents have demonstrated modest effi cacy in the prevention of acute CINV in children and are superior to low-dose metoclo- pramide and prochlorperazine, though with side effects which include euphoria, dizziness i.e., postural hypotension and hallucinations Chan et al. 1987 , Tramer et al. 2001 . Dronabinol is dosed at 5 mgm 2 q6 h prn max 15 mgm 2 dose orally and is typically reserved for refractory patients. Pediatric guidelines recommend nabi- lone 18 kg, 0.5 mgdose PO twice daily; 18–30 kg, 1 mgdose PO twice daily; 30 kg, 1 mgdose PO three times daily in patients for whom corticosteroids are contraindicated receiv- ing moderately to highly emetogenic chemother- apy Dupuis et al. 2013 .10.2.4.6 Other Antiemetic Agents Antihistamines
Antihistamines such as diphenhydramine are commonly used as adjunctive agents in the treat- ment and prevention of CINV although system- atic review of their potential benefi t is not reported in the literature. Antihistamines theo- retically impact the histaminergic receptors in the CTZ and should also be utilized in combination with metoclopramide to prevent extrapyramidal side effects. Adult and pediatric guidelines do not discuss antihistamines beyond utilization with metoclopramide Basch et al. 2011 ; Jordan et al. 2011 ; Ettinger et al. 2012 ; Dupuis et al. 2013 . Benzodiazepines Benzodiazepines such as lorazepam and mid- azolam have become recognized as valuable adjuncts in the prevention and treatment of anticipatory nausea and vomiting associated with chemotherapy. Benzodiazepines have not demon- strated intrinsic antiemetic activity as single agents and thus should be used with other anti- emetics, primarily for the treatment of anticipa- tory and breakthrough CINV Triozzi et al. 1988 ; Hesketh 2008 ; Basch et al. 2011 ; Jordan et al. 2011 ; Ettinger et al. 2012 . Benzodiazepines are thought to act on higher CNS structures, the brainstem, and spinal cord, and they produce anx- iolytic, sedative, and anterograde amnesic effects. Administration of lorazepam may be oral, IV or sublingual. Doses range from 0.03 to 0.05 mgkg max dose 2 mg in children every 6–12 h Van Hoff and Olszewski 1988 . The adverse effects of lorazepam include sedation, visual disturbance, confusion and ataxia. Benzodiazepines as adjunct agents are not mentioned in the recent pediatric guidelines Dupuis et al. 2013 . Olanzapine Olanzapine nonspecifi cally antagonizes D 2 and 5-HT 3 receptors and has been shown in nonran- domized adult studies to be effective in prevent- ing acute and delayed CINV Navari et al. 2005 ; Navari et al. 2007 ; Hesketh 2008 . Adult guide- lines include olanzapine as a suggested adjunct agent in patients with delayed or refractory CINV Basch et al. 2011 ; Jordan et al. 2011 ; Ettinger et al. 2012 . Pediatric data are lacking Dupuis et al. 2013 .10.2.4.7 Alternative Therapies Ginger
Ginger has been traditionally utilized as a treat- ment for upset stomach and is considered safe by the FDA. A Cochrane review of pregnant women showed limited and inconsistent results of ginger on the treatment of nausea Matthews et al. 2014 . Studies in CINV are limited and mixed. In randomized controlled adult trials, Zick et al. 2009 showed no benefi t to ginger in the reduc- tion of severity of acute or delayed CINV, while Ryan et al. 2012 found signifi cant benefi t of 0.5 and 1.0 g ginger in acute CINV when given 3 days prior to chemotherapy initiation. One ran- domized placebo- controlled study in pediatric patients found signifi cant improvement in both acute and delayed CINV with the addition of gin- ger root powder in bone sarcoma patients receiv- ing ondansetron and dexamethasone Pillai et al. 2011 . Further work is required to determine if ginger is a potentially benefi cial adjunctive agent Dupuis et al. 2013 . AcupressureAcupuncture Chinese medicine has for centuries utilized acu- pressure and acupuncture for the treatment of emesis induced by pregnancy and surgery Jindal et al. 2008 . Traditionally, the P6 acupuncture point above the wrist between the palmaris lon- gus and fl exor carpi radialis muscles of the fore- arm is targeted for prevention of nausea and vomiting. The role of acupuncture and acupres- sure has been studied systematically; in a pooled analysis of CINV, Ezzo et al. 2006 demon- strated mild reduction in acute emesis RR = 0.82, 95 CI 0.69, 0.99; p = 0.04, but no change in acute or delayed nausea severity compared with controls. A Cochrane review showed no benefi t to acupuncture and limited evidence for acupres- sure in pregnant women with nausea Matthews et al. 2014 . Continuous pressure to the P6 acu- puncture point can be administered continuously using acupressure wrist bands Sea-Band® Molassiotis et al. 2008 . Studies of acupressure and acupuncture in the pediatric population are limited due to diffi culties in patient accrual, particularly in younger patients who might fear this modality. One study was only able to enroll 11 patients ≥10 years of age in a 2-year period and demonstrated a signifi cantly reduced need for additional antiemetics when acu- pressure was combined with 5-HT 3 antagonists p = 0.024 Reindl et al. 2006 . This conclusion was confounded by the fact that episodes of vomit- ing were not reduced p = 0.374 Reindl et al. 2006 . Small sample sizes continue to be a barrier to future research, though efforts for stronger evi- dence-based studies are ongoing including a ran- domized controlled trial of acupressure to control CINV in children receiving cisplatin sponsored by the Children’s Oncology Group. A validated pedi- atric nausea assessment tool PeNAT will be uti- lized to assess response to therapy in both acute and delayed phases Dupuis et al. 2006 . Hypnosis and Other Therapies Limited data are available in the literature regarding hypnosis although a meta-analysis of fi ve pediatric studies in the prevention of CINV showed signifi - cant reduction in anticipatory CINV Richardson et al. 2007 . Benefi t of hypnosis as well as other behavioral modifi cation techniques such as cog- nitive-behavior therapy, guided imagery, music therapy, muscle relaxation, virtual reality and psychoeducational support have not been sys- tematically studied Dupuis et al. 2013 .10.2.5 Recommendations for Prevention and Treatment
of CINV The advent of new and improved pharmaco- logic antiemetic agents, accumulation of clinicalParts
» Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Introduction Supportive Care in Pediatric Oncology irantextbook.ir 93df
» History and Physical Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Defi ning the Risk for Serious
» Initial Laboratory Evaluation Diagnostic Evaluation
» Chest Radiography CXR A supine CXR may identify pleural effusions,
» Computed Tomography CT Radiographic Imaging
» Magnetic Resonance Imaging MRI
» Positron Emission Tomography PET
» Aspergillus Galactomannan GMN Biomarkers for Invasive
» 1,3-β- Biomarkers for Invasive
» Polymerase Chain Reaction PCR
» Viral Studies Diagnostic Evaluation
» Invasive Procedures: Diagnostic Evaluation
» Adult FN Guidelines Empiric Management
» Monotherapy Versus Combination Therapy
» Which Monotherapy to Choose A Cochrane review of antipseudomonal beta-
» Alterations in Initial Empiric FN Antibiotic Management
» Outpatient Management of FN Although there remains a lack of one uniform
» Choice of Empiric Antifungal Therapy
» Duration of Antimicrobial Empiric Management
» Endovascular Sources Empiric Management
» Adjunctive Treatment Empiric Management
» Emergence of Resistant Empiric Management
» Red Blood Cell Administration
» Granulocyte Transfusion Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Hemolytic Transfusion Risks of Blood Product
» Infection and Sepsis Risks of Blood Product
» Allergic Reactions Risks of Blood Product
» Febrile Nonhemolytic Risks of Blood Product
» Transfusion-Related Acute Risks of Blood Product
» Transfusion-Associated Risks of Blood Product
» Iron Overload Risks of Blood Product
» Laboratory Risk Factors Supportive Care in Pediatric Oncology irantextbook.ir 93df
» General Management Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Alkalinization Urinary alkalinization has been a long-standing
» Allopurinol Allopurinol inhibits xanthine oxidase, an enzyme
» Rasburicase Rasburicase, recombinant urate oxidase, converts
» Renal Interventions Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Pathophysiology Superior Vena Cava
» History and Physical Exam SVCSSMS should be suspected in a patient
» Imaging Studies The diagnosis of SVCSSMS is often made on
» Other Studies Tissue is required to make a defi nitive diagnosis
» Treatment Superior Vena Cava
» History and Physical Exam Small pericardial effusions are frequently asymp-
» Imaging and Other Studies The presence of a pericardial effusion can be
» History and Physical Exam Many patients with small pleural effusions are
» Imaging Studies When a pleural effusion is suspected, a chest
» History and Physical Exam Patients with pheochromocytoma typically have
» Laboratory Studies The diagnosis of pheochromocytoma is best made
» Imaging Studies Clinical Presentation
» Pulmonary Leukostasis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Presentation Spinal Cord Compression
» Differential Diagnosis Spinal Cord Compression
» Imaging MRI of the spine can help narrow the differential
» Surgery Surgery in spinal cord compression can be uti-
» Radiation Therapy The advantages of external beam radiation ther-
» Outcomes Spinal Cord Compression
» Presentation Altered Mental Status
» Initial Management Altered Mental Status
» Metabolic The metabolic causes of AMS or seizure in pedi-
» Chemotherapy-Associated Neurotoxicity Differential Diagnosis
» Posterior Reversible Encephalopathy Syndrome
» Outcomes Altered Mental Status
» Initial Management Increased Intracranial
» Soft Tissue A large meta-analysis of published data suggests
» Cerebrospinal Fluid Hydrocephalus is an excess of CSF within the
» Hemorrhage and Thrombosis Differential Diagnosis
» Idiopathic Intracranial Hypertension Differential Diagnosis
» Presentation of Stroke Cerebrovascular Disease
» Differential Diagnosis Cerebrovascular Disease
» Etiology of Stroke in Pediatric
» Ischemic Stroke After an ischemic stroke is diagnosed, the patient
» Hemorrhagic Stroke Hematomas can expand over several hours from
» Acute Lymphoblastic Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Acute Myelogenous Leukemia Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Acute Promyelocytic Leukemia Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Chronic Myelogenous Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Management of Tumor Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Leukapheresis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Hyperhydration Other Treatment Modalities
» Hydroxyurea Other Treatment Modalities
» Cranial Irradiation Other Treatment Modalities
» Pseudohyperkalemia Hyperleukocytosis has been noted to cause pseudo-
» Pseudohypoxemia Due to the rapid consumption of oxygen by leu-
» Pseudohypoglycemia Consumption of glucose by excess leukocytes
» Pseudothrombocytosis Leukemic blast lysis can lead to cell fragmenta-
» Transfusion Practice with Other Supportive Care
» Anesthetic Procedures Other Supportive Care
» Neutropenic Enterocolitis Gastrointestinal Infection
» Perirectal Abscess Gastrointestinal Infection
» Gastrointestinal Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Pancreatitis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Bowel Obstruction Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Abdominal Compartment Supportive Care in Pediatric Oncology irantextbook.ir 93df
» ALL Risk Factors Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Other Malignancies Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Central Venous Catheters Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Diagnosis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Nociceptive Pain Types of Pain
» Neuropathic Pain Types of Pain
» World Health Organization Pharmacologic Treatment
» Intermittent Opioid Use Pharmacologic Treatment
» Long-Acting Opioids Pharmacologic Treatment
» Breakthrough Dosing Pharmacologic Treatment
» Opioid Rotation Pharmacologic Treatment
» Patient-Controlled Analgesia Pharmacologic Treatment
» Constipation Side Effects of Opioids
» Nausea and Vomiting Nausea and vomiting are rare opioid side effects
» Pruritus Pruritus is a common side effect of opioid use
» Sedation Side Effects of Opioids
» Confusion and Agitation Renal and hepatic function should be checked
» Respiratory Depression When dosed appropriately, opioids rarely result
» Myoclonus Patients receiving very high doses of opioids for
» Urinary Retention Urinary retention can be caused by any opioid but
» Calcium Channel Blockers Neuropathic Pain
» Serotonin and Norepinephrine Neuropathic Pain
» Tricyclic Antidepressants Neuropathic Pain
» Interventional Techniques Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Vincristine-Related Peripheral Oncology-Specifi c Pain
» Osteonecrosis Oncology-Specifi c Pain
» Post-lumbar Puncture Oncology-Specifi c Pain
» Mucositis Pain Oncology-Specifi c Pain
» Pathophysiology of Emesis Chemotherapy-Induced
» Principles of Emesis Control in the Cancer Patient
» Emetogenicity of Chemotherapy Chemotherapy-Induced
» Dopamine Receptor Antagonists Classes of Antiemetics
» Corticosteroids Classes of Antiemetics
» Cannabinoids The plant Cannabis contains more than 60 differ-
» Other Antiemetic Agents Antihistamines
» Alternative Therapies Ginger Classes of Antiemetics
» Management of CINV Management of CINV Table
» Special Considerations Anticipatory Nausea and Vomiting
» Radiation-Induced Nausea Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Initiation The initiation stage occurs immediately following
» Primary Damage Response Pathophysiology of Oral Mucositis
» Signal Amplifi cation Pathophysiology of Oral Mucositis
» Ulceration Ulceration is the phase with the most clinical sig-
» Healing Pathophysiology of Oral Mucositis
» Clinical Course of Oral Mucositis
» Assessment Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Palifermin Prevention and Treatment
» Low-Level Laser Therapy Prevention and Treatment
» Glutamine Prevention and Treatment
» Cryotherapy Prevention and Treatment
» Oral Care Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Oral Infections Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Nutrition Assessment Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Dietary Counseling Nutrition Intervention
» Appetite Stimulants Nutrition Intervention
» Enteral Tube Feeding Nutrition Intervention
» Parenteral Nutrition Nutrition Intervention
» Nutrition and Survivorship Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Management of Neutropenia Hematologic Toxicity
» Management of Thrombocytopenia Hematologic Toxicity
» Management of Anemia Hematologic Toxicity
» Somnolence Syndrome Central Nervous System
» Lhermitte’s Sign Central Nervous System
» Skin Complications Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Oral Mucositis Head and Neck
» Ear Complications Head and Neck
» Laryngeal Complications Head and Neck
» Dysphagia and Esophagitis Gastrointestinal
» Nausea, Vomiting and Anorexia
» Pneumonitis Major Organ Infl ammation
» Pericarditis Major Organ Infl ammation
» Hepatitis Major Organ Infl ammation
» Nephropathy Major Organ Infl ammation
» Cystitis Major Organ Infl ammation
» Risk Stratifi cation Prevention of Bacterial
» Adult Data Antimicrobial Approaches
» Pediatric Data Data regarding the utility of bacterial prophylaxis
» Risks of Prophylaxis Prevention of Bacterial
» Guidelines and Current Usage of Antibacterial Prophylaxis
» Protocols for Line Placement and Care
» Antibiotic and Ethanol Locks
» Chlorhexidine Cleansing Chlorhexidine gluconate CHG is a bactericidal
» Future Directions Prevention of Bacterial
» Risk Stratifi cation Prevention of Fungal
» Approaches to Antifungal Prophylaxis
» Guideline Recommendations for Antifungal Prophylaxis
» Limitations of Current Options for Antifungal Prophylaxis
» Risks of Prophylaxis Prevention of Fungal
» Biomarkers Prevention of Fungal
» Future Directions Prevention of Fungal
» Risk Stratifi cation Prevention of Pneumocystis
» Approaches to PCP Prophylaxis
» Summary of the Recommendations
» Future Directions Prevention of Pneumocystis
» Postexposure Chemoprophylaxis Prevention of Viral Infections
» Suppressive Therapy Prevention of Viral Infections
» Future Directions Prevention of Viral Infections
» Hand Hygiene Infection Control Practices
» Mandatory Vaccination Infection Control Practices
» Hospital Isolation Practices Infection Control Practices
» Visitor Screening Policies Infection Control Practices
» Work Restriction Infection Control Practices
» Cytomegalovirus CMV Status of Transfused Blood
» Treatment of Myelosuppression with
» Prevention of Febrile Neutropenia, Delay
» Treatment of Febrile Neutropenia
» Treatment of Myelosuppression Clinical Usage of Myeloid Growth Factors
» Comparison of Granulocyte Colony-Stimulating Factor
» Optimal Dosing Adult guidelines recommend dosing of 5 mcgkg
» Route of Administration Optimal Administration of Colony-Stimulating Factors
» Optimal Timing Optimal Administration of Colony-Stimulating Factors
» Erythropoietin Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Interleukin-11 Platelet Growth Factors
» Thrombopoietin Receptor Agonists Platelet Growth Factors
» Immune Status Prior Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Immune Status During Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Immune Recovery After Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Immunization Practice Prior Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Diphtheria, Tetanus, and Acellular Pertussis
» Pneumococcal Conjugate Vaccine Recommendations
» Hemophilus Infl uenzae Type b
» Inactivated Infl uenza Vaccine Although in a Cochrane review Goossen et al.
» 2009 H1N1 Pandemic Vaccine Seven studies have reported on effi cacy of the
» Live Attenuated Infl uenza Vaccine
» Meningococcal Conjugate Vaccine Recommendations
» Varicella Zoster Virus Recommendations
» Recommendations Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Treatment of Hypogammaglobulinemia Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Vaccination of Household Contacts
» Peripherally Inserted Central Catheter
» External Tunneled Central Venous Catheter
» Implanted Port Types of Central Venous
» Catheter Insertion Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Exit Site Infection Infection
» Prevention of Infection Infection
» Drug Precipitate or Lipid Residue Occlusion Thrombotic Occlusion
» Evaluation of Catheter- Related Thrombosis
» Treatment of Catheter- Related Thrombosis
» Special Considerations During Anticoagulation Therapy
» Contraindications of Anticoagulant Therapy
» Skin Antisepsis Catheter Maintenance
» Central Venous Catheter Dressings
» Hub Care Catheter Maintenance
» Central Venous Catheter Flushing and Locking
» Chlorhexidine Bathing Chlorhexidine has been shown to be effective in
» Antiseptic Needleless Connectors and Antiseptic
Show more