Treatment of nausea and vomiting in advanced cancer

Nausea and vomiting are frequent symptoms in patients with advanced cancer. Contrary to cancer pain, in this group of patients no uniform, widely accepted principles of the management of nausea and vomiting were elaborated on to-date, which may be connected with only few controlled clinical trials performed in this field. These principles should be based on precise recognition of causes, pathomechanism and the choice of appropriate treatment. Moreover it is indispensable to continue precise symptom assessment and to confirm the efficacy of the applied management through audit and well designed clinical trials. This article is an attempt to sum up the principles of the treatment of nausea and vomiting based on the review of the literature and own experience. This paper presents the management based on frequent symptom assessment, correction of reversible causes, complex non-drug treatments and pharmacotherapy concerning also treatment of other symptoms and holistic approach to the patient. The parenteral route of medication administration, compatibility of selected mixtures of opioid analgesics with antiemetics and principles of the treatment of chemotherapy- and radiotherapy- -induced nausea and vomiting are presented.

The management of nausea and vomiting usually comprises pharmacotherapy; at the beginning first-line antiemetics are administered: metoclopramide, haloperidol and dimenhydrynate (cyclizine). If the control of nausea and vomiting during optimal therapy with the first-line antiemetics is poor, usually second-line antiemetics are introduced: dexamethasone, levomepromazine and hyoscine butylbromide. In selected clinical situations other antiemetics and adjuvants are also applied. On the basis of the review of the literature and own experience we proposed a three-step antiemetic ladder which apart from antiemetics includes different routes of medication administration and supportive therapies.