How do we manage patients with refractory or breakthrough emesis?

Abstract

There is evidence that, in spite of the Perugia consensus, acute and delayed emesis are treated in a suboptimal way. Thus breakthrough and refractory emesis as defined in this paper may be related to inadequate therapy. Several interventions have been used in attempts to stop breakthrough emesis, including use or repeat use of setrons, corticosteroids, D2-receptor antagonists including neuroleptics, or sedatives. It has been documented that refractory emesis responds to various modifications of the original antiemetic regimen, including the addition of a D2-receptor antagonist or a switch to another setron. In conclusion, no level I or II evidence-based guidelines can be given, as few adequate studies have been performed in this area, which therefore remains poorly documented.

Midazolam for acute emesis refractory to dexamethasone and granisetron after highly emetogenic chemotherapy: a phase II study

“…The combination of a 5-hydroxytryptamine 3 receptor antagonist with a corticosteroid is the recommended standard therapy for prevention of acute emesis caused by a highly emetogenic chemotherapy [13]. Anecdotal reports suggest that sedating a patient may be of value in cases of refractory emesis [14]. Thus, the use of various neuroleptic agents or tranquillizers, such as benzodiazepines, is suggested in the ASCO guidelines [13].…”

Antiemetic therapy for multiple-day chemotherapy and high-dose chemotherapy with stem cell transplant: review and consensus statement

“…When a patient is having persistent nausea and vomiting, it is also important to make certain that the cause is from the chemotherapy rather than other factors such as hypercalcemia, azotemia, brain metastases, gastric outlet obstruction, or narcotic analgesics. Dr. Aapro recently published an excellent paper concerning this topic [1]. As pointed out in that paper, a very common cause for refractory emesis is inadequate initial treatment.…”

Akute Therapienebenwirkungen in der gynäkologischen Onkologie

“…Bei einer wirkungslosen antiemetischen Therapie ist die wiederholte Gabe derselben Medikamente wenig sinnvoll [16]. Vielmehr sollten Medikamente einer anderen Substanzklasse verabreicht werden.…”