Management of radiation induced nausea and vomiting

The purpose of this document is to provide guidance to minimise and where possible prevent radiation induced nausea and vomiting (RINV).

This document has been developed for the Australian clinical context using the most recent international guidelines including MASCC/ESMO antiemetic guidelines 2016,^r ASCO guidelines antiemetic Update 2017^r (including the 2016 focused guideline update^r) and NCCN guidelines v.2 2017.^r

Pathophysiology

Nausea and vomiting occur when neurotransmitters are stimulated and an impulse is sent to the autonomic nervous system, causing nausea, and to the somatic and visceral system to produce vomiting.^r

Incidence/prevalence

The incidence and severity of RINV are influenced by the specific RT regimen and by patient-specific factors. Frequency has been reported in 28-39% of patients.^rr Furthermore, uncontrolled nausea and vomiting may result in patients delaying or refusing further radiotherapy.^r

Onset/duration

Nausea can be one of the earliest side-effect of radiotherapy to develop and can appear 1 to 3 days after the commencement of treatment, lasting for several hours after treatment is completed. The first few days after the onset of RINV can be the most severe.

Risk factors

There are multiple risk factors that predispose to the development and severity of RINV. These risk factors can include (but are not limited to) treatment and patient related factors.

Treatment related factors that affect the emetic risk include:

• the area of/in the treatment field:
  • total body irradiation
  • the abdomen
  • the brain
  • extended pelvis fields
  • the epigastric region
  • the para-aortic area
  • in rare cases the chemoreceptor trigger zone (CTZ) in the cerebral cortex of the brain
• the size of the treatment field
• the dose of radiation delivered per fraction and total dose.

Patient related factors that may increase the risk of RINV include:

• concurrent or recent chemotherapy
• younger age (<50 years)
• female
• history of motion sickness and/or nausea in pregnancy
• poor performance status
• no alcohol consumption (i.e. less likely if high chronic alcohol intake)
• previous episodes of RINV
• tumour stage
• anxiety.*

*Due to feelings of anxiety or nervousness at the prospect of receiving radiotherapy or as a conditioned response to previous vomiting, patients may experience anticipatory nausea prior to treatment commencing.^r

The likelihood of experiencing RINV can be divided into the following 4 groups:^r

Levels of emetic risk with radiation therapy

 *For patients having concurrent chemoradiotherapy, patients should receive antiemetic prophylaxis according to the emetogenicity of chemotherapy, unless the emetic risk with the planned radiotherapy is higher. Link to prevention of chemotherapy induced nausea and vomiting.

It is important to assess the patient’s risk of RINV prior to the start of radiotherapy to ascertain whether antiemetic therapy should be given routinely as a preventative measure (prior to treatment each day) or rescue once symptoms have presented.

Signs and symptoms

RINV can include the following signs and symptoms:

• nausea
• vomiting
• pallor
• diaphoresis (increased perspiration)
• salivation
• anorexia (in advanced nausea and vomiting)
• signs/symptoms of dehydration:
  • postural hypotension (dizziness)
  • tachycardia (rapid heart rate)
  • low urine output
  • headaches.

Exclusions

It is easy to assume that nausea and vomiting in a patient who has recently received radiotherapy is the result of their treatment. However, there are several other causes of nausea and vomiting, many of which will commonly present in cancer patients and should therefore be excluded. These include: 

• constipation
• bowel obstruction
• gastroparesis
• malignant ascites
• anxiety
• fluid and electrolyte imbalances (e.g. hypercalcaemia and renal failure)
• uraemia
• metastases or tumour site involving the gastrointestinal tract, liver or central nervous system
• raised intracranial pressure
• peptic ulcer disease
• recent or concurrent chemotherapy
• vestibular dysfunction.

Investigations and diagnosis

The following should be included in an assessment of nausea and vomiting, as part of a complete patient assessment:

• the frequency (number of episodes in 24 hours), intensity, onset and duration of vomiting
• history and compliance with antiemetics
• concomitant medications (e.g. opioids)
• hydration status
• nutritional intake +/- weight loss
• heartburn/dyspepsia
• haematemesis
• blood test
  • full blood count (to assess for neutropenia and/or anaemia)
  • EUC + calcium, magnesium and phosphate (to assess for electrolyte imbalance).

Grading 

Common Terminology Criteria for Adverse Events (CTCAE) v5.0, 27 November, 2017

The aims of RINV management are to:

• prevent an initial emetic episode from occurring
• manage symptoms once they present as a result of radiotherapy.

The suggested management of RINV varies between risk groups and is outlined below:^rrr

Anticipatory nausea

Anticipatory RINV can occur any time after the first course of radiotherapy and is defined as the 'conditioned response to previous vomiting related to radiotherapy'. Prevention of RINV will also prevent anticipatory phase RINV. Therefore, the best management of anticipatory emesis is to ensure best possible control of acute and delayed emesis with optimal antiemetics.^r

• Non-pharmacologic methods such as behavioural/psychological techniques may be useful.
• Pharmacologic methods such as benzodiazepines may also be useful e.g lorazepam 0.5 mg to 2 mg orally before treatment.

Rescue treatment

The general principle of breakthrough treatment is to add in a drug from a different class to that used during the routine prophylactic schedule. Read more about pharmacological agents used for controlling breakthrough emesis.

Educate your patient:

• to take antiemetics as prescribed (e.g. prior to radiotherapy)
• to report signs of dehydration such as:
  • reduced urine output
  • rapid heart rate
  • headaches
  • flushed, dry skin
  • coated tongue
  • irritability
  • confusion
  • dizziness.
• on self care measures such as:
  • avoiding eating or preparing food when they feel sick, and if possible have someone else do the cooking.
  • avoiding fried foods and foods with a strong smell
  • eating cold or warm food if the smell of hot food makes them feel sick
  • eating several small snacks and meals each day (rather than three large meals), and to chew the food well
  • that peppermints or peppermint tea may help with nausea
  • that ginger may help with nausea, and to try ginger biscuits or ginger beer
  • sipping drinks slowly
  • avoiding drinking too much before a meal
  • avoiding alcohol
  • avoiding high volumes of coffee.

Provide the patient with the eviQ nausea and vomiting during cancer treatment patient information sheet. This sheet is available in several languages at eviQ ​patient information in other languages.

Read more about nutrition and diet from the New South Wales Cancer Council.

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