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Chemotherapy-Induced Nausea and Vomiting
Your oncology care providers now have many ways to prevent and ease nausea and vomiting from chemotherapy.
Surveys have shown that many patients and their loved ones believe nausea and vomiting occur with all types of chemotherapy (anti-cancer drugs). In reality, half of the chemotherapy drugs now in use became available in the past several years, and their side effects are not necessarily the same as those caused by older drugs. Though many people receiving chemotherapy may still experience nausea and vomiting, your health care team has many ways to both prevent and ease these symptoms.
It’s important to tell your doctor or nurse about your symptoms, even if what you’re experiencing is just mild queasiness. That feeling in your stomach can be the first sign of nausea, which can be treated with various types of medications. If one type doesn’t work, your doctor, advanced practice nurse or physician’s assistant can likely prescribe something else, so keep your health care team posted on how the medications are working. Be sure to ask about possible dietary adjustments, as they may also be of help.
Even if you’re feeling fine, it’s important to follow your health care team’s instructions on when to take your medications. That’s especially crucial if you are receiving chemotherapy in pill form, as you will need to take the chemotherapy and the anti-nausea drugs in a certain order and at a certain time of day.
Do not accept nausea and vomiting as “the norm,” as there are many medications available to relieve your symptoms. It’s important to seek help from your health care team if you experience symptoms, as nausea and vomiting can:
- Cause dehydration, which can be harmful to your health
- Reduce your quality of life and your ability to enjoy everyday activities
- Affect your outlook and mood
- Make it difficult to work or concentrate
- Potentially result in treatment delays
Your health care team wants to help. Contact them as soon as you experience any symptoms, no matter the severity.
Drug Treatments for Nausea and Vomiting
When receiving chemotherapy, sensors in the digestive system and brain detect its presence and identify it as a foreign substance. In a complex series of signals from the brain to the mouth, stomach, intestines and bloodstream, the chemotherapy stimulates the “vomiting center” in the brain. Several naturally occurring protein transmitters, including ones called serotonin and substance P, are released, triggering the nausea and vomiting reflex.
Although chemotherapy is meant to destroy rapidly dividing and growing cancer cells, it sometimes affects healthy tissues in the body, including those in the lining of the mouth, esophagus (food pipe) and stomach. Some anti-cancer drugs can irritate these areas, leading to nausea and vomiting.
Some people experience nausea and vomiting within the first few hours of receiving chemotherapy (known as an acute reaction). Others don’t feel symptoms the day of chemotherapy but develop nausea and vomiting during the following few days (a delayed reaction). It’s important to notify your health care team when you experience these symptoms, no matter when they occur.
Because some people receiving chemotherapy may expect to feel ill, they may experience symptoms even before a treatment session begins. Sometimes the sights, sounds or smells of the treatment room can trigger an anticipatory reaction.
There are many anti-nausea medications that have become available in recent decades. Your doctor will decide which (if any) medications to prescribe, based on the type of chemotherapy you are receiving and the anticipated severity of nausea and vomiting side effects. Your age, gender and other health conditions may also be a factor in your doctor’s recommendation.
If you are receiving treatment in a clinic or hospital, you will usually receive anti-nausea drugs intravenously (delivered through a needle into a vein). Some anti-nausea medications are also available in pill or liquid form or as a suppository (a soft preparation containing medication that dissolves in the rectum).
After chemotherapy, you may also be given anti-nausea medications to take at home. It’s important to understand how these drugs should be taken. Some medications are designed to be taken regularly for several days, whether you feel nauseated or not. Other medications are meant to be taken only when you feel symptoms. If you have any questions about when you should take your anti-nausea medication, be sure to contact your health care team.
Types of Anti-Nausea Drugs
Anti-anxiety drugs
Medications such as lorazepam (Ativan and others) or diazepam (Valium and others) are used to help block nausea and vomiting. These sedatives can be given intravenously and in pill form. Benzodiazepines such as lorazepam and diazepam do not stop nausea and vomiting directly, but they help other anti-nausea medicines work effectively and relieve the anxiety that people can feel when they believe they’re about to experience these symptoms.
To avoid becoming dependent on such medications, a careful schedule should be worked out with your doctor or nurse. They can also effectively relieve the anxiety that people can feel when they believe they’re about to experience these symptoms.
Corticosteroids
Corticosteroids, which are related to the natural hormone cortisol, are widely used to help prevent nausea and vomiting caused by chemotherapy. They have been successfully used for many years, especially to prevent delayed nausea and vomiting. Corticosteroids such as dexamethasone (Decadron, Hexadrol and others) can be given in different forms and are often combined with other anti-nausea drugs for maximum benefit.
Serotonin antagonists
Serotonin antagonists are often used to counter nausea and vomiting resulting from chemotherapy drugs that can cause stronger nausea or vomiting, such as cisplatin (Platinol and others) and cyclophosphamide (Cytoxan, Neosar and others). Serotonin antagonists stop serotonin (a substance occurring naturally in the brain) from sending a signal that causes vomiting. These drugs are usually administered intravenously before chemotherapy begins.
One of these drugs, palonosetron (Aloxi), was specifically tested to work for days after a single injection. It can prevent both acute and delayed nausea and vomiting. Other similar serotonin antagonists include ondansetron (Zofran and others), granisetron (Kytril) and dolasetron (Anzemet). Like palonosetron, dolasetron is given as an injection. Ondansetron is given in tablet or liquid form, and granisetron is given either via an injection or in tablet form.
Aprepitant
Aprepitant (Emend) works in the vomiting center of the brain to prevent nausea and vomiting caused by chemotherapy. It blocks the action of substance P, a peptide that triggers nausea and vomiting reflexes. Aprepitant is sometimes given in combination with corticosteroids and serotonin antagonists. It is available as a capsule and is taken before a chemotherapy session and for two days afterward. A related drug, fosaprepitant dimeglumine (Emend for Injection), gives patients receiving chemotherapy another option for preventing nausea and vomiting. It is delivered intravenously and converted to aprepitant in the body.
Cannabinoids
Cannabinoids contain the active ingredient found in marijuana. For a number of years doctors have prescribed dronabinol (Marinol) as an anti-vomiting medication. In 2006, the U.S. Food and Drug Administration approved nabilone (Cesamet), which can control chemotherapy-related nausea and vomiting in cancer patients who have not been adequately helped by other anti-nausea medications. Cannabinoids can be taken in combination with, but not as a replacement for, other types of anti-nausea drugs. These pill forms of cannabinoids are made with the same safety and purity standards for all prescription drugs.
They are safer to use than other commercially available forms of marijuana products as they are the specific sub-types of cannabis that most suppress nausea and vomiting. Smoked cannabis is best avoided since the burning process irritates the mouth and throat and can introduce sources of infection at a time when the system is least able to fight it off.
Frequently Asked Questions
Q: Are there other types of drugs not related to my chemotherapy treatment that can cause nausea and vomiting?
A: There are a number of drugs that can cause nausea and vomiting, including bronchial dilators, pain medications and some antibiotics. The cancer itself can also cause these symptoms. It’s important for you to keep track of the severity of your symptoms and when they begin and end and to share that information with your health care team, as the pattern will help them determine the best course of action.
Q: My insurance company won’t cover the anti-nausea drug my doctor prescribed. What can I do?
A: Insurance coverage can differ significantly depending on the company and the specific plan. It could be that your plan will cover one formulation of the prescribed drug but not another (e.g. will cover an injection but not the oral form of a drug). Talk to a benefits specialist at your insurance company about what your plan does cover and share that information with your health care team so that the best decision about your treatment can be made.
If you need financial help, CancerCare’s financial assistance program can help pay the cost of treatment-related expenses. Additionally, the Partnership for Prescription Assistance (PPA) helps patients without prescription coverage get the medicines they need through the public or private program that’s right for them. For patients who qualify, drugs can often be obtained free of charge or at low cost. The PPA helps people find the right patient assistance program from among more than 475 such programs, including more than 150 offered by pharmaceutical companies. Their contact information can be found in the Resources section.
Q: Is acupuncture an effective treatment for nausea and vomiting caused by chemotherapy?
A: There have been a number of studies on acupuncture used for this purpose—with mixed results. Talk to your doctor before deciding to try acupuncture to make sure he or she thinks it’s a good approach in your specific situation. Consider acupuncture as a complement to, not a replacement for, the medications your doctor has prescribed.
Q: I’ve heard that tea made with ginger can calm an upset stomach. Is there any evidence that this can help me with nausea now that I’m getting chemotherapy?
A: There is limited data on whether ginger can help prevent nausea in patients receiving chemotherapy. It’s likely safe for you to drink ginger tea, but check with your health care team to make sure there’s no medical reason why you should avoid ginger. If you get the go-ahead, view ginger tea as a complement to any medication your doctor prescribes, and enjoy!
Q: Can meditation or other relaxation methods help control my nausea and vomiting?
A: Any healthy technique that reduces stress may be helpful and should be considered as a complement to—not a replacement for—medications your doctor may prescribe. Such techniques include meditation, yoga, deep breathing exercises and listening to music.