International Group Preparing Guidelines for Antiemesis Agents

NEW YORK—Members of eight major oncologic organizations are working together to produce a set of uniform guidelines for the prevention and control of nausea and vomiting in cancer patients undergoing chemotherapy.

The ad hoc international group is working to reconcile the six sets of guidelines already issued by various professional organizations, according to Richard Gralla, MD, associate director and professor of medicine, Herbert Irving Comprehensive Cancer Center of Columbia University College of Medicine.

Broad Collaboration

The collaboration includes representatives of oncology nursing, pharmacy, and medical oncology, as well as of the Multinational Society for Supportive Care in Cancer, Dr. Gralla said during an international teleconference for health professionals sponsored by the European Association for Cancer Education and Cancer Care, Inc.

Nurses’ Role in Antiemesis

Proper management of nausea and vomiting requires in-depth knowledge of both risk factors and available treatments, said Jackie Green, RGN, lead cancer nurse and senior nurse at the Hematology and Cancer Services, Kings College Hospital NHS Trust Medical Care Group, London. She emphasized that a personalized, detailed, multidimensional assessment of each patient is needed to tailor an effective treatment plan.

"Nurses play the key role in the multidisciplinary team because of their expertise in assessment and patient education," Dr. Richard Gralla said. He added that good communication among team members is crucial to providing the best possible treatment for each patient.

The international collaboration on guidelines aims to help in this effort, he said. The group hopes that its efforts will result in simple, clear tools such as standing orders and easy-to-use forms that will ease the ordering of appropriate medications and assist nurses in administering them and in educating patients and family members to use them correctly.

Dr. Gralla is one of about 20 individuals from the United States, Canada, the United Kingdom, and Europe involved in the guidelines project. He said that preliminary results have been presented at several meetings in the United States and Europe, with the final document slated for submission for publication later this year.

When the guidelines are finalized, the group hopes to make them easily available in such forms as laminated cards and files that can be downloaded from the Internet.

Different countries now follow varying guidelines for prevention and treatment of nausea and vomiting, although studies point to a single set of effective approaches. The dosages of various agents currently being prescribed vary widely, he observed. In addition, studies show that even existing guidelines are often not followed.

An important feature of the forthcoming guidelines is a uniform set of risk categories that divide patients into groups at high, moderate, and low risk for nausea and emesis, he said. Although sex, age, and individual characteristics have some effect on a patient’s risk, he noted, by far the greatest risk factor is the chemotherapeutic agents used. For patients receiving multiple agents, the one with the highest risk for emesis or nausea determines the risk group to which the patient belongs.

Control of emesis and nausea has improved greatly over the past 20 years, Dr. Gralla commented, but he added that it still remains "a very important problem." The goal must be to prevent these troubling side effects of chemotherapy rather than to treat them after they occur, he said. This means that patients in the moderate- and high-risk groups, who face more than a 10% risk of nausea and emesis, should receive therapy routinely.

Existing agents, such as serotonin antagonists and corticosteroids, are extremely useful, especially if used to best advantage, he said. In addition, newer agents that exploit the NK1 neurokinin pathway also "appear interesting." Older agents such as cannabinoids are "no longer particularly relevant," he said.

The new guidelines will call for using the lowest doses known to be fully effective, Dr. Gralla said. This approach both reduces the risk of side effects and controls cost.

In addition, the collaborative group has recognized that oral and intravenous administration of antiemesis agents produce equivalent results, that all antiserotonin drugs appear to be equivalent in efficacy, and that a single adequately sized dose of an antiserotonin agent is as effective as multiple doses because it saturates all receptors. The group also agrees that corticosteroids should be used in conjunction with serotonin inhibitors.