Olanzapine

Olanzapine

PEP Topic 
Chemotherapy-Induced Nausea and Vomiting—Adult
Description 

Olanzapine is an antipsychotic used in the treatment of schizophrenia and bipolar disorder. It also has been evaluated as an adjunctive medication for the prevention and treatment of chemotherapy-induced nausea and vomiting (CINV) in patients with cancer.

Effectiveness Not Established

Research Evidence Summaries

Abe, M., Hirashima, Y., Kasamatsu, Y., Kado, N., Komeda, S., Kuji, S., . . . Ito, K. (2015). Efficacy and safety of olanzapine combined with aprepitant, palonosetron, and dexamethasone for preventing nausea and vomiting induced by cisplatin-based chemotherapy in gynecological cancer: KCOG-G1301 phase II trial. Supportive Care in Cancer, 24, 675–682. 

doi: 10.1007/s00520-015-2829-z
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Study Purpose:

To investigate the effects of olanzapine as an adjunct to triplet antiemetic therapy for the prevention of chemotherapy-induced nausea and vomiting (CINV) in patients receiving highly emetogenic chemotherapy

Intervention Characteristics/Basic Study Process:

All patients in the trial were receiving triplet therapy in accordance with Japanese guidelines and 5 mg olanzapine one day prior to cisplatin administration then once daily on days 1–5 at bedtime. Metoclopramide was used as rescue therapy for breakthrough emesis. Patients were hospitalized during treatment.

Sample Characteristics:

  • N = 40
  • MEDIAN AGE = 57 years (range 25–76 years)
  • FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: All had cervical, endometrial, or vulval cancer at varied stages. 50% experienced emesis during pregnancy, and 32.5% had a history of motion sickness. Most received cisplatin at a dose of 50mg/m2 and 95% had multiagent regimens.

Setting:

  • SITE: Multi-site  
  • SETTING TYPE: Inpatient    
  • LOCATION: Japan

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Active antitumor treatment

Study Design:

Prospective trial

Measurement Instruments/Methods:

  • Patient diary for daily self-reported symptoms
  • Eleven-point Numeric Rating Scale (NRS) for nausea
  • Complete response defined as no vomiting, no rescue therapy and no significant nausea
  • Common Terminology Criteria for Adverse Events (CTCAE) version 4.0

Results:

There were no grade 3 or 4 adverse events. In the overall phase (acute and delayed phases), the complete response rate was 92.5% with 97.5% in the acute phase and 95% in the delayed phase. The rate for no nausea was 87.5% in the acute phase and 67.5% in the delayed phase. The authors provided a comparison of this study's results with those of a collaborative group trial using triplet therapy. This comparison showed that the addition of olanzapine was associated with better response rates across all phases and higher rates of nausea control. The adverse effects reported were low-grade and included constipation, dry mouth, and dizziness.

Conclusions:

The addition of olanzapine to triplet antiemetic therapy in patients receiving highly emetogenic chemotherapy was associated with high rates of complete CINV control across all phases and relatively low rates of nausea during the acute phase.

Limitations:

  • Small sample (< 100)
  • Risk of bias (no control group)
  • Risk of bias (no blinding)
  • Risk of bias (no random assignment)
  • Other limitations/explanation: The results were complete control and no significant nausea, but these were not defined and the level of no significant nausea was not clear. The way in which the numeric scale data were used was not clear (i.e., was this the average, worst, or least scores recorded by the patient).

Nursing Implications:

Triplet drug therapy to prevent CINV is recommended and is effective with highly emetogenic chemotherapy. However, even with this approach, the control and prevention of nausea is challenging. The findings of this study suggest the addition of olanzapine to triplet therapy may improve nausea control and overall CINV prevention with no severe adverse effects. This study has several limitations, but provides promising results. Additional, well-designed research testing the impact of olanzapine for CINV prevention is warranted.

Liu, J., Tan, L., Zhang, H., Li, H., Liu, X., Yan, Z., . . . Zhang, D. (2015). QoL evaluation of olanzapine for chemotherapy-induced nausea and vomiting comparing with 5-HT3 receptor antagonist. European Journal of Cancer Care, 24, 436–443. 

doi: 10.1111/ecc.12260
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Study Purpose:

To evaluate the effect of olanzapine on quality of life (QOL) during chemotherapy compared with a 5HT3 receptor antagonist

Intervention Characteristics/Basic Study Process:

Patients receiving multiple different chemotherapy regimens were randomized to one of two groups. Group one received olanzapine 10 mg PO, azasetron 10mg IV, and dexamethasone 10 mg IV, followed by olanzapine 10 mg PO on days 2-5. The control group received azasetron 10 mg IV and dexamethasone 10 mg IV, followed by dexamethasone 10 mg IV on days 2-5. Use of breakthrough antiemetics was permitted based on clinical circumstances. It is not reported whether patients received one cycle only. Patients were not all chemotherapy naive, but this was not controlled in the sample description.

Sample Characteristics:

  • N = 229  
  • AGE = 18-74 years
  • MALES: 65%-72%, FEMALES: 43%-49%
  • KEY DISEASE CHARACTERISTICS: lung, breast, colorectal, lymphoma, ovarian, stomach, esophageal, teratoma, thymus, oropharyngeal, cervical, gingival, melanoma, and glioblastoma. All patients were receiving moderately or highly emetogenic chemotherapy.
  • OTHER KEY SAMPLE CHARACTERISTICS: normal CBC, LFTs, metabolic profile, normal cardiac function, EKG, performance status of 2 or better, no nausea preceding 24 hours. Multiple exclusion criteria.

Setting:

  • SITE: Single site    
  • SETTING TYPE: Not specified    
  • LOCATION: Harbin Medical University, China

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Active antitumor treatment

Study Design:

  • Randomized trial using random digits

Measurement Instruments/Methods:

  • EORTC-QLQ C30 was measured on day 0 and 6. CINV was measured with Common Toxicity Criteria.

Results:

There was no significant difference in acute CINV, but delayed CINV showed complete response rates of 76.85% in the olanzapine group and 46.2% in the 5HT3 group (p < 0.05). CINV was also better controlled in five days post chemotherapy, with 85.95% in the olanzapine arm and 67.59% in the control arm. Not all patients completed QOL. Global health status, emotional functioning, social functioning, fatigue, CINV, and insomnia were improved in the olanzapine group. Pain and dyspnea improved in both groups.

Conclusions:

CINV influences QOL for patients undergoing chemotherapy. Although olanzapine did not change CINV in the acute phase, it showed significance in the delayed CINV group. This demonstrated improvements in global health status, fatigue, and insomnia. 5HT3 antagonists were effective against acute CINV but not effective in delayed CINV.

Limitations:

  • Risk of bias (no blinding)
  • Other limitations/explanation: The authors did not identify any limitations. All data comparisons were not identified. Description of prior treatments for patients were not listed. No subgroup analysis was completed between those receiving MEC and HEC regimens. No information was provided regarding use of other antiemetics as allowed in the study protocol

Nursing Implications:

Olanazapine offers another option for treatment of CINV. Other symptoms may also be controlled with this medication, such as insomnia, appetite loss, fatigue, and global health status. Nurses can consider this when standard medications are ineffective.

Mizukami, N., Yamauchi, M., Koike, K., Watanabe, A., Ichihara, K., Masumori, N., & Yamakage, M. (2014). Olanzapine for the prevention of chemotherapy-induced nausea and vomiting in patients receiving highly or moderately emetogenic chemotherapy: A randomized, double-blind, placebo-controlled study. Journal of Pain and Symptom Management, 47(3), 542–550.

doi: 10.1016/j.jpainsymman.2013.05.003
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Study Purpose:

To determine whether adding olanzapine to current standard antiemetic therapy could reduce the frequency of chemotherapy-induced nausea and vomiting (CINV) and improve patients’ quality of life (QOL) during chemotherapy

Intervention Characteristics/Basic Study Process:

Olanzapine 5 mg/day PO on days 0–5 versus a placebo in addition to 5-HT3RA (either granisetron, ondansetron, ramosetron, or palonosetron), dexamethasone (9.9 mg IV on day 1 followed by 6.6 mg IV on days 2–4), and NK1RA (aprepitant 125 mg orally on day 1 followed by 80 mg aprepitant orally on days 2 and 3 as a rescue drug for CINV). 10 mg of metoclopramide was administered intravenously as needed. Patients could use the rescue drug up to three times a day. The different 5-HT3 receptor antagonists used were administered as follows: granisetron 3–6 mg/day on days 1–3; ondansetron 4 mg/day on days 1–2; ramosetron 0.6 mg/day on days 1–3; and palonosetron 0.75 mg/day on day 1.

Sample Characteristics:

  • N = 44 
  • MEAN AGE = 63 years (olanzapine group), 55 years (control group), non-significant difference p = .06
  • MALES: 50%, FEMALES: 50%
  • KEY DISEASE CHARACTERISTICS: Cancer patients receiving highly emetogenic chemotherapy (HEC) or moderately emetogenic chemotherapy (MEC) with an Eastern Cooperative Oncology performance status of 0–2.
  • OTHER KEY SAMPLE CHARACTERISTICS: Patients had not experienced NVR in the 24 hours before the start of the trial, had not scheduled to receive concurrent abdominal radiation therapy, had no history of DM, were not receiving other antipsychotic agents, and were not hypersensitive to olanzapine.

Setting:

  • SITE: Multi-site  
  • SETTING TYPE: Inpatient  
  • LOCATION: Sapporo, Hokkaido, Japan

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Active antitumor treatment

Study Design:

Randomized, double-blind, placebo-controlled trial

Measurement Instruments/Methods:

  • Primary endpoint: Total control (no vomiting, no use of rescue medications, and maximum nausea of < 5/100 mm)
  • Secondary endpoint: Functional Living Index–Emesis (FILE) questionnaire scores on days 0 and 6
  • Additional: QOL (FLIE), amount of diet intake during CTx, satisfaction, complete response (no vomiting, no use of rescue medication), complete control (complete response + nausea < 25 mm/100 mm), and Visual Analog Scale

Results:

The olanzapine group achieved better total control (59% overall, 86% in the acute phase, and 64% in the delayed phase) than the control group (23% overall, 55% in the acute phase, and 23% in the delayed phase). The olanzapine group also achieved better complete protection and complete response except for acute phase complete response (p < .05). Furthermore, the olanzapine group experienced better QOL (p < .01), and the olanzapine group indicated that CINV did not affect their daily activities whereas 36% of the control group reported influence of CINV on daily life activities. There were significant differences between the VAS for nausea and satisfaction scores for additional medication. Most of the olanzapine group patients (91%) wished to receive same protocol for future chemotherapy. Dietary intake was better maintained by the olanzapine group with a significant difference on day 2 and days 4–6.

Conclusions:

The addition of 5 mg/day of oral olanzapine to standard therapy can reduce the frequency of CINV and improve QOL for patients receiving highly or moderately emetogenic chemotherapy.

Limitations:

  • Small sample (< 100)
  • Baseline sample/group differences of import
  • Risk of bias (sample characteristics)
  • Other limitations/explanation: Age of the olanzapine group was higher than the control (which could have influenced less development of CINV), and other risk factors of the CINV were not taken into consideration. MEC group also received NK1, which is not a standard antiemetic. Combination of palonosetron and olanzapine need to be investigated further, with stratification of emetogenicity of chemotherapy regimen, and the use of first and second generation 5-HT3RA between the two groups (as palonosetron 0.75mg was used in the study).

Nursing Implications:

The addition of olanzapine to standard antiemetics, such as 5-HT3RA, steroids, and NK1RA, could achieve better control of CINV, especially for the delayed phase, with additional benefit in terms of QOL and less change in dietary intake. However, caution needs to be exercised in interpreting the result as the study allowed NK1 for the MEC, had age difference between the olanzapine and control group, and did not take risk factors of CINV into consideration, and the palonosetron dose of 0.75mg was higher than antiemetic recommendations.

Tan, L., Liu, J., Liu, X., Chen, J., Yan, Z., Yang, H., & Zhang, D. (2009). Clinical research of olanzapine for prevention of chemotherapy-induced nausea and vomiting. Journal of Experimental & Clinical Cancer Research, 28, 131.

doi: 10.1186/1756-9966-28-13
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Study Purpose:

To evaluate the efficacy and safety of olanzapine compared with 5-hydroxtryptamine3 (5-HT3) receptor antagonists for the prevention of acute and delayed chemotherapy-induced nausea and vomiting (CINV) in patients receiving highly emetogenic chemotherapy (HEC) or moderately emetogenic chemotherapy (MEC) and to evaluate the impact of olanzapine on quality of life (QOL) of those receiving chemotherapy

Intervention Characteristics/Basic Study Process:

Patients were randomized into the test group or the control group. On day 1, the test group received 10 mg oral olanzapine, 10 mg IV azasetron, and 10 mg IV dexamethasone; the control group received 10 mg IV azasetron and 10 mg IV dexamethasone. On days 2–5, the test group received 10 mg oral olanzapine and the control group received 10 mg IV dexamethasone. Patients were permitted to take other antiemetic therapy for nausea or emesis based on clinical circumstances. Assessments occurred on days 1–5 post-treatment, and QOL was measure on day 6.

Sample Characteristics:

  • The study consisted of 229 participants.
  • Men in the test group had a mean age of 54 ± 9.23; women in the test group had a mean age of 48.25 ± 12.7. Men in the control group had a mean age of 54.5 ± 10.33; women in the control group had a mean age of 49.58 ± 12.12.
  • The test group was 40.5% female and 59.5% male. The control group was 40% was female and 60% male.
  • Cancer diagnoses were breast (24%), lung (23%), colorectal (13%), lymphoma (10%), stomach (9%), esophageal (5%), ovarian (5%), teratoma (2%), thymus (2%), cervical (1%), gingival (1%), glioblastoma (1%), laryngeal (1%), malignant melanoma (1%), and oropharyngeal (1%),
  • Chemotherapy agents were cisplatin (44%), oxaliplatin (23%), epirubicin (18%), adriamycin (8%), carboplatin (6%), and dacarbazine (1%).

Setting:

The setting was not identified.

Phase of Care and Clinical Applications:

All patients were in active treatment.

Study Design:

This was a randomized controlled trial.

Measurement Instruments/Methods:

  • The Common Terminology Criteria for Adverse Events, version 3 (CTAE v.3) observation table was used to grade CINV.
  • The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) was used to evaluate quality of life.

Results:

  • No significant difference was noted between both groups for complete response (CR) for acute periods with HEC or MEC.
  • Respective improvement in CR occurred in the test group for delayed nausea and vomiting with HEC (39%) and MEC (25%). The whole period of nausea improved 41% with HEC and 27% with MEC (p < 0.05).
  • The olanzapine regimen protected more than two-thirds of patients from emesis after receiving HEC and MEC, thus avoiding the use of rescue therapy 2–4 days after chemotherapy.

Conclusions:

Olanzapine can improve the CR of delayed nausea and vomiting and QOL in patients receiving HEC and MEC.

Limitations:

  • The study was not blinded. The test group received oral medication, which the control group did not receive.
  • Other antiemetic therapies were used as needed and not monitored or factored into the analysis.
  • Validity and reliability of the measurement tools was not included.
  • Drug safety and toxicity were not defined or monitored.
  • Reporting of statistical results was unclear; the authors reported two values with each measurement (e.g., "complete response for delayed nausea and vomiting in patients with HEC improved 39%, 22%") without explanation of what these two measurements correspond to.
  • Discrepeancies were reported with the QOL measurements.

Nursing Implications:

Olanzapine may be effective in preventing delayed CINV in patients receiving HEC or MEC, but results should be used cautiously because of poor statistical evaluation and reporting.

Systematic Review/Meta-Analysis

Chow, R., Chiu, L., Navari, R., Passik, S., Chiu, N., Popovic, M., . . . DeAngelis, C. (2015). Efficacy and safety of olanzapine for the prophylaxis of chemotherapy-induced nausea and vomiting (CINV) as reported in phase I and II studies: A systematic review. Supportive Care in Cancer, 24, 1001–1008. 

doi: 10.1007/s00520-015-3000-6
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Purpose:

STUDY PURPOSE: To summarize evidence from phase I and II trials in which olanzapine was used for the prophylaxis of chemotherapy-induced nausea and vomiting (CINV)

TYPE OF STUDY: Systematic review

Search Strategy:

DATABASES USED: MEDLINE, EMBASE, and the Cochrane Collaboration
 
KEYWORDS: Nausea and vomiting, vomiting and chemotherapy, nausea and chemotherapy, and olanzapine and CINV
 
INCLUSION CRITERIA: Phase I and II trials reporting on use of olanzapine for CINV reporting on CINV outcomes; single-arm uncontrolled trials 
 
EXCLUSION CRITERIA: Not specified

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: 356
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: No quality evaluation was described

Sample Characteristics:

  • FINAL NUMBER STUDIES INCLUDED = 7 
  • TOTAL PATIENTS INCLUDED IN REVIEW = 201
  • SAMPLE RANGE ACROSS STUDIES: 3–40 patients
  • KEY SAMPLE CHARACTERISTICS: Multiple tumor types across studies; highly and moderately emetogenic chemotherapy regimens

Phase of Care and Clinical Applications:

PHASE OF CARE: Active antitumor treatment 

Results:

The rate of complete control (no emesis, no rescue medication, and no significant nausea) was only identified in one study. Complete response rates were reported in three studies, and they ranged from 75%–100% in the acute phase and 72%–92.5% in the overall phase. In four trials, olanzapine was used as an adjunct with other antiemetics. One study was a retrospective chart review.

Conclusions:

The findings of this study suggest that olanzapine can be beneficial in preventing CINV.

Limitations:

  • The sample sizes of the studies were small.
  • No information was provided regarding the use of any other antiemetics. 
  • How a study using a retrospective chart review constitutes as a phase I or II study for inclusion was unclear.

Nursing Implications:

The potential role of olanzapine in the prevention and management of CINV is unclear. This review provides limited evidence of the effects of olanzapine for CINV. Future studies need to compare olanzapine as an adjuvant to recommended antiemetics or olanzapine as a single agent compared to regimens with clear efficacy for the prevention of CINV.

Wang, X.F., Feng, Y., Chen, Y., Gao, B.L., & Han, B.H. (2014). A meta-analysis of olanzapine for the prevention of chemotherapy-induced nausea and vomiting. Scientific Reports, 4, 4813. 

doi: 10.1038/srep04813
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Purpose:

STUDY PURPOSE: To determine the effectiveness of olanzapine in the prevention of chemotherapy-induced nausea and vomiting (CINV) after moderately to highly emetogenic chemotherapy
 
TYPE OF STUDY: Meta-analysis and systematic review

Search Strategy:

DATABASES USED: MEDLINE, PubMed, The China National Knowledge Infrastructure, Wanfang Data, and the Weipu Periodical Database  
 
KEYWORDS: Olanzapine, CINV, chemotherapy-induced nausea and vomiting, nausea, and vomiting 
 
INCLUSION CRITERIA: Randomized controlled trials; olanzapine use in CINV; blinded studies; published studies; cost-effective studies; published in English or Chinese; date range 1990 through October 2013
 
EXCLUSION CRITERIA: Studies that were not cost-effective; repetition with former research; retrospective studies; use in patients with incomplete bowel obstruction; and use for breakthrough emesis

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: Thirteen relevant articles
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: A flow diagram of the search strategy was developed by the investigators and used to select relevant articles. Both English and Chinese literature were searched.

Sample Characteristics:

  • FINAL NUMBER STUDIES INCLUDED = 6 
  • TOTAL PATIENTS INCLUDED IN REVIEW = 726
  • KEY SAMPLE CHARACTERISTICS: All studies defined complete response as no vomiting or use of rescue medications. Five studies compared standard antiemetic regimens without olanzapine to standard antiemetic regimens with olanzapine.

Phase of Care and Clinical Applications:

PHASE OF CARE: Active antitumor treatment
 
APPLICATIONS: Elder care, palliative care 

Results:

Five out of six studies demonstrated an increase in complete response in patients receiving standard antiemetic regimens plus olanzapine on day 1 of chemotherapy (odds ratio [OR] = 1.95, 95%; confidence interval [CI] = 1.17–3.23; p = 0.01). Five out of six studies showed a cumulative delay in vomiting (OR = 2.65, 95%; CI = 1.36–5.15; p = 0.004). Overall complete response relative risk was improved (4.07, 95%; CI = 1.59–10.43). Also note the following: delayed-phase antinausea effects in olanzapine-containing antiemetic regimens (OR = 2.79, 95%; CI = 1.76–4.43; p = 0.0001); antinausea effects in the overall phase (OR = 3.40, 95% CI = 2.32–5.00; p = 0.00001); and no superiority in the acute phase (RR = 1.34, 95%; CI = 0.77–2.34; p = 0.30).

Conclusions:

Complete response is more likely in patients who received antiemetic regimens containing olanzapine compared to patients who did not receive olanzapine. Olanzapine is more effective in delayed CINV than acute.

Limitations:

  • Small sample
  • Differences in what drugs were included in standard antiemetic regimens in each study
  • One study used aprepitant in the standard antiemetic regimen.

Nursing Implications:

Olanzapine may add CINV control when added to a standard antiemetic regimen during the delayed phase.

Guideline/Expert Opinion

Frame, D.G. (2010). Best practice management of CINV in oncology patients: I. Physiology and treatment of CINV. Multiple neurotransmitters and receptors and the need for combination therapeutic approaches. Journal of Supportive Oncology, 8(2, Suppl. 1), 5–9.

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Results Provided in the Reference:

  • This article reviewed the neurotransmitter and receptor systems involved with chemotherapy-induced nausea and vomiting (CINV) and a brief history of development of antiemetic therapies. CINV classifications was defined as follows.
    • Acute—occurring and resolving within 24 hours of chemotherapy
    • Delayed—occurring more than 24 hours after chemotherapy administration
    • Breakthrough—occurring despite antiemetic therapy
    • Refractory—unmanageable with current antiemetics
    • Anticipatory—conditioned response after prior inadequately controlled CINV.
  • The article stated that anticipatory CINV is the most common kind.
  • The article reviewed the mechanism of action and current knowledge regarding common antiemetic regimens and noted that given the physiology involved, optimal treatment requires a combination of therapies targeting multiple systems.

Guidelines & Recommendations:

  • Dexamethasone in combination with 5-HT3 receptor antagonists is recommended (unless contraindicated or not tolerated). The author noted that this is too often not included.
  • In delayed emesis, metoclopramide has been shown to be equivalent to ondansetron in controlling delayed CINV. Metoclopramide is also associated with extrapyramidal symptoms.
  • Differences among 5-HT3 receptor antagonists were noted.
    • Among first generation drugs, overall efficacy of the agents are similar.
    • Palonosetron is a second generation drug with a longer half-life, which appears to be associated with some preventive benefits.
    • Results of studies indicate that without some combination therapy, these drugs alone will fail in 40%–50% of patients.
    • The author noted that some individuals have a genetic tendency to metabolize these drugs differently and those with ultra-rapid metabolism have less therapeutic benefit. Palonosetron appears to have a smaller effect in this area.
  • The effects of 2 mg per day of oral granisetron and 3.1 mg per day via epidermal patch appear to be similar.
  • The addition of aprepitant (a neurokinin 1 [NK1] antagonist) to 5-HT3 receptor antagonists and dexamethasone has demonstrated success. A larger benefit has been found for women than for men. The current approved regimen for aprepitant is a three-day regimen; however, ongoing studies are under way to determine if additional doses are helpful. When using aprepitant, the dexamethasone dosage should be reduced. A potential interaction between aprepitant and chemotherapeutic agents such as ifosfamide have been noted. In one study, the combination was associated with increased neurotoxicity.
  • Olanzapine is an antipsychotic that blocks multiple neurotransmitters involved in CINV. Trials of olanzapine in combination with granisetron plus dexamethasone and palonosetron plus dexamethasone have demonstrated effectiveness in preventing CINV.

Nursing Implications:

This article demonstrated the importance of combination therapy for prevention and management of CINV. The author provides a good overview of relevant physiology, mechanism of action of current agents, and current regimens used. The article points to the need for additional research with the use of olanzapine for CINV.

Wickham, R. (2010). Best practice management of CINV in oncology patients: II. Antiemetic guidelines and rationale for use. Journal of Supportive Oncology, 8(2, Suppl. 1), 10–15.

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Type of Resource/Evidence-Based Process:

The search strategy was not applicable or stated.

Results Provided in the Reference:

This article discussed underlying shared principles in chemotherapy-induced nausea and vomiting (CINV) guidelines from the American Society of Clinical Oncology (ASCO), the Multinational Association for Supportive Care in Cancer (MASCC), and the National Comprehensive Cancer Network (NCCN).

  • Common goals among these guidelines are to prevent CINV and to identify the risk period for CINV asscociated with at least four days of moderate- and high-intensity emetogenic treatments.
  • The guidelines report that oral and IV formulations of 5-HT3 receptor antagonists are equally effective.
  • Selection of an antiemetic regimen should be based on the emetic risk of the chemotherapy being used as well as patient factors and experience.
  • Prophylactic antiemetics should be used when the risk of CINV is 10% or more.
  • A table of chemotherapeutic medications by emetogenic risk was provided. The author noted that such risk assignment does not provide for moving up the CINV risk ladder according to differing patient experience. Current guidelines are similar in terms of antiemetic regimens but only outline this for the first course of chemotherapy.
  • The article provided a brief review of current specific antiemetic recommendations provided in guidelines. Substantial differences exist between physician and nursing assignment of patient risk for delayed CINV, and limited evidence exists regarding the best approaches for breakthrough CINV.

Guidelines & Recommendations:

Currently recommended agents for breakthrough CINV are prochlorperazine, metoclopramide with or without diphenhydramine, haloperidol, dexamethasone, dronabinol nabilone, lorazepam, alternating 5-HT3 receptor antagonists, olanzapine, and promethazine. The author noted that guidelines are useful, but guideline adherence can only go to a certain extent in preventing CINV, particularly with delayed symptoms, multiple-day chemotherapeutic regimens, high-dose chemotherapy, breakthrough CINV, and refractory CINV.

Nursing Implications:

CINV guidelines are a good clinical tool to help clinicians implement evidence-based practice; however, their use needs to be accompanied by accurate patient assessments throughout the period of CINV risk. A standard guideline may not fit the needs of all patients and recommendations need to be viewed as a starting point for individualized patient care. More study and attention needs to be given to issues of delayed, breakthrough, and refractory CINV. This article is expert opinion-based and does not provide evidence for all information provided.

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