Expert Opinion

Lorazepam

for Chemotherapy-Induced Nausea and Vomiting—Adult

Lorazepam is a type of benzodiazepine, an antianxiety medication that is metabolized more rapidly than many other benzodiazepines. Lorazepam is mainly used for the short-term relief of symptoms of anxiety associated with depression, and it has been used to treat insomnia, nausea, and vomiting. Lorazepam has been evaluated as an adjunctive medication for the prevention of chemotherapy-induced nausea and vomiting in patients with cancer.

Guideline / Expert Opinion

Herrstedt, J., & Roila, F. (2008). Chemotherapy-induced nausea and vomiting: ESMO clinical recommendations for prophylaxis. Annals of Oncology, 19(Suppl. 2), ii110–ii112. 

Purpose & Patient Population

PURPOSE: To provide guidance to clinicians for the prevention and management of chemotherapy-induced nausea and vomiting

PATIENT POPULATION: Patients receiving cancer chemotherapy of varying emetogenic potential

Type of Resource/Evidence-Based Process

PROCESS OF DEVELOPMENT: The process was not fully described. The references cited were the antiemetic resource center on the Multinational Association of Supportive Care in Cancer's (MASCC's) website and the Antiemetic Subcommittee of MASCC's 2004 consensus conference, cited in Annals of Oncology 2006, volume 17, pages 20–28. The levels of evidence and grades of recommendation used by the American Society of Clinical Oncology were applied to specific recommendations and considered by the authors and ESMO faculty.

Results Provided in the Reference

This reference provides definitions of nausea and vomiting; the relative emetogenic potential of oral and IV drugs; recommendations of drugs, dosing, and schedules for antiemetic drugs; and recommendations for the management of nausea and vomiting based on emetogenic potential.

Guidelines & Recommendations

Stated level (I–V) and grade of evidence assessed are shown in parentheses.
 
• Acute nausea and vomiting
– High emetogenic potential: Serotonin antagonists + corticosteroid + aprepitant (I,A)
– Anthracycline + cyclophosphamide: Serotonin antagonist + dexamethasone + aprepitant (II,A)
– Moderate potential: Serotonin antagonist + corticosteroid (I,A)
– Low potential: Single agent such as corticosteroid (III,IV, D)
– Minimal potential: No prophylaxis (V, D)
• Delayed nausea and vomiting
– High emetogenic potential: Corticosteroid + aprepitant (II, A)
– Anthracycline +cyclophosphamide: Dexamethasone or aprepitant (II, A)
– Moderate potential: Corticosteroid (I,A) or serotonin antagonist (II,B)
– Low potential: No routine prophylaxis
– Minimal potential: No routine prophylaxis
• Specific issue recommendations
– Multiple-day chemotherapy: Treat as acute on chemotherapy days and as delayed one to two days after chemotherapy.
– Refractory nausea and vomiting: Consider aprepitant if it is not already used, or add dopamine antagonists to serotonin antagonists and corticosteroids (V,D).
– Anticipatory nausea and vomiting: Lorazepam or similar drugs and behavioral techniques (V,D)
– High-dose chemotherapy: Corticosteroids and serotonin and dopamine antagonists in full doses (III,C)

Limitations

  • The principal author contributed to an ad hoc advisory board activity for multiple pharmaceutical companies and is conducting research sponsored by Merck. The secondary author is a member of an advisory board on palonosetron and aprepitant, has been a sponsored speaker, and conducts research on casopitant and fosaprepitant.
  • The recommended timing of interventions for delayed nausea and vomiting prophylaxis is unclear. It is not stated whether the recommendation is to prophylactically use these medications to prevent the problem or to intervene if the delayed symptoms occur.
  • There is no discussion of any dosage titration approaches to individualize management.

Nursing Implications

This guideline provides a good reference for the classification of chemotherapeutic agents according to emetogenic potential. It is a good reference for initial dosing of medications used. It is noted that the recommendations here assume that the patients being treated are chemotherapy-naïve. The recommendations focus on pharmaceutical management except for the consideration of behavioral techniques for anticipatory nausea and vomiting. 
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