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What is Chemotherapy Induced Nausea and Vomiting?

Few side effects of cancer treatment are more feared by the patient than nausea and vomiting. Although nausea and emesis (vomiting and/or retching) can also result from surgery, opiates, or radiotherapy, chemotherapy-induced nausea and vomiting is potentially the most severe and most distressing. Although significant progress has been made with the development of a number of effective and well-tolerated antiemetic treatments, chemotherapy induced nausea and vomiting remains an important adverse effect of treatment.

There are three main types of chemotherapy induced vomiting:

Acute vomiting (emesis) — Acute vomiting is defined as emesis occurring during the first 24 hours after chemotherapy. In the absence of effective prophylaxis, it most commonly begins within one to two hours of chemotherapy and usually peaks in the first four to six hours.

Delayed emesis — Emesis occurring more than 24 hours after chemotherapy is classified as delayed. It is best characterized following treatment with high-dose cisplatin or chemotherapy for breast cancer. While the frequency and number of episodes of emesis may be less during the delayed period compared to acute emesis, the delayed form is less well controlled with current antiemetic medications. Delayed emesis occurs most frequently after cisplatin but can also occur following other agents, including carboplatin, cyclophosphamide, anthracyclines and oxalipaltin.

Anticipatory emesis — Anticipatory emesis is a conditioned response in patients who have developed significant nausea and vomiting during previous cycles of chemotherapy. It can occur when the patient reenters the chemotherapy suite when he/she has experience nausea and vomiting before. As antiemetic control during the initial cycle of chemotherapy has progressively improved, anticipatory emesis has become a less significant clinical problem.

Chemotherapeutic Drugs and their risk of Causing Emesis as per uptodate.com:

LevelFrequency of emesis, percentChemotherapeutic drug and dose



Cyclophosphamide ≥1500 mg/m2











Cyclophosphamide <1500 mg/m2

Cytarabine >1000 mg/m2


Denileukin diftitox












Cytarabine ≤1000 mg/m2












Pegylated liposomal doxorubicin


















The Following Medicines are used commonly to prevent and treat chemotherapy induced emesis:

  • Prochlorperazine (Compazine) is a very commonly used agent used in all kinds of vomiting. It is effective in chemotherapy caused by low to medium risk drugs.
  • Metoclopramide (Reglan) is an effective agent used in chemotherapy induced nausea and vomiting. It is available as pills and injections for administration in your veins.
  • Ondansetron (Zofran), Granisetron, Dolasetron and Palonosetron (Aloxi) are specialized agents used for nausea and vomiting caused by chemotherapy. They belong to the class of drugs called 5HT3 antagonists. These are extremely potent agents that are very effective nausea and vomiting of any severity. Palonoseteron is specifically indicated for delayed nausea and vomiting along with other agents.
  • There is now a 5HT3 Patch available called Sancuso.
  • Dexamethasone and methylprednisolone are steroids. They have a definite role in adding to vomiting and nausea control when added to other antiemetic drugs. They are also often admistered before chemotherapy to prevent anticipatory nausea and vomiting.

The most commonly used combination of drugs used for control of nausea and vomiting caused by moderate to highly emetegenic agents include a 5HT3 antagonist like ondansetron and granisetron along with a steroid agent like dexamethasone.

  • Aprepitant (Emend) is a new agent that has shown efficacy in both acute and delayed nausea and vomiting. When added to 5HT3 antagonists, they have added benefit in controlling nausea and vomiting with highly emetogenic chemotherapy agents.
  • Lorazepam, Alprazolam and Midazolam are anti-anxiety and sedative agents that are effective in controlling severe nausea and vomiting when added to standard anti-emetic combinations of 5HT3 anatagonists and steroids.

Why might people have nausea and vomiting with cancer treatment? 

Nausea and vomiting are common side effects of a cancer treatment called chemotherapy. Chemotherapy is the term doctors use to describe a group of medicines that kill cancer cells.

Not everyone who gets chemotherapy will have nausea and vomiting. Your doctor will tell you how likely it is that you will have these symptoms and how severe they will be.

When people have nausea and vomiting after chemotherapy, they usually feel better within 1 to 2 days. But some people have symptoms up to 3 to 4 days after their chemotherapy. This will depend on the type of chemotherapy medicines, dose, and treatment schedule.

Another cancer treatment, called radiation therapy, can also cause nausea and vomiting. Not everyone who gets radiation therapy will have nausea and vomiting. It will depend on the part of the body part treated, dose of radiation, and if the person gets chemotherapy at the same time.

Can nausea and vomiting be prevented? 

Yes. If your chemotherapy is likely to cause nausea and vomiting, your doctor will give you medicines before your treatment. These medicines can prevent nausea and vomiting. There are different medicines your doctor can use, and they come in different forms. They can come as a pill, skin patch, or tablet that melts on the tongue, or they can go into your vein. People can get 1 or more medicines.

People who are likely to have nausea and vomiting for a few days after chemotherapy might also take these medicines for 2 to 4 days after treatment.

If your radiation therapy causes nausea and vomiting, your doctor will prescribe medicine for you to take before each radiation treatment.

What can I do to manage my nausea and vomiting?

 To manage your symptoms, you can:

  • Take the medicines your doctor prescribes to prevent nausea and vomiting, even if you feel fine. The best way to manage nausea and vomiting is to prevent it from happening.
  • Make sure to drink enough fluids so that you don’t get dehydrated. Dehydration is when the body loses too much water. It can cause people to have dark yellow urine and feel thirsty, tired, dizzy, or confused.
  • Eat 5 or 6 small meals during the day after chemotherapy instead of 3 big ones, especially if you feel queasy.
  • Learn how much to eat or drink before your treatment. Some people feel better when they eat or drink a small amount before treatment. Other people feel better if they don’t have any food or drink beforehand.
  • Avoid foods that are spicy, greasy, or “heavy.” Instead, eat foods that are bland, such as crackers, rice, and toast. Other good food choices are soup broths, clear soda, tea, bananas, chicken (broiled or baked), oatmeal, yogurt (plain or vanilla), pasta, and popsicles.
  • Wait 1 hour after your treatment before you eat or drink.
  • Eat and drink slowly.
  • Ask someone else to cook your food, if the smell of food bothers you.
  • Drink ginger ale or take over-the-counter ginger supplements to settle your stomach.
  • Ask your doctor about an alternative treatment called acupuncture, which might be helpful for some people.

When should I call my doctor or nurse? 

Call your doctor or nurse if you:

  • Are unable to keep any food or drink in your stomach
  • Vomit up the medicines your doctor gives you to prevent nausea and vomiting

Thank you uptodate.com

Here, Dr. Tony Talebi discusses "What is chemotherapy induced nausea and vomiting" with Jessica Macintyre.