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Prevention of Acute / Delayed Nausea and Vomiting (Emesis)

Table 2. Comparison of Aprepitant and Standard Regimens continued...

Prednisone and adrenocorticotropic hormone (ACTH) given concomitantly with other active antiemetic agents have also demonstrated efficacy against N&V caused by cisplatin-containing chemotherapy during the acute phase (within 24 hours after receiving chemotherapy).[85,86,87] In a double-blind, randomized study of metoclopramide and dexamethasone with or without 1 mg of ACTH, patients receiving ACTH prophylaxis for cisplatin-containing chemotherapy experienced a significantly decreased incidence and severity of delayed emesis for up to 72 hours after treatment.[87]

Cannabis

The plant Cannabis contains more than 60 different types of cannabinoids, or components that have physiologic activity. The most popular, and perhaps the most psychoactive, is delta-9-tetrahydrocannabinol (delta-9-THC).[88] There are two FDA-approved products for CINV:

  • Dronabinol (a synthetic delta-9-THC), as prophylaxis for CINV, 5 mg/m2 orally 1 to 3 hours before chemotherapy and every 2 to 4 hours after chemotherapy, for a total of no more than 6 doses per day.
  • Nabilone, 1 to 2 mg orally twice a day, for CINV that has failed to respond to other antiemetics.

With respect to CINV, Cannabis products probably target cannabinoid-1 (CB-1) and CB-2 receptors, which are in the central nervous system.[89] Another product, Sativex, a cannabidiol that is a buccal spray, is under investigation.[90,91]

Much of the research on this class of agent was conducted in the late 1970s and 1980s and compared Cannabis to older antiemetic agents that targeted the dopamine receptor, such as prochlorperazine (Compazine) and metoclopramide (Reglan).[88,92,93,94,95,96,97,98,99] This group of studies demonstrated that Cannabis was as effective for moderately emetogenic chemotherapy as dopaminergic antiemetics or was more effective than placebo.[88] Side effects of Cannabis products included euphoria, dizziness, dysphoria, hallucinations, and hypotension.[88] Despite earlier reports of efficacy, in at least one study, patients did not significantly prefer Cannabis agents because of the side effects.[92]

Research in nausea and vomiting since the 1990s has elucidated newer and more physiologic targets, namely 5-HT3 and NK-1 receptors. Subsequently, 5-HT3 and NK-1 receptor antagonists have become standard prophylactic therapy for CINV. Studies investigating the role of Cannabis with these newer agents are few; therefore, limited conclusions can be drawn. In published trials, however, Cannabis has not demonstrated more efficacy than 5-HT3 receptor antagonists, and synergistic or additive effects have not been fully investigated.[89,100,101]

In summary, the place of Cannabis in today's arsenal of antiemetics for the prevention and treatment of CINV is not known. Discussions with patients about its use should include responses to available agents, known side effects of Cannabis, and an assessment of the risks versus benefits of this therapy.[102]

For a broader discussion of the issues surrounding Cannabis use, refer to the PDQ summary on Cannabis and Cannabinoids.

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