Treatment for uncontrolled N/V post chemo

[MillieT]

I have a heartbreaking patient who has uncontrolled N/V for 2 weeks + post chemo. She was on Zofran 8mg TID and up to 25mg phenergan IV every 4hrs prn, which I gave 12.5mg-25mg IV every 4hrs and one dose of Compazine 5mg. She was neutropenic, febrile, confused with possible hallucinations, tremors, hpotensive and then developed rigors after 4 episodes of intense vomiting. After getting home, I wondered if the confusion, tremors, rigor and possibly the low BP could of been from the phenergan, so I started researching protocols for N/V treatment. If so phenergan sucks.

I found that the most common regimen online was Zofran, Emend and dexamethosone. Does anyone else use Emend and dexamethosone regularly? Is it effective? Is there a reason dexamethasone couldn't be used in neutropenic pts (I know it can be immunosuppressive at higher doses)?

Thanks for any info, I want to be able to suggest other options if this happens again.

[NBMom1225]

I've also found Ativan given sublingually to be a great benefit to some of my chemo patients. Most antiemetics such as Zofran are given ATC on my unit, along with Compazine ordered prn. With a patient who is having alot of difficulties with N/V, I try to "stack" the antiemetics, giving each one as though it is an ATC...we also give use up to 16mg Zofran IVPB both pre-chemo and after, depends on how the physician orders it. We also frequently use Dexamethasone as a pre-med, they're not usually immunosuppressed prior to chemo (depends). Good Luck!

[Testa Rosa, RN]

Sounds like Ativan needs to be added to the regime. More frequent Zofran as well.

[MillieT]

Thanks all, she did have Ativan ordered prn, but I was hesitant to give it since she became confused after taking it the night before and with pain meds and phenergan she was becoming rather sedated with sats in the 88-92 range and BP of 88/50.

She definitely could've used a higher or more frequent dose of Zofran.

I work tomorrow and plan to ask the NP about their use of Emend and dexamethasone. I've never seen either used, but I'm new to this hospital.

[nursie_pants]

At my last job, docs never ordered phenergan for those side effects you list above. Like other people mentioned, alternating zofran and compazine ATC seems to help folks + ativan PRN. Dex and Emend also seem to work.... I just heard from a pt that Emend was costing her $100/pill w/her prescription. Craziness.

[beckabeckahi]

We use Emend and dexamethasone regularly, as well as Aloxi, which would be given day of treatment. They both work well, also the Ativan as others have mentioned.

[sashamay]

Ive had A LOT of patients that Zofran doesn't seem to do anything at all for... My last shift I had a pt with severely delayed gastric emptying/slow peristalsis who said she had tried everything (and we had given her a lot of different stuff over the few weeks we had her) and the only thing that actually kept the vomiting away was 2mg of IV Ativan every 3 hours. She remained a bit nauseated but was able to keep Boost down periodically.

[annacat]

We use Zofran IV, dexamethasone IV, ativan IV and Emend with varying results. zofran and dex are most commonly used. compazine is used prn for breakthrough nuasea. Emmend is very expensive but seems to be effective for up to 3 days per dose. There is also an IV form of Emend calle fosaprepitant that is effective if the person is not able to keep a pill down.

[Munch]

When I worked in oncology, Actually a common regime for nausea and vomiting is Zofran, Ativan and Benadryl. Many patients/caregivers ask why benadryl and it is used because benadryl can be relaxing hence the more relaxed you are the less intense the vomiting is(a lot of times this regime is used for children, but it is used in adults too). Doesn't work for everyone though. Also steroids are used to prevent nausea and vomiting(depending on the chemo the steroid is given BEFORE the chemo treatment begins). Also with the steroids such as decadron and prednisone can be helpful in stimulating patients appetite which is obviously a big problem with oncology patients.

[tewdles, RN]

I find that edible marijuana, made from the oils/tincture is very effective in curbing my post chemo nausea. They dissolve in my mouth very quickly and I experience improvement within 30 min and total relief in an hour. It is cheaper for me than my copay on the zofran and does not make me as sleepy as the compazine or ativan. Interestingly, I am not aware of any "head buzz" and do not feel "stoned" when I use these lozenges.

This may be an option for your patients in states that have legalized medical marijuana.

Oh yeah, I think it does help to improve my appetite a little, although it is difficult to know. I may just eat a bit better because I am not wretching.

[Munch]

I find that edible marijuana, made from the oils/tincture is very effective in curbing my post chemo nausea. They dissolve in my mouth very quickly and I experience improvement within 30 min and total relief in an hour. It is cheaper for me than my copay on the zofran and does not make me as sleepy as the compazine or ativan. Interestingly, I am not aware of any "head buzz" and do not feel "stoned" when I use these lozenges.

I do have to agree about the zofran copay. I get a script for zofran every month because one of the medications I take daily makes me extremely nauseous. The copay I have to pay is 80 dollars for 90 pills...highway robbery if you ask me. As if cancer treatment wasn't expensive enough, the support medications combined with cancer medications can make you go bankrupt.

[KelliD]

we pre med with IV aloxi, benadryl, zofran and ativan. We have had a lot of luck using IV emend for pt's with really severe post chemo nausea. The only down side is its a bit** to get the ins. companies to pay for it. Sancuso patches have worked very well too for at home management when Zofran or compazine isnt enough.