How Is Nausea and Vomiting Treated?

Today, there are many medicines available to prevent or control nausea and vomiting and so there are many treatment options. No single medicine can control nausea and vomiting 100% of the time, in part, because the chemotherapy agents act differently on the brain and because people respond differently. To choose the best treatment plan, the doctor:

• selects anti-nausea/vomiting medicines based on how strongly the chemotherapy agents stimulate the vomiting center in the brain,
  
• considers how likely the chemotherapy agent is to cause nausea and vomiting in the absence of effective anti-nausea/ vomiting treatment,
  
• reviews the patient’s past experiences with nausea and vomiting and with anti-nausea/vomiting medicines,
  
• carefully monitors how the person responds to the anti-nausea/vomiting treatment,
  
• considers the side effects of the anti-nausea/vomiting medicines,
  
• uses the lowest effective dose of the anti-nausea/vomiting medicine before chemotherapy or radiation therapy is given, and
  
• strives to prevent (and not just control) the nausea and vomiting.

Prevention of nausea and vomiting is the goal. In general, to provide the best protection against chemotherapy-related nausea and vomiting, preventive treatment should be started before the chemotherapy is given and should be continued for as long as the chemotherapy is likely to cause vomiting. Anti-nausea/vomiting medicines are usually given on a regular schedule around the clock. Sometimes the patient may be asked to take a medicine on an “as needed” schedule. Because nausea and vomiting can occur for different reasons, several different anti-nausea/vomiting medicines may be given. It is not unusual to take 2 or more medicines.

Anti-nausea/vomiting Medicines

Many different anti-nausea/vomiting medicines are available. These medicines are not equally effective for all people. Therefore, patients should receive anti-nausea/vomiting medicines based on the specific chemotherapy drugs they are receiving. For example, if you are receiving chemotherapy drugs that are likely to cause nausea and vomiting, you should receive the anti-nausea/vomiting medicines that have been most effective in controlling these side effects for other people receiving the same chemotherapy drugs. If these medicines do not prevent nausea and vomiting, it is important to tell your doctor so you can be given different medicines. The NCCN Treatment Guidelines use the anti-nausea/ vomiting medicines in Table 3. For more information on these anti-nausea/vomiting medicines, please see Table 4.

How Are the Anti-nausea/vomiting Medicines Given?

Anti-nausea/vomiting medicines are given based on the person’s condition, ability, and preference. If pills can be taken by mouth, this is usually the best and easiest way to prevent nausea and vomiting. For those having severe vomiting or those who are unable to swallow, the drugs can be given in other ways. Many medicines may be given intravenously (into a vein). Some are available as suppositories to be placed into the rectum, as tablets that may be placed under the tongue (sublingual), or as patches that stick on the skin (transdermal). How a medicine is given does not affect its ability to prevent or control nausea and vomiting.

Other Treatments for Nausea and Vomiting

Although anti-nausea/vomiting medicines are the main treatment for nausea and vomiting, several non-drug treatments are used for the anticipatory type of nausea and vomiting. These non-drug treatments involve using the mind and body with the help of a qualified therapist. The patient should ask a member of their health care team for a referral to a therapist trained in these techniques. Non-drug treatments may be used alone or together with anti-nausea/vomiting medicines. All of these techniques try to:

• promote relaxation which may decrease nausea and vomiting
• serve to distract the individual’s attention
• enhance feelings of control
• reduce feelings of helplessness

Listed below are treatments that do not involve drugs, have no side effects, and with the proper training can be used by anyone:

Self-hypnosis was the first technique involving behavior changes to control nausea and vomiting. It involves creating a state of intense attention, willingness, and readiness to accept an idea. This technique has been successful with children and adolescents.

Progressive muscle relaxation (PMR) teaches a person to relax by progressively tensing and releasing different muscle groups. It has been effective in decreasing nausea and vomiting caused by chemotherapy. Patients who learn PMR often continue to use this method as a general coping mechanism after completing chemotherapy. It is also used for nervousness, pain, anger, headaches, and depression.

Biofeedback helps people reach a state of relaxation. Using biofeedback, a person learns to control a specific physical response of the body, such as nausea and vomiting. This is done by receiving information about moment-to-moment physical changes of the body that are associated with the physical response. For example, biofeedback can be used to prevent skin temperature changes, such as those that occur before nausea and vomiting. The use of biofeedback alone for nausea and vomiting has not been as effective as the combination of biofeedback and PMR.

Guided imagery allows people to mentally remove themselves from the site of chemotherapy and relocate to a place that is relaxing for them. The place can be a vacation spot, a specific room at home, or some other safe or pleasant place. While trying to imagine what they usually feel, hear, see, and taste in the pleasant place, people can mentally block the nausea and vomiting.

Systematic desensitization helps people learn how to imagine an anxiety-producing situation (such as nausea and vomiting) and reduce the anxiety related to the situation. Usually what the person can imagine without anxiety, he or she can then experience in the real world without anxiety.

The Benefits of Good Nutrition

Good nutrition is especially important for people being treated for cancer. This is because many factors related to the illness itself, as well as cancer treatments, may affect appetite and the body’s ability to tolerate food and use nutrients. Your nutritional needs will vary during cancer treatment. Your health care team can assist you in determining specific nutritional goals and finding an approach to eating that meets your special needs. Eating healthy foods while undergoing cancer therapy can help patients to:

• feel better
• sustain their strength and energy level
• maintain a healthy weight
• keep up their body’s nutritional stores
• better tolerate treatment-related side effects
• decrease the risk of infection
• recover and heal as quickly as possible

Eating well means eating a variety of foods full of essential nutrients for healing.

Nutrition Suggestions for People Receiving Chemotherapy

• On the days chemotherapy is given, patients should make sure they have had something to eat. Most people find that a light meal or snack before chemotherapy is best.
  
• Most chemotherapy is given on an outpatient basis, such as in an infusion center or a doctor’s office. Receiving chemotherapy can take minutes or up to several hours. Patients should plan ahead and bring a light meal or snacks with them. Many treatment centers have refrigerators and microwaves available for patient use.
  
• Fatigue (tiredness or lack of energy) is commonly experienced when receiving chemotherapy. Conserving energy, setting priorities, pacing yourself, delegating responsibilities, scheduling activities at times of peak energy, recognizing one’s limits, and eating a nutritionally balanced diet are some of the general strategies that can help patients deal with fatigue.
  
• Patients should not be too hard on themselves if side effects make it difficult to eat. Try eating small, frequent meals or snacks. Choose the foods that appeal to you the most. Food preferences can change on an almost day-to-day basis during cancer treatment.
  
• Patients should make the most of days when they are feeling well and their appetite is good. Always try to eat regular meals and snacks but listen to your body. Never force yourself to eat something that does not appeal to you, or if you feel full.
  
• Ask family and friends for help with shopping, cooking, and meal preparation. If no one is available to help, consider having meals delivered to your home or consider having lunch at a community or senior center. Contact community assistance organizations, area churches, your local American Cancer Society office, or call 1-800-ACS-2345 for more ideas.
  
• Most side effects are temporary and go away when treatment is over. If symptoms persist, patients should alert their health care team. Prompt attention to managing nutrition-related side effects helps keep up weight and energy.

Nutrition Suggestions for People Receiving Radiation Therapy

The types of side effects experienced during radiation therapy depend on the area of the body receiving radiation, the size of the area being treated, the total dose of radiation, and the number of treatments. Table 5 shows possible nutrition-related side effects according to the area of the body being treated.
Eating well is important both during and after treatment. If side effects develop or if the anti-nausea/vomiting medicines are not working, please talk to your health care team.

Some patients need to be treated at a center far from their home, which often makes it difficult to eat well. Most treatment centers will have some type of kitchen space available. Patients can use this area to store and prepare frozen foods, soups, single servings of fruits, puddings, gelatin, ice cream, or cereals. If a kitchen is not available, patients should bring food items that do not require refrigeration, such as single servings of canned fruit, gelatin, puddings, cheese or peanut butter crackers, granola bars, or cereal. Patients may talk to a nurse or social worker for suggestions about places to stay and eat while receiving treatment.

The following are nutrition suggestions for people having radiation therapy:

• Try to eat something at least 1 hour before treatment rather than coming with an empty stomach.
• If traveling a long distance each day for treatment, bring foods or nutrition supplements to eat or drink on the ride to and from treatment.
• Eat small, frequent meals. Ask friends and family members to help prepare meals, do the shopping, and select the foods and drinks that appeal to you most that day.
• Do not expect to have the same side effects as someone else being treated for cancer in another area of the body. Even people with the exact same treatments have different degrees of side effects.
• Other patients can be a great source of information and support. Get to know and talk with others about their experiences, or join a support group.

Managing Side Effects

IIf you are having difficulty eating and/or you are on a special diet (such as for diabetes or heart disease), your diet restrictions might be relaxed during treatment. You should speak with your health care team before making any changes in your diet.

• Try to eat small frequent meals rather than 3 large meals.
• Add extra calories and protein to foods. Nutrition supplements are convenient and can be helpful during this time. Try a variety of supplements to find out which ones work best for you. Your doctor, nurse, or a dietitian can be a great source of information about types of products available and may have samples you can try.
• Try eating most foods during the time of day when you are best able to eat. Many people find that breakfast time is best.
• Let the health care team know when eating is a problem. A dietitian can be consulted to provide more tips and suggestions to help with eating.
• Let the health care team know when nausea and vomiting are not relieved by anti-nausea/vomiting medicines.

There are things you can do to help manage or reduce your nausea and vomiting. Here are a few suggestions:

• Eat foods and drink beverages that are “easy on the stomach” for you or made you feel better when you had the flu or morning sickness (such as ginger ale, bland foods, sour candy, and dry crackers or toast).
• Do NOT force yourself to eat when you feel nauseated.
  
• Eat small frequent meals.
  
• Restrict fluids with meals.
  
• Eat food cold or at room temperature.
  
• Have someone else make the meals if you are nauseated.
  
• Keep your mouth clean and do oral care after each episode of vomiting.
  
• Wear loose fitting clothes.
  
• Get fresh air with a fan or open window.
  
• Limit sounds, sights, and smells that cause nausea and vomiting.
  
• Call your doctor or nurse if your nausea or vomiting is not controlled with the medicines you have.

TYPES OF NAUSEA AND VOMITING

For more information on these treatment guidelines, or on cancer in general, call the NCCN at 1-888-909-NCCN or the American Cancer Society at 1-800-ACS-2345. Or you can visit these organizations’ web sites at www.cancer.org (ACS) and www.nccn.org (NCCN).

© 2007 by the National Comprehensive Cancer Network (NCCN) and the American Cancer Society (ACS). All rights reserved. The information herein may not be reproduced in any form for commercial purposes or downloaded and stored in any information-retrieval system without the express written permission of the NCCN and the ACS. Single copies of each page may be printed out for personal, noncommercial use only.