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PATIENT PRESENTATION

Chief Complaint

“I have been throwing up all day and I feel horrible”

History of Present Illness

Justine Rush is a 68-year-old female who presents to the emergency department with eight episodes of nausea and vomiting today. Today is day 5 of her first cycle of chemotherapy with carboplatin (AUC 5 mg/mL/min), etoposide, and atezolizumab to treat extensive stage small-cell lung cancer.

Student Work-Up

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Missing Information?

Evaluate:

Patient Database

Drug Therapy Problems

Care Plan (by Problem)

TARGETED QUESTIONS

  1. What is the underlying pathophysiology and associated receptors that play an important role in the development and treatment of chemotherapy induced nausea and vomiting (CINV)?

    Hint: See Figure 21-1, and the Pathophysiology sections in chapters 21 and 99 in PPP.

  2. How is this patient’s CINV most accurately classified (acute, delayed, anticipatory, or breakthrough)?

    Hint: See Chapter 99, Clinical Presentation and Diagnosis and Chapter 21, Chemotherapy Induced Nausea and Vomiting section in PPP.

  3. Did this patient receive an appropriate antiemetic prophylaxis regimen for this chemotherapy regimen?

    Hint: See Table 21-3 and 99-2 in PPP.

  4. How should this patient’s current nausea and vomiting be treated?

    Hint: See Chapter 21 Chemotherapy Induced Nausea and Vomiting section in PPP.

  5. What important counseling points should you share with this patient regarding their therapy for nausea and vomiting?

    Hint: See table 21-2 and chapter 21 Outcome Evaluation section and Pharmacist’s Patient Care Process box in PPP.

FOLLOW-UP

This patient’s CINV resolves with your recommended interventions. What antiemetic regimen will you recommend for CINV prophylaxis for her next cycle of chemotherapy?

Hint: See Table 21-3 and 99-2 in PPP.

CASE SUMMARY

Global Perspective

European and United States guidelines (ASCO, NCCN, MASCC and ESMO) agree regarding classifying emetogenic risk of chemotherapeutic agents as high, moderate, low or minimal, and regarding the classification of chemotherapy induced nausea and vomiting (CINV) as acute or delayed. The two guidelines from the United States further classify the emetogenic potential of carboplatin-based therapy based on the dosing and area under the curve (AUC). A carboplatin AUC of four or greater is considered highly emetogenic, whereas an AUC of less than 4 is considered moderately emetogenic. All the European and United States guidelines have incorporated olanzapine into recommendations for CINV prevention for both acute and delayed phases with special attention for its role in delayed nausea control.

Azasetron, Ramesetron and Tropisetron are 5HT3 receptor antagonists that are available outside of the United States. Tropisetron is approved in other countries for prevention of CINV as well as prophylaxis and treatment of postoperative nausea ...

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