The CancerCare Connect Booklet Series offers up-to-date, easy-to-readinformation on the latest treatments, managing side effects and copingwith cancer.Founded in 1944, CancerCare is the leading national organization providingfree, professional support services and information to help people managethe emotional, practical and financial challenges of cancer. Our comprehensiveservices include counseling and support groups over the phone, online andin person, educational workshops, publications and financial and co-paymentassistance. All CancerCare services are provided by oncology social workersand world-leading cancer experts.CancerCare relies on the generosity of supporters to provide our servicescompletely free of charge to anyone facing a cancer diagnosis. If you havefound this resource helpful and wish to donate, please do so online You may also mail a check, payable toCancerCare, to CancerCare, Attn: Donations, 275 Seventh Avenue,New York, NY 10001.Thank you.CancerCare National Office275 Seventh AvenueNew York, NY 10001Coping WithNausea and VomitingFrom ChemotherapyTABLE OF CONTENTSIntroduction. 4Why Chemotherapy Causes Nausea and Vomiting. 6Drug Treatments for Nausea and Vomiting. 8Types of Anti-Nausea Drugs.10CancerCare’s Free Support Services and Programs. 15Frequently Asked Questions. 16Resources. 19EDITORToll-free 800-813-HOPE (4673)Fax 212-712-8495Email [email protected] www.cancercare.orgStewart B. Fleishman, MDFounding Director, Cancer Support Services,Continuum Cancer Centers of New York, Accreditation Surveyor,American College of Surgeons Commission on CancerThe content of this booklet is independent, non-promotional and free of commercial influence and bias. 2018 CancerCare . All rights reserved. 5/182WWW.CANCERCARE.ORGCANCERCARE COPING WITH NAUSEA AND VOMITING FROM CHEMOTHERAPY3

Your oncology care providersnow have many ways to preventand ease nausea and vomitingfrom chemotherapy.Surveys have shown that many patients and their loved onesbelieve nausea and vomiting occur with all types of chemotherapy(anti-cancer drugs). In reality, half of the chemotherapy drugsnow in use became available in the past several years, and theirside effects are not necessarily the same as those caused by olderdrugs. Though many people receiving chemotherapy may stillexperience nausea and vomiting, your health care team has manyways to both prevent and ease these symptoms.It’s important to tell your doctor or nurse about your symptoms,even if what you’re experiencing is just mild queasiness. Thatfeeling in your stomach can be the first sign of nausea, whichcan be treated with various types of medications. If one typedoesn’t work, your doctor, advanced practice nurse or physician’sassistant can likely prescribe something else, so keep your healthcare team posted on how the medications are working. Be sureto ask about possible dietary adjustments, as they may also beof help.The Importance of Getting HelpDo not accept nausea and vomiting as “the norm,” as thereare many medications available to relieve your symptoms.It’s important to seek help from your health care team ifyou experience symptoms, as nausea and vomiting can: Cause dehydration, which can be harmful to your health(see the Avoiding Dehydration sidebar on page 7) Reduce your quality of life and your ability to enjoyeveryday activities Affect your outlook and mood Make it difficult to work or concentrate Potentially result in treatment delaysYour health care team wants to help. Contact them as soonas you experience any symptoms, no matter the severity.Even if you’re feeling fine, it’s important to follow your health careteam’s instructions on when to take your medications. That’sespecially crucial if you are receiving chemotherapy in pill form, asyou will need to take the chemotherapy and the anti-nausea drugsin a certain order and at a certain time of day.4WWW.CANCERCARE.ORGCANCERCARE COPING WITH NAUSEA AND VOMITING FROM CHEMOTHERAPY5

Why Chemotherapy CausesNausea and VomitingWhen receiving chemotherapy, sensors in the digestive systemand brain detect its presence and identify it as a foreignsubstance. In a complex series of signals from the brain to themouth, stomach, intestines and bloodstream, the chemotherapystimulates the “vomiting center” in the brain. Several naturallyoccurring protein transmitters, including ones called serotoninand substance P, are released, triggering the nausea andvomiting reflex.Although chemotherapy is meant to destroy rapidly dividing andgrowing cancer cells, it sometimes affects healthy tissues in thebody, including those in the lining of the mouth, esophagus (foodpipe) and stomach. Some anti-cancer drugs can irritate theseareas, leading to nausea and vomiting.Some people experience nausea and vomiting within the first fewhours of receiving chemotherapy (known as an acute reaction).Others don’t feel symptoms the day of chemotherapy but developnausea and vomiting during the following few days (a delayedreaction). It’s important to notify your health care team when youexperience these symptoms, no matter when they occur.Avoiding DehydrationWhen nausea or vomiting becomes severe, it can causedehydration. This is a serious condition that should not beneglected, as it can lead to: Dizziness Low blood pressure Muscle spasms and cramps Weight loss Mental confusion Damage to the heart, lungs or kidneysAsk your health care team about things you can do to stayhydrated or correct dehydration, such as drinking plenty ofwater or other clear liquids and taking a product such asPedialyte. Available over the counter, Pedialyte containsthe medically recommended balance of sugar and sodium(an electrolyte) to promote hydration. It is marketed forchildren, but adults can use it as well.If dehydration becomes severe, your doctor may recommendthat an intravenous saline solution (a salt solution deliveredthrough a needle into a vein) be administered until your bodychemistry returns to normal.Because some people receiving chemotherapy may expect tofeel ill, they may experience symptoms even before a treatmentsession begins. Sometimes the sights, sounds or smells of thetreatment room can trigger an anticipatory reaction.6WWW.CANCERCARE.ORGCANCERCARE COPING WITH NAUSEA AND VOMITING FROM CHEMOTHERAPY7

Drug Treatments forNausea and VomitingThere are many anti-nausea medications that have becomeavailable in recent decades. Your doctor will decide which (if any)medications to prescribe, based on the type of chemotherapy youare receiving and the anticipated severity of nausea and vomitingside effects. Your age, gender and other health conditions mayalso be a factor in your doctor’s recommendation.If you are receiving treatment in a clinic or hospital, you willusually receive anti-nausea drugs intravenously (deliveredthrough a needle into a vein). Some anti-nausea medicationsare also available in pill or liquid form or as a suppository (a softpreparation containing medication that dissolves in the rectum).After chemotherapy, you may also be given anti-nauseamedications to take at home. It’s important to understand howthese drugs should be taken. Some medications are designed tobe taken regularly for several days, whether you feel nauseatedor not. Other medications are meant to be taken only when youfeel symptoms. If you have any questions about when youshould take your anti-nausea medication, be sure to contactyour health care team.8WWW.CANCERCARE.ORGCANCERCARE COPING WITH NAUSEA AND VOMITING FROM CHEMOTHERAPY9

Types of Anti-Nausea DrugsAnti-anxiety drugsMedications such as lorazepam (Ativan and others) ordiazepam (Valium and others) are used to help block nauseaand vomiting. These sedatives can be given intravenouslyand in pill form. Benzodiazepines such as lorazepam anddiazepam do not stop nausea and vomiting directly, but theyhelp other anti-nausea medicines work effectively and relievethe anxiety that people can feel when they believe they’reabout to experience these symptoms.To avoid becoming dependent on such medications, acareful schedule should be worked out with your doctoror nurse. They can also effectively relieve the anxiety thatpeople can feel when they believe they’re about toexperience these symptoms.others) and cyclophosphamide (Cytoxan, Neosar and others).Serotonin antagonists stop serotonin (a substance occurringnaturally in the brain) from sending a signal that causes vomiting.These drugs are usually administered intravenously beforechemotherapy begins.One of these drugs, palonosetron (Aloxi), was specificallytested to work for days after a single injection. It can preventboth acute and delayed nausea and vomiting. Other similarserotonin antagonists include ondansetron (Zofran and others),granisetron (Kytril) and dolasetron (Anzemet). Like palonosetron,dolasetron is given as an injection. Ondansetron is given in tabletor liquid form, and granisetron is given either via an injection orin tablet form.CorticosteroidsCorticosteroids, which are related to the natural hormonecortisol, are widely used to help prevent nausea and vomitingcaused by chemotherapy. They have been successfully used formany years, especially to prevent delayed nausea and vomiting.Corticosteroids such as dexamethasone (Decadron, Hexadroland others) can be given in different forms and are oftencombined with other anti-nausea drugs for maximum benefit.Serotonin antagonistsSerotonin antagonists are often used to counter nausea andvomiting resulting from chemotherapy drugs that can causestronger nausea or vomiting, such as cisplatin (Platinol and10WWW.CANCERCARE.ORGCANCERCARE COPING WITH NAUSEA AND VOMITING FROM CHEMOTHERAPY11

AprepitantAprepitant (Emend) works in the vomiting center of the brain toprevent nausea and vomiting caused by chemotherapy. It blocksthe action of substance P, a peptide that triggers nausea andvomiting reflexes. Aprepitant is sometimes given in combinationwith corticosteroids and serotonin antagonists. It is available asa capsule and is taken before a chemotherapy session and fortwo days afterward. A related drug, fosaprepitant dimeglumine(Emend for Injection), gives patients receiving chemotherapyanother option for preventing nausea and vomiting. It is deliveredintravenously and converted to aprepitant in the body.CannabinoidsCannabinoids contain the active ingredient found in marijuana.For a number of years doctors have prescribed dronabinol(Marinol) as an anti-vomiting medication. In 2006, the U.S. Foodand Drug Administration approved nabilone (Cesamet), whichcan control chemotherapy-related nausea and vomiting incancer patients who have not been adequately helped byother anti-nausea medications. Cannabinoids can be taken incombination with, but not as a replacement for, other types ofanti-nausea drugs. These pill forms of cannabinoids are madewith the same safety and purity standards for all prescriptiondrugs. They are safer to use than other commercially availableforms of marijuana products as they are the specific sub-typesof cannabis that most suppress nausea and vomiting. Smokedcannabis is best avoided since the burning process irritates themouth and throat and can introduce sources of infection at atime when the system is least able to fight it off.12WWW.CANCERCARE.ORGWhat You Can DoThese tips can help prevent—or help you copewith—feelings of nausea after receiving chemotherapy: Be sure that you fully understand your health care team’sinstructions for taking your anti-nausea medicines and thatyou have a sufficient supply at all times. Talk to your doctor about any other medications you maybe taking (including over-the-counter medicines andsupplements), as they might contribute to your feeling ofnausea. Your doctor may recommend changes or advisethat you take special precautions. Ask your health care team about proper nutrition and howto avoid dehydration while you are receiving chemotherapy(see the Avoiding Dehydration sidebar on page 7). Eat and drink slowly, and try having four or five small mealsthroughout the day, rather than three larger meals. Avoid cooking or eating food with strong odors, as well asoverly sweet, greasy, fried or highly seasoned food. Highlycaffeinated drinks should also be avoided. Keep a log of what you eat and drink and how you feelafterwards, as this will allow you to easily determine ifcertain foods and liquids lead to symptoms of nauseaand vomiting.Additionally, a registered dietician can be a valuable resourcefor people who are coping with nausea and vomiting, as theycan help you put together an eating plan that will meet yournutritional and hydration needs.CANCERCARE COPING WITH NAUSEA AND VOMITING FROM CHEMOTHERAPY13

CancerCare’s FreeSupport Services and ProgramsWhen you are diagnosed with cancer, you are faced with a seriesof important choices, and you might not be sure where to turn foranswers to your questions.CancerCare can help. We are the leading national nonprofitorganization providing free, professional support services toanyone affected by cancer. Our licensed oncology social workerscan provide you with counseling, education, resources, help innavigating the complicated health care system and informationon support groups and other resources, including those that maybe able to provide financial help.To learn more about how CancerCare helps, call us at800-813-HOPE (4673) or visit a cancer diagnosis, you will likely build your own personalsupport network, comprised of family and friends. In doing so,it’s best to take some time to think about the people in your lifeand how they are best suited to help. Match the task to theirstrengths—ask a family member who loves to cook to prepare ameal for you; ask a friend who’s a good listener to come overfor a chat.14WWW.CANCERCARE.ORGCANCERCARE COPING WITH NAUSEA AND VOMITING FROM CHEMOTHERAPY15

Frequently Asked QuestionsQ: Are there other types of drugs not related to mychemotherapy treatment that can cause nauseaand vomiting?A: There are a number of drugs that can cause nausea andvomiting, including bronchial dilators, pain medications andsome antibiotics. The cancer itself can also cause thesesymptoms. It’s important for you to keep track of the severityof your symptoms and when they begin and end and to sharethat information with your health care team, as the patternwill help them determine the best course of action.Q: My insurance company won’t cover the anti-nausea drugmy doctor prescribed. What can I do?A: Insurance coverage can differ significantly depending on thecompany and the specific plan. It could be that your plan willcover one formulation of the prescribed drug but not another(e.g. will cover an injection but not the oral form of a drug).Talk to a benefits specialist at your insurance company aboutwhat your plan does cover and share that information with yourhealth care team so that the best decision about your treatmentcan be made.If you need financial help, CancerCare’s financial assistanceprogram can help pay the cost of treatment-related expenses.Additionally, the Partnership for Prescription Assistance (PPA)helps patients without prescription coverage get the medicinesthey need through the public or private program that’s right forthem. For patients who qualify, drugs can often be obtained freeof charge or at low cost. The PPA helps people find the right16WWW.CANCERCARE.ORGpatient assistance program from among more than 475 suchprograms, including more than 150 offered by pharmaceuticalcompanies. Their contact information can be found in theResources section.Q: Is acupuncture an effective treatment for nausea andvomiting caused by chemotherapy?A: There have been a number of studies on acupuncture usedfor this purpose—with mixed results. Talk to your doctor beforedeciding to try acupuncture to make sure he or she thinks it’s agood approach in your specific situation. Consider acupunctureas a complement to, not a replacement for, the medicationsyour doctor has prescribed.Q: I’ve heard that tea made with ginger can calm an upsetstomach. Is there any evidence that this can help me withnausea now that I’m getting chemotherapy?A: There is limited data on whether ginger can help preventnausea in patients receiving chemotherapy. It’s likely safe foryou to drink ginger tea, but check with your health care teamto make sure there’s no medical reason why you should avoidginger. If you get the go-ahead, view ginger tea as a complementto any medication your doctor prescribes, and enjoy!Q: Can meditation or other relaxation methods help controlmy nausea and vomiting?A: Any healthy technique that reduces stress may be helpful andshould be considered as a complement to—not a replacementfor—medications your doctor may prescribe. Such techniquesinclude meditation, yoga, deep breathing exercises and listeningto music.CANCERCARE COPING WITH NAUSEA AND VOMITING FROM CHEMOTHERAPY17

ResourcesGeneral Cancer OrganizationsCancerCare800-813-HOPE (4673)www.cancercare.orgAmerican Cancer t information from the American Society of Clinical Oncology)www.cancer.netNational Cancer Institute800-422-6237www.cancer.govPartnership for Prescription Assistance888-477-2669www.pparx.orgThis booklet was made possible by AbbVie.18WWW.CANCERCARE.ORGCANCERCARE COPING WITH NAUSEA AND VOMITING FROM CHEMOTHERAPY19


After chemotherapy, you may also be given anti-nausea medications to take at home. It's important to understand how these drugs should be taken. Some medications are designed to be taken regularly for several days, whether you feel nauseated or not. Other medications are meant to be taken only when you feel symptoms.