Dr Paper Document Template · Web viewI wanted to develop a way to promote patient comfort by ensuring proper, consistent antiemetic usage and prevent chemotherapy-induced nausea

Running head: PROJECT SCOPE AND PLAN FOR ANTIEMETIC CHEMOTHERAPY

Analyzing Inconsistent Antiemetic Usage and Developing a Plan

Anne M. Hendricks

Ferris State University

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Abstract

Inconsistent usage of antiemetic therapies during chemotherapy treatment led me to question

what I could do to help? I utilized information from our Oncology Pharmacist (Joanne McGurn)

and several evidence-based research articles to formulate charts of the recommended treatments

and dosages for high, moderate and low emetogenic chemotherapy (Appendixes A,B,C). I

placed the charts in our medication room in a binder, and sent copies to all seven Oncologists

that we serve. I developed a chart that measures each time a correction is made on an order for

specific physicians (Appendix D). I developed another chart to measure patient subjective

perceptions of nausea and vomiting (Appendix E). Severity of nausea will be measured by

number 1-4, with 1 =minor nausea/vomiting, 2=more severe nausea/vomiting which influences

activity slightly, 3= very activity limiting nausea/vomiting, 4=debilitating nausea/vomiting.

Research of monthly data and collaboration with physician/pharmacist will ensure best patient

outcome.

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Analyzing Inconsistent Antiemetic Usage and Developing a Plan

I work in the Infusion Clinic at Munson Medical Center and I have a National Oncology

Certification. I have noticed some inconsistency with the usage of antiemetics amongst

physicians treating our cancer patients. Our Oncologists tend to rely on nursing or pharmacy to

catch/correct antiemetic errors. Because of the dynamic nature of cancer and chemotherapy

treatments, and the different Oncologists’ preferences for antiemetics, it is difficult for the nurse

to know if the antiemetic chosen is appropriate. There are times when the most appropriate

medication is missed and the patient suffers. I wanted to develop a way to promote patient

comfort by ensuring proper, consistent antiemetic usage and prevent chemotherapy-induced

nausea and vomiting. My research is from the most current antiemetic studies which I have

summarized.

My first research was a study performed by Warr and Oliver (2005) regarding

Neurokinin-1 (NK1) receptor antagonist (Aprepitant). Warr and Oliver’s (2005) study came from

randomized controlled trials, one systematic review, and one meta-analysis; and the funding

came from Cancer Care Ontario and Ontario Ministry of Health and Long-Term Care. The

subjects were > 16 years old, with a Karnofsky performance Index > 60, which meant that they

were at least able to perform normal activities without much assist and able to live at home

(Warr & Oliver, 2005). The subjects were stratified by gender, had solid tumors, and were to be

receiving high dose Cisplatin, a chemotherapy with a high emetogenic index ( Warr & Olviver,

2005). Differing doses of Aprepitant from 40 mg- 400 mg were compared, with 125 mg being

the most efficacious by showing a 90% receptor occupancy on day one of treatment ( Warr &

Oliver,2005). The five trials revealed a significant increase, 12.5 %-20 %, in complete protection

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from nausea and vomiting with Aprepitant ( Warr & Oliver, 2005 ).

Another study by Kris et al. (2006) published in the American Society of Clinical

Oncology analyzed antiemetic data found in the Medline Database and Cochrane Library.

Update committee members contributed articles and reviewed collected material on published,

randomized, controlled trials in phase II and III (Kris et al. 2006). The focus was on Aprepitant,

(Neurokinin-1 [NK1] receptor antagonists), 5-hydroxytryptamine(3) (5-HT3) receptor

antagonists and Dexamethasone in high-dose Cisplatin therapy (Kris et al. 2006). The study

defined chemotherapy emetic risks as High: 90% chance, Moderate: 30%-90%, Low: 10%-30%,

and Minimal: <10% (Kris et al. 2006). The study also gave recommendations for antiemetic

regimens based on the chemotherapy emetic potential. High: 5-HT3, Dexamethasone and

Aprepitant pre-chemo day 1, Aprepitant and Dexamethasone day 2 and day 3 (Kris et al. 2006).

Moderate: 5-HT3, Dexamethasone and Aprepitant day 1 and 5-HT3 or Dexamethasone day 2

and day 3 and Low: Dexamethasone pre, no delayed prevention routinely (Kris et al. 2006). Kris

et al. (2006) also noted that combination chemotherapy regimens require treating the highest

emetic risk and multiple-consecutive days of chemotherapy require treating the highest emetic

risk each day of therapy and 2 days post treatment. The study by Kris et al. (2006) did offer

one area of concern regarding the NK1 decreasing clearance of certain chemotherapies via

cytochrome P450 (CYP3A4), leading to potential toxicity, but stressed that there is not enough

evidence to support this at this time.

The third source of information is from the National Comprehensive Cancer Network

(NCCN) guidelines (2008) found at http://www.nccn.org, which, according to J. McGurn,PhD,

are the guidelines followed by our Oncology pharmacy (personal communication, October 29,

2008). The NCCN uses a multidisciplinary panel to review the latest treatments, support clinical

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trials, and update its guidelines with the most current and comprehensive information available

(NCCN, October 2008). For the purpose of this paper, I mention only the latest findings from

the website which are in addition to my research defined above. More information is available at

the website (http://www.nccn.org). According to the NCCN 2008 guidelines, a new FDA

approved drug for high and moderate emetogenic chemotherapy was introduced: Fosaprepitant

Dimeglumine 115 mg intraveneous administered over 15 minutes can replace Aprepitant 125 mg

orally on day 1 of treatment, followed by Aprepitant oral 80 mg day 2 and day 3. Careful

monitoring of drugs metabolized by cytochrome P450 and enzyme 3A4 (CYP3A4) is suggested

when using the drug Aprepitant because it can alter metabolism (NCCN,2008,MS-4). The

NCCN (2008) mention another drug Palnosetron, 5-HT3 antagonist with 100-fold higher binding

affinity compared to other 5-HT3, which has a half-life of approximately 40 hours and has

shown superiority in delayed emesis. The NCCN does state that further research is being

performed on safety of this drug, and I know that neither Palnosetron nor Fosaprepitant

Dimeglumine are in our hospital formulary as of yet (personal communication J.McGurn,

October 30, 2008). The rest of the antiemetic protocols are as my prior research showed.

How I conducted my research: I began in Medline Database under “antiemetics” and I

found several articles but I narrowed my search by choosing the most recent. I then called our

Oncology Pharmacist (J. McGurn) to find out what the current guidelines were for the hospital.

J.McGurn said that the pharmacists utilize http://www.nccn.org website then go under “Clinical

Practice Guidelines in Oncology”, then under “Guidelines for Supportive Care”, then under

“Antiemesis”, and finally “V.3.2008”. I compiled a list of the drugs currently on formulary, both

chemo and antiemetic, to comprise charts (Appendix A,B,C) which I placed in our medication

room in an “important information” folder. The charts define which of the drugs that we use in

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the clinic as High, Moderate or Low risk and have the appropriate antiemetic therapy available

below each category. I am hoping that this will be an easy reference tool to prevent antiemetic

errors. If a nurse finds a discrepancy she (all females in our clinic) is to alert the Oncology

Pharmacist who can then make a corrected order or refer the nurse to the appropriate Oncologist.

I am also going to send copies of the Appendix A-C to each of the Oncologists.

I hope to measure our success by keeping a check sheet with dates for each calendar

month and each of our Oncologists’ names, so that if a nurse finds an error in antiemetic that

requires correction by physician or pharmacist they mark the appropriate physician

corresponding with appropriate date of occurrence (Appendix D). Comparison studies for each

calendar month will be kept for reference.

Another measure (Appendix E) will be subjective information gathered from the patient.

The nurses are to record nausea and vomiting with a patient-defined number of severity: 1=mild

nausea, 2=Slight nausea/vomiting: interferes somewhat with activity, 3=Severe nausea/vomiting:

interferes greatly with activity, 4=Debilitating nausea/vomiting: unable to care for self. Patient

name sticker will be placed, which also has physician name, in the date correlating with

symptoms. This chart can be used in many ways, to monitor the physician, the patient, and the

chemotherapy for any patterns. The information can be utilized by the nurses, physicians and

pharmacists.

The nursing theory that I felt most related to my project was Kolcaba’s Theory of

Comfort, which according to Alligood and Tomey (2006), states that health care needs are needs

of comfort which can be measured by nursing interventions specific to the patient. According to

Herrstedt (2007), patients consider nausea and vomiting some of the worst side-effects of

chemo. Navari (2003) sites chemo-induced nausea and vomiting as a condition to “quality of

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life”. I feel that if nausea and vomiting can be controlled through consistent use of antiemetics

then patients’ healthcare needs of comfort will be better met.

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References

Alligood, M..R., & Tomey, A.M. (2006). Nursing theorists and their work (6th ed.). Missouri:

Mosby-Elsevier.

Food and Drug Administration. (2008, October). RX trials institute drug pipeline alert: AP

pharma gets mixed results. 6 (41). Retrieved October 23,2008, from

http://fdanews.com/newsletter/article?issueId=12025&articleId=111062

Herrstedt, J.(2007). Medical treatment of chemotherapy-induced nausea and vomiting. Ugeskr

Laeger,169 (9),799-805.

Kris, M.G.,Hesketh,P.J.,Somerfield,M.R.,Fever,P.,Clark- Snow,R.,Koeller,J.M.,et al. (update

2006). Guideline for antiemetics in oncology. American Society of Clinical Oncology,24

(18) 1-16.[110references].

National Comprehensive Cancer Network. (2008, February 5). Clinical practice guidelines in

oncology: guidelines for supportive care-antiemesis. (v.3 2008) [electronic version]

retrieved October 30,2008, from

http://www.nccn.org/professionals/physician_gls/PDF/antiemesis.pdf.

Navari,R.M.(2003).Pathogenesis-based treatment of chemotherapy-induced nausea and vomiting

—two new agents. Journal of Supportive Oncology, 1(2),89-103.

Warr,D.& Oliver,T. (2005). The role of neurokinin-1 receptor antagonists in the prevention of

emesis due to high-dose cisplatin. Cancer Care Ontario (2005, April 5).p.27 (Evidence-

based series no.12-4).[20 references].

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Appendix A

Antiemetic Chart

High Emetogenic: (90 % likelihood of emesis)

Adriamycin and Cytoxan

Cisplatin

Cytoxan >1500mg/m2

DTIC

Antiemetic regimen for highly emetogenic medications:

Aprepitant 125 mg PO day 1, 80mg PO day 2 and day3

OR

Fosaprepitant Dimeglumine 115mg IV day 1,

Aprepitant 80mg PO day 2 and day3

AND

Dexamethasone 12 mg PO/IV day1, 8 mg PO/IV days 2-4

AND

5-HT3 antagonist which include one of the following:

Ondansetron 16-24 mg PO or 8-12 mg (max. 32 mg) IV day 1 OR

Granisetron 2 mg PO or 1 mg PO BID or max 1mg IV day 1 OR

Palososetron 0.25 mg IV day 1 AND

prn. Lorazepam 0.5-2 mg PO/IV/SL every 4-6 hours days 1-4

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Appendix B

Antiemetic Chart

Moderate emetogenic: (30-90% frequency of emesis)

Amifostine >300mg/m2

Carboplatin

Cisplatin <50 mg/m2

Cytoxan < 1500mg/m2 or PO

Doxorubicin

Daunorubicin

Epirubicin

Etoposide

Idarubicin

Ifosfamide

Irinotecan

Methotrexate

Oxaliplatin >75mg/m2

Antiemetic regimen for moderately emetogenic chemotherapy:

Aprepitant 125 mg PO day 1, 80 mg PO day 2 and day 3 OR Fosaprepitant dimeglumine 115 mg

IV day 1 with Aprepitant 80 mg PO day 2 and day 3

Dexamethasone 12 mg PO/IV day 1, 8 mg PO/IV daily Or 4mg BID day 2-4

5-HT3 antagonist: Palonosetron 0.25 mg IV day 1 Or Granisetron 1-2mg PO or 1 mg PO BID

day 1Or Ondansetron 16-24 mg PO or max 32 mg/day IV

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5-HT3 can be added day 2 and day 3. Lorazepam 0.5 mg-2 mg PO/IV/SL every 4-6 prn

Appendix C

Antiemetic Chart

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Low Emetogenic: (10-30% frequency of emesis)

Amifostine < 300mg

Capecitabine

Cytarabine 100-2--mg/m2

Docetaxal

Doxorubicin (liposomal)

Etoposide

5-Flourouracil

Gemcitabine

Methotrexate 50-250mg/m2

Mitomycin

Mitoxantrone

Paclitaxel and Paclitaxel-albumin

Pemetrexed

Topotecan

Antiemetic regimen for low emetogenic chemotherapy

Dexamethasone 12 mg PO/IV daily OR

Prochlorperazine 10 mg PO/IV every 4-6hours OR

Diphenhydramine 25-50mg PO/IV every 4-6 hours OR

Lorazepam 0.5-2mg PO/IV every 4-6 hours if needed

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Dr. Gordon

Dr. Hughes

Dr. Kohler

Dr. Kosinski

Dr. Michelin

Dr. Ramsdell

Dr. Schwert

Oncology Providers Licensed to Practice at Munson/Appendix D

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Appendix E

Mon Tue Wed Thu Fri November 2008

Place patient identification

On the correct date with number

corresponding to

Severity of nausea and vomiting:

1=Mild Nausea

3 4 5 6 7

2=Slight Influence on Activity10 11 12 13 14

3=Very Activity Limiting Nausea and

Vomiting17 18 19 20 21

24 25 26 27 28 4=Debilitating Nausea and Vomiting

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