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Chemotherapy-Induced Nausea and Vomiting (CINV): A Comprehensive Management Guide

Understanding the mechanisms of emetics and prevention strategies: a comprehensive approach to relief tailored for Hong Kong patients.

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Chemotherapy-induced nausea and vomiting (CINV) is one of the most feared side effects among cancer patients. It not only disrupts daily life and diet but can also undermine the will to fight cancer, potentially reducing treatment adherence and outcomes. Clinical data indicate that the severity and type of CINV depend on the emetogenic potential of different chemotherapy regimens, categorized as high, moderate, low, or minimal risk, each requiring distinct preventive strategies and drug combinations (NCCN, Wikipedia).

Introduction

Pathophysiology and Risk Factors

Mechanisms
Chemotherapy drugs can stimulate enterochromaffin cells in the gastrointestinal tract to release serotonin (5-HT). This activates the vagus nerve, transmitting signals to the medullary vomiting center, triggering acute vomiting. Delayed vomiting, on the other hand, is associated with Substance P and the NK₁ receptor, typically occurring 24 hours to 3–4 days after administration (Wikipedia).

Risk Classification and Patient Factors
Chemotherapy agents are categorized by emetogenic risk (high to minimal). Patient-related risk factors include anticipatory anxiety, female sex, younger age, limited history of alcohol consumption, history of motion sickness, and nausea/vomiting during pregnancy (Wikipedia).

Pharmacological Prevention and Management

Emetogenic Risk Category
Management Strategy
High-Risk Regimens
(e.g., Cisplatin)
Employ a "triple prophylaxis" approach: 5-HT₃ receptor antagonists (e.g., ondansetron, palonosetron) + NK₁ receptor antagonists (e.g., aprepitant, rolapitant) + corticosteroids, effectively reducing both acute and delayed vomiting.
Switch to "dual prophylaxis" (NK₁ + corticosteroid) 2–4 days post-treatment.
Wikipedia, NWC Cancer Network
Moderate-Risk Regimens
(e.g., Doxorubicin Alone)
Administer 5-HT₃ antagonist + corticosteroid 30–60 minutes before chemotherapy, followed by corticosteroid continuation for 2–3 days.
Pinkbook, SpringerLink, NWC Cancer Network
Low / Minimal-Risk Regimens
Low-risk agents (e.g., Paclitaxel): single-agent prophylaxis before chemotherapy is sufficient.
Minimal-risk agents (e.g., Vincristine): routine prophylaxis is generally not required.
NCCN, Wikipedia

Supportive and Integrative Approaches

Ginger
Several randomized controlled trials (RCTs) and meta-analyses show that ginger supplementation (≤1 g/day) can significantly reduce acute vomiting. However, its effects on nausea and delayed vomiting remain inconsistent, warranting larger studies. Ginger may be considered as an adjunctive option.

Diet and Nutrition Management

  • Eat small, frequent meals.
  • Avoid greasy or sugary foods.
  • Start with dry foods (e.g., toast, bananas).
  • Separate solid foods from liquids; drink fluids with lemon or passionfruit for better tolerance.
  • Avoid large amounts of fluid right before or after meals.

Other supportive measures

  • Traditional remedies such as ginger tea or sour plum drinks may ease nausea.
  • Acupressure wristbands stimulating the P6 (Neiguan) acupoint may help reduce vomiting.
  • Avoid strong odors or irritants.
  • Light physical activity such as walking can improve tolerance.
  • Mindfulness and meditation can lower anxiety, which contributes to nausea.

Practical Recommendations for Patients in Hong Kong

  1. Pre-treatment education and expectation setting
    Patients should be informed about different CINV types and preventive strategies, emphasizing proactive management to reduce treatment interruption.

  2. Tiered prevention strategies
    High- and moderate-risk regimens should always follow standard “triple” or “dual” protection protocols, ensuring proper timing and dosage.

  3. Incorporating adjunctive measures
    Add ginger supplementation, dietary adjustments, lifestyle modifications, and acupressure wristbands as supportive strategies.

  4. Close monitoring and individual adjustments
    Breakthrough or frequent vomiting requires contacting the healthcare team promptly to adjust antiemetic therapy or investigate other potential causes (e.g., bowel obstruction, brain metastases).

Conclusion

Although chemotherapy-induced nausea and vomiting can be highly distressing, standardized pharmacological prevention combined with supportive nutritional and lifestyle strategies, along with early patient education, can greatly improve treatment adherence and quality of life. For patients in Hong Kong, an integrated, patient-centered support system is key to ensuring that side effects do not become obstacles to effective cancer therapy.

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References

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