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I. Nausea and Vomiting
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Chemotherapy Table of Contents
Nausea and vomiting are common side effects of chemotherapy drugs that are used to treat cancer. Some chemotherapy drugs are worse offenders than others are. In almost cases, patients will be given anti-vomiting (antiemetics) and anti-nausea medication prior to the administration of chemotherapy. Some of the commonly used antiemetics are listed in the chart below. As you can see, these drugs may also have some side effects of their own. Several antiemetics are available by prescription for use at home in the event that nausea or vomiting are persistent.
| Drug Name | Usual Dose | Side Effects | Cost |
| Compazine (prochlorperazine) | 10 mg orally every 8 hours as needed | Sleepiness, dystonic reactions, lockjaw | $0.20/tablet |
| Lorazepam (Ativan) | 0.5 to 1 mg orally every 4 to 6 hrs as needed | Sleepiness, confusion | $0.50/1 mg tablet |
| Ondansetron (Zofran) | 4 to 8 mg orally 2 to 3 times daily | Headache, constipation | $15.00/8 mg tablet |
| Granisetron (Kytril) | 1 mg orally twice a day or 2 mg once daily | Headache, constipation | $35.00/1 mg tablet |
| Dolasetron (Anzemet) | 100 mg orally once daily | Headache, constipation | $20.00/100 mg tablet |
| Dronabinol (Marinol) | 2.5 to 5 mg orally four times daily | Sleepiness, appetite stimulation, confusion | $1.00/tablet |
| Dexamethasone | 4 to 8 mg orally twice daily with meals | Insomnia, stomach upset | $0.50/tablet |
| Metoclopramide (Reglan) | 10 to 20 mg orally four times daily | Diarrhea, anxiety, sleepiness | $0.60/tablet |
Delayed nausea and vomiting can occur after cisplatin, carboplatin, and cyclophosphamide chemotherapy. The most effective antinausea medications for delayed nausea and vomiting are Reglan and dexamethasone. However, these drugs have more side effects than the "setrons" (ondansetron, granisetron, and dolasetron). A setron should be used after Reglan and dexamethasone has been tried. If effective a setron may be used as a preventative therapy during the next cycle of chemotherapy.
II. Mouth Sores
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The mouth and digestive tract are composed of cells (mucosa) that are more sensitive to chemotherapy. Thus, during or after chemotherapy or radiation therapy, a cancer patient may present with some sort of mouth problem, ranging from dryness to ulcers. These mouth problems may be related to the cancer itself, but more are often due to chemotherapy or other medication. Three to ten days following chemotherapy, patients may experience a burning sensation, followed by ulcers. When ulceration develops, treatment is mostly supportive until the cells regenerate themselves, which takes about 7 to 14 days. This can impact on oral comfort and nutrition, but adequate care can minimize these effects.
Prevention Basic mouth hygiene is of primary importance, and should be initiated before chemotherapy starts. Patients should brush their teeth 3 to 4 times a day with a soft toothbrush or sponge and use floss. Patients at high risk (those receiving 5-FU or methotrexate) should rinse their mouth frequently with salt water, baking soda or chlorhexidine following chemotherapy.
Treatment. Once mouth sores developed, analgesics and anesthetics can be employed. Xylocaine is a local anesthetic available as a gel or spray used to decrease pain, but has a short duration of action. It should not be used prior to meals, as it can cause choking. Protective agents (sucralfate, kaopectate) are also used to cover ulcers and decrease irritation. It is important to stay away from irritant substances like peroxide as they way worsen the ulcers. Topical steroids should not be used as they may facilitate infections. In addition, patients should not eat spicy, hot, acidic or coarse foods or juice. Preference should be put on soft moist foods.
| Drug name | Usual dose | Side Effects | Cost |
| Saline mouthwash | 10-30 mL swish and swallow every 2 to 6 hours | Few | None |
| Baking soda mouthwash | 1/2 tsp. salt plus 1/2 tsp. baking soda in a cup of warm water, rinse every 3 or 4 hours | Few | None |
| Chlorhexidine (Peridex) | Rinse every 4 hours | Taste, color, teeth staining | $ |
| Betadine mouthwash | Diluted with water 50-50 10 cc 3 times a day and as needed applied locally or swish | Iodine allergy, color, teeth staining | $ |
| Xylocaine | GEL: 5 to 15 mL every 4 hours SPRAY: 1 spray every 4 hours | Possible systemic effect Choking if taken before meals | $$ |
| Sucralfate or kaopectate | 10 to 30 mL every 2 to 6 hours, swish and spit | Taste | $$ |
Damage to the mucosa can facilitate some infections, such as candida or herpes simplex virus infections. Appropriate treatment should be started. Thrush can be treated with topical antifungals, such as clotrimazole or nystatin. When infection is more severe, oral ketoconazole, fluconazole, or intravenous amphotericin may be used.
| Drug Name | Usual dose | Side effects | Cost |
| Clotrimazole troches (Mycelex) | Place troche in mouth 4 to 5 times a day, for 7 to 14 days | Well tolerated, taste | $$ |
| Nystatin suspension | 1 teaspoonful every 4 to 6 hours, swish and swallow | Well tolerated, irritation | $$ |
| Fluconazole (Diflucan) | 100mg every day | Nausea, vomiting, itching | $$$ |
| Amphotericin B | Intravenous dose varies | Headache, fever, chills. | $$ |
| Amphotericin B mouthwash | 10mg swish and swallow every day | Taste | $$$ |
Dry mouth (xerostomia) can occur in certain patients and can be easily treated with drinking fluids, sodas, sucking ice chips, eating fresh fruits or chewing gum. Preparation containing alcohol or glycerin should not be used because they may irritate or aggravate dryness. Artificial saliva (MoiStir, Artisial) is commercially available and can be useful in some patients. Dryness should not be overlooked, as it may predispose to ulcers and infections.
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