Is a comparison guide for common medications used for side-effect management, such as constipation, nausea, anxiety, etc. that includes a cost comparison available? —Name withheld on request
Nausea and vomiting is a common side effect of cancer treatment. Chemotherapy-induced nausea and vomiting (CINV) is a challenging side effect to manage, especially when patients are treated in the outpatient setting or CINV manifests as a late or anticipatory effect. The list below presents information on medications indicated for managing nausea and vomiting. This list is not all-inclusive; it does not include medications indicated for pregnancy-related nausea and vomiting or motion sickness. Future installments of this chart will present information on other side-effect management medications. —The editors
TABLE 1. Nausea and vomiting medications.
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| Product or generic (brand name) | Indication | Contraindications | Warnings/ Cautions |
Interactions | Adverse reactions |
Price (OTC or Rx) |
| aprepitant (Emend) | In combination with other antiemetic agents to prevent acute and delayed nausea and vomiting associated with initial and repeat courses of moderately to highly emetogenic cancer chemotherapy, including high-dose cisplatin
Prevention of post-op nausea and vomiting |
Concomitant pimozide, cisapride | Not for chronic continuous use
Severe hepatic insufficiency Pregnancy (Cat.B) Nursing mothers: not recommended |
See contraindications Monitor, and caution with, CYP3A4 substrates, including chemotherapy agents (eg, ifosfamide, vinblastine, vincristine); Potentiates dexamethasone (reduce dose by 50%), methylprednisolone (reduce IV dose by 25% and oral dose by 50%), midazolam, alprazolam, triazolam May antagonize warfarin (closely monitor INR for 2 weeks after starting each regimen); phenytoin, tolbutamide, other CYP2C9 substrates; paroxetine, oral contraceptives (use alternative or backup method during and for 1 month after last dose) |
Asthenia
Fatigue Hiccups ALT/AST Headache Constipation Anorexia GI upset Eructation Hypotenion Pruritus Pyrexia Injection site pain |
$$ (Rx) |
| dolasetron mesylate (Anzemet) | Prevention of nausea and vomiting associated with moderately emetogenic cancer chemotherapy, including initial and repeat courses | Injection solution administered by IV: This formulation is contraindicated for prevention of nausea and vomiting associated with cancer chemotherapy |
Increased risk of developing QTc, PR, and QRS interval prolongation
Avoid in patients with congenital QT syndrome, hypokalemia, hypomagnesemia, complete heart block, or risk of (unless paced) Correct electrolyte imbalances prior to therapy Monitor ECG periodically Congestive heart failure Bradycardia Pre-existing conduction abnormalities and underlying structural heart disease Sick sinus syndrome Atrial fibrillation with slow ventricular response Recent MI Renal impairment Elderly Pregnancy (Cat.B) Nursing mothers |
Caution with drugs
which can prolong ECG intervals (eg, verapamil, flecainide, quinidine), diuretics, and with cumulative high-dose anthracycline therapy Potentiated by cimetidine, atenolol (IV dolasetron) Antagonized by rifampin |
Headache
Dizziness Pain Fatigue Diarrhea Bradycardia Tachycardia Dsypepsia Chills/shivers ECG changes 2nd or |
$$$$ (Rx) |
| dronabinol (Marinol) | Refractory nausea and vomiting associated with cancer chemotherapy |
Seizure or cardiac disorders History ofpsychiatric Write script for smallest practical amount Keep patient under responsible adult supervision (especially when dose is adjusted) Children Elderly (minotor: especially with dementia) Pregnancy (Cat.C) Nursing mothers: not recommended |
Potentiates CNS depression with benzodiazepines, barbiturates, alcohol, other CNS depressants and other psychoactive substances (avoid)
May affect, or be affected by other drugs that are highly protein bound (eg, sympathomimetics, anticholinergics, tricyclic antidepressants) Antagonizes theophylline Phenothiazines may potentiate effect without additional toxicities |
Psychomimetic reactions Euphoria Depression Behavior disorders Drowsiness Dizziness Fatigue Somnolence Altered mental status Seizures Ataxia Anxiety Paresthesia Tachycardia Hypotension Vasodilation Tolerance and withdrawal syndrome |
$$$-$$$$ (Clll) | |
| droperidol | To reduce incidence of nausea and vomiting associated with surgical and diagnostic procedures | QT prolongation (including congenial long QT syndrome) |
Perform ECG prior to administration to determine if prolonged QT interval present; Risk factors for QT prolongation: CHF, bradycardia, cardiac hypertrophy, hypokalemia, hypomagnesemia, >65 y, alcohol abuse Pheochromocytoma Hepatic or renal impairment Elderly Debilitated Critically ill Labor and delivery: not recommended Pregnancy (Cat.C) Nursing mothers |
Risk of QT prolongation with concomitant Class I and III antiarrhythmics, MAOIs, antimalarials, calcium channel blockers, benzodiazepines, volatile anesthetics, IV opiates, other drugs that prolong QT interval Caution with drugs that induce hypokalemia, hypomagnesemia (eg, diuretics, laxatives) Additive effects with CNS depressants (eg, barbiturates, tranquilizers, opioids, general anesthetics) Possible hypertension with concomitant fentanyl citrate injection |
Hypoention Tachycardia Dysphoria Drowsiness Restlessness Hyperactivity Anxiety QT prolongation Torsade de pointes Cardiac arrest Ventricular tachycardia Neuroleptic malignant syndrome Post-op hallucinatory episodes |
$$ (Rx) |
| Emetrol | Nausea and vomiting |
Do not dilute or permit oral fluids immediately before or for 15 minutes after dosage Diabetes |
$ (OTC) | |||
| granisetron (Granisol, Sancuso) |
Prevention of nausea and vomiting associated with chemotherapy (including high-dose cisplatin) Prevention and treatment of post-op nausea and vomiting |
Abdominal surgery May mask progressive ileus and/or gastric distention Pre-existing arrhythmias or cardiac conduction disorders Cardiac disease, concomitant cardio-toxic chemotherapy or electrolyte abnormalities: increased risk of QT prolongation Pregnancy (Cat.B) Nursing mothers |
Caution with drugs that affect CYP450 or prolong the QT interval |
Headache Asthenia Diarrhea Constipation QT prolongation |
$$-$$$$ (Rx) | |
| nabilone (Cesamet | Treatment of nausea and vomiting associated with cancer chemotherapy in patients who have not responded adequately to other antiemetics |
Hypertension Heart disease History of psychiatric disorders (eg, bipolar disorder, depression, schizophrenia) or substance abuse Write script for limited quantity (ie, enough for one chemotherapy course) Keep patient under responsible adult supervision (especially when dose is adjusted) Renal or hepatic impairment Elderly Pregnancy (Cat.C) Nursing mothers: not recommended |
Potentiates CNS depression with benzodiazepines, barbiturates, alcohol, other CNS depressants and other psychoactive substances (avoid) May affect, or be affected by, other drugs that undergo first-pass hepatic metabolism or that are highly protein bound (eg, sympathomimetics, anticholinergics, tricyclic antidepressants) Cross-tolerance and mutual potentiation with opioids Naltrexone: see literature |
Drowsiness Vertigo Dry mouth Euphoria/dysphoria Ataxis Headache Tachycardia Hypotension Concentration difficulties Sleep disturbance Other psychiatric reactions (may persist for several days after dosing) Changes in appetite |
$$$$ (CII) | |
| ondansetron (Zofran, Zuplenz) |
Prevention of nausea and vomiting associated with highly emetogenic chemotherapy, including cisplatin ≥50 mg/m2 Prevention of nausea and vomiting associated with initial and repeat courses of moderately emetogenic chemotherapy Prevention of nausea and vomiting associated with radiotherapy in patients receiving total body irradiation, single high-dose fraction to the abdomen, or daily fractions to the abdomen Prevention of post-op nausea and vomiting |
Concomitant apomorphine |
Age <4 months (monitor closely) Not a substitute for nasogastric suction in gastric or intestinal peristalsis Congenital long QT syndrome: avoid Electrolyte abnormalities, CHF, bradyarrhythmias, concomitant drugs that prolong QT: monitor ECG May mask progressive ileus and/or gastric distention Hepatic dysfunction Pregnancy (Cat.B) Nursing mothers |
See contraindications Profound hypotension, loss of consciousness with apormorphine May antagonize tramadol |
Diarrhea Headache Fever Constipation Fatigue Transient blindness Rare: angina, bronchospasm, anaphylaxis, seizures, ECG changes (including QT prolongation) |
$$-$$$ (Rx) |
| palonosetron (Aloxi) |
Prevention of acute nausea and vomiting due to initial and repeat courses of emetogenic chemotherapy in adults Prevention of delayed nausea and vomiting due to initial and repeat courses of moderately emetogenic chemotherapy in adults Prevention of acute nausea and vomiting due to initial and repeat courses of emetogenic chemotherapy, including highly emetogenic cancer chemotherapy in children 1 month to <17 y Prevention of post-op nausea and vomiting for up to 24 h after surgery in adults |
Pregnancy (Cat.B) Nursing mothers: not recommended |
Headache Constipation Bradycardia QT prolongation Diarrhea Dizziness Tachycardia Hypotention |
$$$$ (Rx) | ||
| Perphenazine |
Severe nausea and vomiting Others: Psychosis |
Coma Concomitant large doses of CNS depressants Blood dyscrasias Bone marrow depression Liver damage Subcortical brain damage |
CNS depression Epilepsy Cardiovascular disease Respiratory disorders History of breast cancer Pheochromocytoma Avoid sun, exposure to extreme heat or phosphorus insecticides Surgery: consider lower anesthetic dose Monitor blood, hepatic, and renal function Write script for smallest practical amounts Reevaluate periodically Debilitated Elderly Pregnancy, nursing mothers: not recommended |
Potentiates CNS depression with alcohol, other CNS depressants Adjust anticonvulsant doses Additive anticholinergic effects with atropine or related drugs |
Tardive dyskinesia Drowsiness Jaundice Blood dyscrasias Hypotension ECG changes Retinopathy May mask emetic signs of disease Lowered seizure threshold Rash Skin pigmentation Anticholinergic effects Insomnia Adynamic ileus Hyperprolactinemia Extrapyramidal reactions Neuroleptic malignant syndrome |
$$$$ (Rx) |
| Prochlorperazine |
Severe nausea and vomiting Others: Anxiety/OCD, Psychosis |
Coma CNS depression Pediatric surgery Children <2 y or <20 lb |
Discontinue 48 h before to 24 h after myelography Cardiovascular disease Epilepsy Bone marrow depression Reye’s syndrome Glaucoma History of breast cancer Exposure to extreme heat Monitor blood, liver, and ocular function Write sript using fractions rather than decimals Children with acute illness or dehydration Debilitated Elderly Pregnancy, nursing mothers: not recommended |
Potentiates CNS depression with alcohol, other CNS depressants Potentiates a-blockers Levels of both drugs increased with propranolol May potentiate phenytoin; monitor for toxicity Adjust anticonvulsant doses May antagonize oral anticoagulants Hypotension potentiated with thiazide diuretics Antagonized by anticholinergics Decreases guanethidine effects Monitor for neurologic toxicity with lithium; discontinue if occurs May cause false (+) PKU test |
Drowsiness Dizziness Amenorrhea Blurred vision Other anticoholinergic effects Skin reactions Hypotension Cholestatic jaundice Photosensitivity Leukopenia Agranulocytosis Neuroleptic malignant syndrome Agitation Insomnia Dystonias Extrapyramidal reactions Pseudoparkinsonism Tardive dyskinesia May mask emetic signs of disease Lowered seizure threshold EKG changes Aspiration Deep sleep Hyperprolactinemia Paradoxical excitement in children |
$$ (Rx) |
| Promethazine |
Motion sickness Prevention and treatment of nausea and vomiting with anesthesia and surgery Others: Allergies, Nonnarcotic analgesics, Sleep-wake disorders |
Children <2 y Coma Intra-arterial or subcutaneous injection |
Sulfite sensitivity CNS depression Impaired respiratory function (eg, COPD, sleep apnea) Narrow-angle glaucoma GI or GU obstruction Cardiovascular or liver disease Seizure disorders Peptic ulcer Bone marrow depression Elderly Pregnancy (Cat.C) Labor and delivery Nursing mothers: not recommended |
Potentiates CNS depression with alcohol, other CNS depressants Caution with epinephrine, anticholinergics, MAOIs May alter hCG pregnancy test results and glucose tolerance tests |
Injection site reactions CNS depression/drawsinss Lowered seizure threshold Cholestatic jaundice Anticholinergic and extrapyramidal effects Neuroleptic malignant syndrome Photosensitivity Hypo- or hypertension Rash Blood dyscrasias Nausea Dry mouth Paradoxical reactions Children: respiratory depression (may be fatal) |
$$ (Rx) |
| Key: $, <$50; $$, $50-$99; $$$, $100-$199; $$$$, ≥$200; OTC, over-the-counter; Rx, prescription. Sources: OTC Prices were found via Internet search for the over-the-counter or consumer product. Prescription prices are from: Healthcare Bluebook. https://healthcarebluebook.com/page_Default.aspx. Accessed March 24, 2015. Indications, contraindications, warnings/cautions, interactions, and adverse effects information is from MPR Drug Database, accessed via MPR app. Accessed December 8, 2014. |
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To access Part 1 of this series, Comparison of constipation management medications, click here.
To access Part 3 of this series, Comparison of medications for managing anxiety, click here.
