Treatment Algorithm for Nausea and Vomiting in the Palliative Phase
Treatment Algorithm for Nausea and Vomiting in the Palliative Phase
Nausea and vomiting are frequently occurring problems in the palliative phase of patients
 with cancer. Between 20-50% of them regularly suffer from nausea, retching or vomiting. Often
 the cause of nausea and vomiting is multifactorial and symptomatic treatment is necessary.

 Potential drugs for symptomatic anti-nausea therapy are metoclopramide, serotonin
 antagonists, the combination of both and dexamethasone as rescue medication in case of
 failure. There is no data that depicts which strategy is the best. This study will be
 conducted to unravel which treatment algorithm is most successful.
Nausea and vomiting are frequently occurring problems in the palliative phase of patients
 with cancer. Between 20-50% of them regularly suffer from nausea, retching or vomiting. Often
 the cause of nausea and vomiting is multifactorial and symptomatic treatment is necessary.

 Potential drugs for symptomatic anti-nausea therapy are metoclopramide, serotonin
 antagonists, the combination of both and dexamethasone as rescue medication in case of
 failure. There is no data that depicts which strategy is the best. This study will be
 conducted to unravel which treatment algorithm is most successful: 1 to start with
 metoclopramide, to add a serotonin antagonist (granisetron transdermal patch and 2 milligram
 granisetron oral loading dose if the patient can swallow) in case of failure and to add
 dexamethasone as rescue medication versus 2 an algorithm to start with a serotonin antagonist
 (granisetron transdermal patch and 2 milligram granisetron oral loading dose if the patient
 can swallow), to add metoclopramide in case of failure and to add dexamethasone as rescue
 medication. Granisetron plaster is a new formulation of a well known serotonin antagonist and
 might be useful especially within the patient group in the palliative phase.

 The questions are:

 Is it feasible to compare treatment algorithms for symptomatic treatment of nausea and
 vomiting in palliative cancer patients? And is a stepwise symptomatic treatment algorithm to
 manage nausea and vomiting using metoclopramide or granisetron transdermal patch as a start
 medication effective in palliative patients in at least one of both treatment arms? Patients
 will be asked to complete the QLQC30 and ESAS on different moments during the study. Besides,
 they will be asked to complete a diary for nausea severity (NRS scale 0-10) and for the
 frequency of vomiting and retching twice daily.

 Success of a treatment algorithm is defined as nausea is < 3 on NRS or a decrease of >2 on
 NRS for nausea combined with an absence of vomiting or retching in the last 3 days.
 Incomplete success is defined as nausea of 3 on NRS during one occasion of the last 3 days
 before the end of study but less than 4, no more than one retching a day during that period
 and absence of vomiting. Complete failure is defined as nausea of 4 or more on an NRS during
 the last 3 days or more than one retching daily or any vomiting or in case the patient has
 stopped all medication due to side effects.
Inclusion Criteria:

 -  patients 18 years or older in the palliative phase and

 -  who suffer from nausea or vomiting with a rating on a numeric rating scale (NRS) of
 more than 2 and

 -  have a wish to be treated and

 -  where no treatable cause is assignable

 Exclusion Criteria:

 -  Patients not able to sign informed consent.

 -  Patients with known contra-indications for metoclopramide, 5HT-3 antagonists or
 dexamethasone.