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PREMEDIKASI DAN CINV

(CHEMOTHERAPY INDUCED NAUSEA AND VOMITING )

Drs. Muhammad Yahya., Sp.FRS, Apt.

 Premedikasi pada kemoterapi
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Premidikasi : obat yang diberikan 30-60 menit

sebelum kemoterapi obat
Pemedikasi untuk Hypersensitivitas

Premedikasi untuk mula muntah

Premedikasi hidrasi

Premedikasi untuk diarrhea (irinotecan)

 Atropine 0,2 mg sc atau iv

 Premedikasi
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Antimuntah ;
 5-HT3 receptor antagonist ; ondancetron
 Motlity agent ; metoclopramid, donperidon
 Corticosteroid ; Dexamethason

Hipersensitivitas
 Dexamethason ; Diphenhidramin ; Ranitidin
 Premedikasi untuk HRS (Hypersensitivity
reactions)
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 45 minutes before paclitaxel, dexamethasone 20

mg IV
 30 minutes before paclitaxel, diphenhydramine 50
mg IV and ranitidine 50 mg IV.
 Hydration Regimen for Adults
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 Contoh
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Ny My TB = 155 ; 56 ; Umur = 48 th Sc = 1,2 di terpi dengan Cisplatin 50

mg/m2 dlm 500 ml
 Bagai mana cara p[enyiapan sedian Csplatin
 Bagaimana cara melakukan hidrasinya
Jawab :
 BSA = 1,55
 IMT = 23,31
 GFR = 50,69 jika GFR <30 maka lihat penyesuaian dosis
 Dosis = 50 x 1,55 = 77,5 mg dilarut dlm NS berapa Lihat preparation
stabiltas
P
A
T
H
O

P
H
Y
S
I
O
L
O
G
Y7 7
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 The physiologic mechanism for
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CINV
 Chemotherapy stimulates the Chemoreceptor Trigger Zone
(CTZ) directly.
 Chemotherapy stimulates enterochromaffin cells in the GI
tract to release serotonin.
 Serotonin activates 5-HT3 receptors in 3 areas: vagal afferents
in the GI tract, Nucleus Tractus Solitarius (NTS), and the CTZ
 Dopamine-2, histamine, and neurokinin-1 receptors are
stimulated.
 Impulses feed into the VC.
 When a threshold is reached in the VC, nerve impulses are
carried by efferent nerves to stimulate emesis.
 TWO PHASE of CINV
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 Acute phase
occure in first 24 hour and is mediated by release
of serotonin from enterochromaffin cells within GI
tract

 Deleyed phase
- occure during 24 hour periode post
chemoterapy until 72 hour
- Including cisplatin, carboplatin, cyclophosphamid,
and antracyclines (eq. doxorubicine, epirubicin)
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 CINV (Chemotherapy-Induced Nausea andVomiting)

Level 4

Level 3
Level 2

Level 1
 Asses the Emetognicity
of the combination
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 Level 1 agents do not contribute to the

emetogenicity of a given regimen.

 Adding one or more level 2 agents increases

emetogenicity of the combination by one level
greater than the most emetogenic agent in the
combination.

 Adding level 3 and 4 agents increases

emetogenicity of thecombination by one level per
agent.
 Contoh
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A B C Lmual muntah
Level 1 Level 2 Level 3 Kombinasi ?

A B C D Mual muntah
Level 2 Level 2 Level 3 Level 3 Kombinasi ?

A B C D Mual muntah
Level 2 Level 2 Level 3 Level 4 ombinasi ?

DOXOrubicin 60 mg/m2 (H1) + cyclophosphamide 600 mg (H1)  Mual muntah kombinasi ?

DOXOrubicin 50 mg (H1)+ cyclophosphamide 500 mg (H1) + DOCEtaxel 75 mg : (H1)  Mual

muntah kombinasi ?

Fluorouracil 500 mg (H1) + Epirubicin 100 mg (H1) + Cyclophophamide 500 mg (H1)  Mual
muntah kombinasi ?
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 Antiemetic Regimen for prophylaxis of CINV

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Acut Nausea Vomoting
(first 24 hours)
Emetic potensial : High Frequency of emesis >90%
5-HT3 antagonist corticosteroid
aprepitant (all given as single doses
30–60 minutes prior to chemotherapy)
Deleyed Nausea/Vomiting
(day 2-5)
Aprepitant + corticosteroid
Di Soetomo : Ondancetron 2x8 mg tab
Metochopramid 3x10 mg Tab
Dexamethason 3x0,5 mg tab

Emetic potensial : Moderate Frequency of emesis 30–60%

5- HT3 antagonist corticosteroid Aprepitant (if aprepitant is
aprepitant (all given as single doses used for acute prophylaxis)
30–60 minutes prior to chemotherapy or
Corticosteroid
or
5-HT3 antagonist
 Antiemetic Regimen for prophylaxis of CINV
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Acut Nausea Vomoting Deleyed Nausea/Vomiting
(first 24 hours) (day 2-5)

Emetic potensial : Low Frequency of emesis 10–30%

Corticosteroid (a single dose Not necessary
30 minutes prior to chemotherapy
or
Dopaminergic antagonist (a single dose
30 minutes prior to chemotherapy)
Note: Antiemetic prophylaxis may often
be unnecessary
Emetic potensial : Minimal Frequency of emesis <10%
Antiemetic prophylaxis is usually not Not necessary
Necessary
 Dosing Recommendation for CINV Prophylaxi (Adults)
for Moderate to Highly Emetic Chemotherapy (level 3–
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5) Acut CINV Prophylaxis (day 1) Deleyed CINV Tablet/Caps
(single dose given 30 minutes Prophylaxis Size for Oral
before chemotherapy) (days 2-5) Administration
Agent Oral (po) Intravenous (iv)

5HT3 Receptor Antagoists

Dolasetron 100-200 mg po 100 mg or 1.8 100-200 mg po 50 mg, 100 mg
mg/kg IV daily x 2-4 days
Granisetron 2 mg po 10 mg/kg IV 1 mg po twice 1 mg
daily x 2-4 days
Ondansetron 24 mg po 8 mg or 0,15 8 mg po twice 4, 8 mg
mg/kg iv daily x 2-4 days

Palanosetron NA 0,25 mg iv NA
Because of its extended half-life palonosetron should be given only on day 1, Repeat doses
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Acut CINV Prophylaxis (day 1) Deleyed CINV Tablet/Caps
(single dose given 30 minutes Prophylaxis Size for Oral
before chemotherapy) (days 2-5) Administration
Agent Oral (PO) Intravenous (IV)

Subtituted Benzamid
Metoclopramid NA Prechemotherap 20-40 mg (or 5, 10 mg
y 2-3 mg/kg IV, 0.5 mg/kg) PO 4
then every 2-4 times daily x 2-
hours 4 days
Metoclopramide is not first-line agent for acute CINV prophylaxis and should be reserved
for refractory patients. Multiple-dose regimen are required and concomitant use of
diphenhydramine or benztropine or required to prevent extrapyramidal side effects
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