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如何防治化疗所致的恶心呕吐?权威止吐指南来支招

2016-10-22 佚名 肿瘤时间

化疗所致恶心呕吐(CINV)是肿瘤治疗过程中常见的并发症之一,处理不当将对患者后续治疗及疾病转归造成严重影响。本文通过解读最新的国内外指南,阐述止吐药阿瑞匹坦预防 CINV 的新进展。顾名思义,化疗所致的恶心呕吐是因化疗药物导致的恶心呕吐反应。按照发生时间的不同,CINV 可分为 5 类:急性、延迟性、预期性、爆发性及难治性急性呕吐。急性呕吐发生在初次化疗后 24 小时以内,迟发型呕吐则在初次

化疗所致恶心呕吐(CINV)是肿瘤治疗过程中常见的并发症之一,处理不当将对患者后续治疗及疾病转归造成严重影响。本文通过解读最新的国内外指南,阐述止吐药阿瑞匹坦预防 CINV 的新进展。


顾名思义,化疗所致的恶心呕吐是因化疗药物导致的恶心呕吐反应。按照发生时间的不同,CINV 可分为 5 类:急性、延迟性、预期性、爆发性及难治性急性呕吐。急性呕吐发生在初次化疗后 24 小时以内,迟发型呕吐则在初次化疗后几天发生。以下主要讨论急性和延迟性 CINV 的防治。


止吐药的分类简介


1、多巴胺受体抑制剂,代表药物有甲氧氯普胺、多潘立酮,因其能够促进泌乳素分泌而不适用于乳腺癌患者。


2、NK-1 受体抑制剂,已经批准使用的药物有阿瑞匹坦,可用于急性呕吐和延迟性呕吐的预防。


3、5HT3 受体抑制剂(5HT3RA)包括昂丹司琼、格拉斯琼、托烷司琼、多拉司琼、雷莫司琼等。主要用于预防急性期呕吐。本类药物最突出的不良反应为便秘,应注意预防。帕洛诺司琼是一种新型的第 2 代 5HT3RA,与 5HT 有高亲和性,并能够抑制 P 物质,可用于延迟性呕吐的治疗。


此外,地塞米松具有强大的抗炎作用,主要防治延迟性呕吐,故指南推荐在多日化疗所致的 CINV 中应用至化疗结束后 2-3 天。


国内外最新指南推荐


表 1. 2016 MASCC/ESMO 指南


注:5HT3 RA,5-羟色胺受体拮抗剂;AC,蒽环类药物-环磷酰胺;DEX,地塞米松;

a 低度 风险 (10–30% 患者);中度 风险 (31–90% 患者);高度风险 (>90% 患者);

b 若患者第 1 天接受福沙匹坦 (或奈妥吡坦或罗拉匹坦) 治疗,则无需在第 2 或 3 天接受延迟期阿瑞匹坦或 DEX 治疗。


表 2. 2016 NCCN 止吐指南


注:5HT3 RA,5-羟色胺受体拮抗剂;DEX,地塞米松;

a 低度 风险 (10–30% 患者);中度 风险 (31–90% 患者);高度风险 (>90% 患者);

b 若患者第 1 天接受福沙匹坦或罗拉匹坦治疗,则无需在第 2 或 3 天接受延迟期阿瑞匹坦治疗。


表 3. 2015 ASCO 止吐指南


注:5HT3 RA,5-羟色胺受体拮抗剂; DEX,地塞米松;


表 4. 2014 中国肿瘤治疗相关呕吐防治指南


注:5HT3 RA,5-羟色胺受体拮抗剂; DEX,地塞米松; PPI,质子泵抑制剂。

a 低度 风险 (10–30% 患者);中度 风险 (31–90% 患者);高度风险 (>90% 患者);

b H2 受体拮抗剂或 PPI 选择性用于有胃部疾病的患者。


对症下药 因病施治


高度催吐药物的防治方案首选 NK-1 受体抑制剂+5HT3 受体抑制剂+地塞米松三联方案。中度催吐药物的防治,急性期应用 5HT3 受体抑制剂+地塞米松,延迟期可应用地塞米松。低度催吐方案可以选用单一药物进行防治。另外,轻微催吐方案未导致 CINV 者,不必常规应用止吐药物,出现恶心、呕吐者,根据具体情况予以镇吐治疗。


除上述针对性的止吐用药外,还可常规使用质子泵抑制剂、组胺受体拮抗剂等药物。此外,呕吐期间,还应注意防治电解质紊乱,保证液体及热量供应。部分患者虽无严重呕吐,但食欲低下,饮食量少,也应给予一定的营养支持。


CINV 对肿瘤患者的情感、社会和体力功能都会产生明显的负面影响,降低了患者的生活质量和对于治疗的依从性,且可能造成患者代谢紊乱、营养失调、体重减轻,增加患者对治疗的恐惧感,严重时不得不终止抗肿瘤治疗。因此临床工作中必须重视恶心、呕吐的防治,保障患者的生活质量和后续抗肿瘤治疗的顺利进行。


参考文献:

1. NCCN Clinical Practice Guidelines in Oncology: Antiemesis. Version 2.2016.

2. Herrstedt J, et al. 2016 Updated MASCC/ESMO Consensus Recommendations: Prevention of Nausea and Vomiting Following High Emetic Risk Chemotherapy[J]. Support Care Cancer. 2016 Jul 22.

3. Roila F, et al. 2016 updated MASCC/ESMO consensus recommendations: Prevention of nausea and vomiting following moderately emetogenic chemotherapy[J]. Support Care Cancer. 2016 Aug 11.

4. Hesketh PJ. Antiemetics: American Society of Clinical Oncology Focused Guideline Update[J]. Journal of clinical oncology. 2016(4):381-6.

5. 中国临床肿瘤学会抗肿瘤药物安全管理专家委员会中国抗癌协会癌症康复与姑息治疗专业委员会. 肿瘤治疗相关呕吐防治指南(2014 版)[J]. 临床肿瘤学杂志, 2014(3):263-273.

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  2. [GetPortalCommentsPageByObjectIdResponse(id=1774947, encodeId=04171e7494711, content=<a href='/topic/show?id=17135e073b5' target=_blank style='color:#2F92EE;'>#支招#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=89, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=57073, encryptionId=17135e073b5, topicName=支招)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c21738724507, createdName=psybestwish, createdTime=Sat Apr 22 07:15:00 CST 2017, time=2017-04-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=152771, encodeId=26f6152e71ad, content=好东东,学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=89, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160824/IMG57BDA6843F0F38922.jpg, createdBy=8fdd1925645, createdName=1e0b9de5m54(暂无匿称), createdTime=Tue Nov 01 22:25:22 CST 2016, time=2016-11-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=152029, encodeId=8a5f15202985, content=好好学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=86a2106217, createdName=oldzhao, createdTime=Sat Oct 29 18:15:20 CST 2016, time=2016-10-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1396547, encodeId=8095139654ea7, content=<a href='/topic/show?id=3497528842b' target=_blank style='color:#2F92EE;'>#恶心#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=52884, encryptionId=3497528842b, topicName=恶心)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4dfa37, createdName=智者为医08, createdTime=Mon Oct 24 14:15:00 CST 2016, time=2016-10-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1408399, encodeId=44c31408399d3, content=<a href='/topic/show?id=b2785288540' target=_blank style='color:#2F92EE;'>#恶心呕吐#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=52885, encryptionId=b2785288540, topicName=恶心呕吐)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=89b42741498, createdName=vividelife, createdTime=Mon Oct 24 14:15:00 CST 2016, time=2016-10-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=150826, encodeId=c25115082643, content=学习了,好东东, beContent=null, objectType=article, channel=null, level=null, likeNumber=88, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160824/IMG57BDA6843F0F38922.jpg, createdBy=8fdd1925645, createdName=1e0b9de5m54(暂无匿称), createdTime=Mon Oct 24 13:18:14 CST 2016, time=2016-10-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=150656, encodeId=2d941506560a, content=学习中, beContent=null, objectType=article, channel=null, level=null, likeNumber=111, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=bb011944781, createdName=紫色云龙, createdTime=Sun Oct 23 17:57:01 CST 2016, time=2016-10-23, status=1, ipAttribution=)]
    2016-11-01 1e0b9de5m54(暂无匿称)

    好东东,学习了

    0

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    2016-10-29 oldzhao

    好好学习

    0

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  5. [GetPortalCommentsPageByObjectIdResponse(id=1774947, encodeId=04171e7494711, content=<a href='/topic/show?id=17135e073b5' target=_blank style='color:#2F92EE;'>#支招#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=89, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=57073, encryptionId=17135e073b5, topicName=支招)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c21738724507, createdName=psybestwish, createdTime=Sat Apr 22 07:15:00 CST 2017, time=2017-04-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=152771, encodeId=26f6152e71ad, content=好东东,学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=89, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160824/IMG57BDA6843F0F38922.jpg, createdBy=8fdd1925645, createdName=1e0b9de5m54(暂无匿称), createdTime=Tue Nov 01 22:25:22 CST 2016, time=2016-11-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=152029, encodeId=8a5f15202985, content=好好学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=86a2106217, createdName=oldzhao, createdTime=Sat Oct 29 18:15:20 CST 2016, time=2016-10-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1396547, encodeId=8095139654ea7, content=<a href='/topic/show?id=3497528842b' target=_blank style='color:#2F92EE;'>#恶心#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=52884, encryptionId=3497528842b, topicName=恶心)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4dfa37, createdName=智者为医08, createdTime=Mon Oct 24 14:15:00 CST 2016, time=2016-10-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1408399, encodeId=44c31408399d3, content=<a href='/topic/show?id=b2785288540' target=_blank style='color:#2F92EE;'>#恶心呕吐#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=52885, encryptionId=b2785288540, topicName=恶心呕吐)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=89b42741498, createdName=vividelife, createdTime=Mon Oct 24 14:15:00 CST 2016, time=2016-10-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=150826, encodeId=c25115082643, content=学习了,好东东, beContent=null, objectType=article, channel=null, level=null, likeNumber=88, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160824/IMG57BDA6843F0F38922.jpg, createdBy=8fdd1925645, createdName=1e0b9de5m54(暂无匿称), createdTime=Mon Oct 24 13:18:14 CST 2016, time=2016-10-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=150656, encodeId=2d941506560a, content=学习中, beContent=null, objectType=article, channel=null, level=null, likeNumber=111, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=bb011944781, createdName=紫色云龙, createdTime=Sun Oct 23 17:57:01 CST 2016, time=2016-10-23, status=1, ipAttribution=)]
  6. [GetPortalCommentsPageByObjectIdResponse(id=1774947, encodeId=04171e7494711, content=<a href='/topic/show?id=17135e073b5' target=_blank style='color:#2F92EE;'>#支招#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=89, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=57073, encryptionId=17135e073b5, topicName=支招)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c21738724507, createdName=psybestwish, createdTime=Sat Apr 22 07:15:00 CST 2017, time=2017-04-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=152771, encodeId=26f6152e71ad, content=好东东,学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=89, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160824/IMG57BDA6843F0F38922.jpg, createdBy=8fdd1925645, createdName=1e0b9de5m54(暂无匿称), createdTime=Tue Nov 01 22:25:22 CST 2016, time=2016-11-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=152029, encodeId=8a5f15202985, content=好好学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=86a2106217, createdName=oldzhao, createdTime=Sat Oct 29 18:15:20 CST 2016, time=2016-10-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1396547, encodeId=8095139654ea7, content=<a href='/topic/show?id=3497528842b' target=_blank style='color:#2F92EE;'>#恶心#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=52884, encryptionId=3497528842b, topicName=恶心)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4dfa37, createdName=智者为医08, createdTime=Mon Oct 24 14:15:00 CST 2016, time=2016-10-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1408399, encodeId=44c31408399d3, content=<a href='/topic/show?id=b2785288540' target=_blank style='color:#2F92EE;'>#恶心呕吐#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=52885, encryptionId=b2785288540, topicName=恶心呕吐)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=89b42741498, createdName=vividelife, createdTime=Mon Oct 24 14:15:00 CST 2016, time=2016-10-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=150826, encodeId=c25115082643, content=学习了,好东东, beContent=null, objectType=article, channel=null, level=null, likeNumber=88, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160824/IMG57BDA6843F0F38922.jpg, createdBy=8fdd1925645, createdName=1e0b9de5m54(暂无匿称), createdTime=Mon Oct 24 13:18:14 CST 2016, time=2016-10-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=150656, encodeId=2d941506560a, content=学习中, beContent=null, objectType=article, channel=null, level=null, likeNumber=111, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=bb011944781, createdName=紫色云龙, createdTime=Sun Oct 23 17:57:01 CST 2016, time=2016-10-23, status=1, ipAttribution=)]
    2016-10-24 1e0b9de5m54(暂无匿称)

    学习了,好东东

    0

  7. [GetPortalCommentsPageByObjectIdResponse(id=1774947, encodeId=04171e7494711, content=<a href='/topic/show?id=17135e073b5' target=_blank style='color:#2F92EE;'>#支招#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=89, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=57073, encryptionId=17135e073b5, topicName=支招)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c21738724507, createdName=psybestwish, createdTime=Sat Apr 22 07:15:00 CST 2017, time=2017-04-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=152771, encodeId=26f6152e71ad, content=好东东,学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=89, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160824/IMG57BDA6843F0F38922.jpg, createdBy=8fdd1925645, createdName=1e0b9de5m54(暂无匿称), createdTime=Tue Nov 01 22:25:22 CST 2016, time=2016-11-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=152029, encodeId=8a5f15202985, content=好好学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=86a2106217, createdName=oldzhao, createdTime=Sat Oct 29 18:15:20 CST 2016, time=2016-10-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1396547, encodeId=8095139654ea7, content=<a href='/topic/show?id=3497528842b' target=_blank style='color:#2F92EE;'>#恶心#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=52884, encryptionId=3497528842b, topicName=恶心)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4dfa37, createdName=智者为医08, createdTime=Mon Oct 24 14:15:00 CST 2016, time=2016-10-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1408399, encodeId=44c31408399d3, content=<a href='/topic/show?id=b2785288540' target=_blank style='color:#2F92EE;'>#恶心呕吐#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=52885, encryptionId=b2785288540, topicName=恶心呕吐)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=89b42741498, createdName=vividelife, createdTime=Mon Oct 24 14:15:00 CST 2016, time=2016-10-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=150826, encodeId=c25115082643, content=学习了,好东东, beContent=null, objectType=article, channel=null, level=null, likeNumber=88, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160824/IMG57BDA6843F0F38922.jpg, createdBy=8fdd1925645, createdName=1e0b9de5m54(暂无匿称), createdTime=Mon Oct 24 13:18:14 CST 2016, time=2016-10-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=150656, encodeId=2d941506560a, content=学习中, beContent=null, objectType=article, channel=null, level=null, likeNumber=111, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=bb011944781, createdName=紫色云龙, createdTime=Sun Oct 23 17:57:01 CST 2016, time=2016-10-23, status=1, ipAttribution=)]
    2016-10-23 紫色云龙

    学习中

    0

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