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CHAPTER 5: Coping with Nausea

Of the possible side effects of cancer treatments, people often say they dread feeling nauseated and vomiting the most. They may have known someone who received chemotherapy or radiation therapy and who suffered severe nausea without effective antinausea medication. Or, they may recall times during their own lives when they were nauseated and remember how debilitating it was.

      It's a misconception that people who receive cancer-fighting treatments such as chemotherapy and radiation therapy suffer continuous, unrelieved nausea and vomiting. First, it is important to remember that not all cancer-fighting treatments cause severe nausea. Some may cause mild nausea or no nausea at all. Second, nausea caused by chemotherapy or radiation therapy usually lasts for a limited amount of time (from two to forty-eight hours for most chemotherapy drugs, or for a few hours after radiation). Third, extensive research has led to the development of new medications that can prevent or relieve the nausea associated with cancer treatments.

What Causes Nausea?
The feeling of nausea and the act of vomiting are not really caused by your stomach. There is actually an area in your brain that, when stimulated, causes these feelings. It is called the chemo-receptor trigger zone (CTZ), and it lies in the center of your brain. This area may be stimulated by a number of different events. The CTZ may be simulated by a feeling of fullness in your stomach (from too much pizza and beer, for example), or it may be stimulated by dizziness (sea sickness or motion sickness). Certain sights, smells, or thoughts may cause nausea as well. Some people may feel nauseated and even vomit from anxiety, fear, stage fright, the sight of blood, unpleasant smells, or the thought of getting an injection.

Nausea and Chemotherapy
The CTZ is sensitive to the chemicals in your body. Some chemotherapy drugs make your body release other chemicals, such as dopamine or seratonin, which can stimulate the CTZ. Every chemotherapy drug has been rated as to its emetic potential - the chances that it will cause you to feel nauseated or to vomit. Some drugs rarely cause nausea (meaning that less than 30 percent of people taking the drug feel that symptom). Some are considered only moderately nauseating. And then there are drugs that are very likely to make you feel nauseated, meaning that 90 percent of the people report the symptom. So, right from the beginning, your doctor can tell you if nausea is likely to be a problem.

      Another factor that may determine how nauseated you feel is the dose. A chemotherapy drug may not cause nausea at a low dose, but it may cause the problem at higher doses or when given in combination with other more nauseating drugs.

Nausea and Radiation Therapy
Nausea can be a problem if radiation therapy is directed to your digestive system. Sometimes the radiation is not directly focused on the digestive system, but it may be exposed to radiation if other nearby structures are being radiated. For instance, radiation to lymph nodes in the abdomen can cause nausea when the stomach or intestines come within the radiation field. Nausea can also be a problem when radiation treatments cause a decrease in the normal amount of stomach secretions, or change how the small intestines absorb fluids. The CTZ can also be stimulated by waste products (created by the destruction of tumor cells), or more directly, when the brain itself is radiated.

      There are always individual differences in how people react to any treatment. Some people are just more likely to feel nauseated, just as there are some people who are more likely to suffer morning sickness or motion sickness. Your doctor may try to predict how much of a problem nausea will be, but you may be less or more nauseated than expected. The key is to work with your doctor and nurse to determine the type and the amount of antinausea medication you need to prevent or minimize the problem.

Types of Antinausea Medicines and How They Work
The stimulus that triggers nausea can come from different places in your body - from the stomach, the inner ear, even from sensations and thoughts, as well as from chemicals or radiation. To prevent or relieve nausea, different drugs work in different ways. Some drugs prevent nausea by blocking the body's release of histamine, dopamine, or serotonin, so that the CTZ will not be stimulated. Some drugs speed up the stomach and intestines to make the stomach empty quickly so that there is less fullness to stimulate the CTZ. Some drugs block or neutralize stomach acids. Other medications help you relax and even sleep through the period of time when you are most likely to feel nauseated.

      Keep in mind that whether or not you become nauseated from chemotherapy or radiation does not indicate if the treatments are working. And when you get medications to prevent or relieve the nausea, it does not make the treatments less effective.

      The following group of drugs is commonly used to prevent nausea during chemotherapy and radiation treatments. The generic name is given first, followed by the brand name(s) that may be more familiar to you. Next comes a general discussion of how the drug works, and some side effects to watch out for.

      Prochlorperazine (Compazine®). This drug has been the mainstay of antinausea treatment for over thirty years. It acts in the CTZ by blocking dopamine receptors. Dopamine is released by the body in response to some chemotherapy drugs and can cause nausea. Compazine can be used alone for preventing nausea when you are getting mildly nauseating chemotherapy or radiation treatments. It is available in many forms, including a pill, a long-acting capsule, a rectal suppository, an injection in the muscle, or by IV.

      Side effects to watch for are drowsiness (don't drive) and low blood pressure (usually only a problem if given by IV). Compazine may also cause an uncomfortable jittery feeling or restlessness. This reaction is called akathesia and it goes away if you take a mild tranquilizer such as diazepam (Valium®), or loraze-pam (Ativan®). You may also experience a tightness in the muscles of your jaw or face. This is called dystonia and is easily relieved by taking a mild antihistamine, such as diphenhydramine (Benadryl®), which is available from the drugstore without a prescription. If you are having any of these side effects, be sure to call your doctor to see if he or she wants you to change to a different medication or to take additional medications to counteract these symptoms.

      Lorazepam (Ativan®). This drug is a tranquilizer in the same family as Valium. It doesn't block dopamine at the CTZ or speed up the digestive tract, but works by making you relaxed, forgetful, and sleepy. It is sometimes used alone, but often in combination with other antinausea drugs when patients are getting moderately to highly nauseating chemotherapy or radiation therapy. You can take this drug by mouth, by injection in the muscle, or by IV. Only the nongeneric (brand name) form of this drug (Ativan®) is easily absorbed under the tongue through the mucous membranes. This is particularly helpful if you are vomiting or having difficulty getting pills down.

      The side effects to watch for are sedation and forgetfulness. Do not drive when taking this drug. You may find that you do not remember events or conversations you have had while taking lorazepam. It may also cause unsteadiness, weakness, or a mild lowering of blood pressure. Call your doctor if these side effects are a problem. You may need to use a smaller dose, take it less often, or change to a different medication. Taken at night, lorazepam can help you fall asleep, as well as relieve nausea.

      Ondansetron (Zofran®). This relatively new antinausea drug has been used since 1991. It works by preventing serotonin (a chemical released by your body in response to chemotherapy or radiation therapy) from getting through to the CTZ and causing nausea. Zofran is very effective in preventing nausea from even the most nauseating cancer-fighting treatments. It is sometimes given by IV right before chemotherapy and again after four and eight hours. It is also effective at a higher dose given just once prior to chemotherapy, and the effect will last for about twenty-four hours. If nausea lasts longer than twenty-four hours, Zofran can be repeated daily for the next few days as well, although it seems to work better during the early phase of nausea. Zofran is now available as a pill that you can take every eight to twelve hours to relieve nausea at home after radiation therapy or chemotherapy.

      One advantage of Zofran is that it does not have the side effects of some of the other antinausea medicines. It will not make you sleepy, and does not cause the restlessness or muscle stiffness that prochlorperazine (Compazine) has been known to cause. One possible side effect of Zofran is constipation. To prevent this problem you should increase your fluids and take a stool softener on the days you are using this drug. You may also need to take a laxative if you don't have a bowel movement after a day or so. Zofran can also cause a mild headache. Ask your doctor or nurse for a pain reliever if you are having this symptom.

      Granisetron (Kytril®). Kytril is similar to Zofran. It works by preventing seratonin from getting through to the CTZ and causing nausea. Kytril is usually given once prior to chemotherapy to prevent nausea, and the antinausea effect lasts about twenty-four hours. Kytril is now available by pill and is taken twice a day to prevent nausea at home. Kytril does not cause sleepiness or muscle stiffness like Compazine, but like Zofran, it can cause constipation. Increase fluids and take a stool softener to prevent this problem, or use a laxative if neccessary. Kytril has also been known to cause headache, which can be relieved with a mild pain reliever.

      Steroids (dexamethasone-Decadron®, Hexadrol®). It is not known exactly how steroids work to prevent nausea. It's possible that they prevent the chemicals that are released by the body in response to chemotherapy or radiation therapy from getting through to the CTZ, and therefore make it less likely that you will feel nauseated. This drug is available as a pill, but it is usually given by IV in combination with other antinausea drugs prior to treatment. For instance, you may get IV Decadron along with Zofran or Kytril.

      Side effects to watch for are water retention, restlessness, confusion, insomnia, and euphoria (feeling high). Also, if it is given too rapidly by IV, steroids may cause a temporary feeling of itchiness or burning in the vaginal or rectal area, but this lasts only a few minutes and goes away on its own. People who have diabetes need to be aware that steroids can cause a temporary elevation in blood sugar. Steroids taken by pill can be irritating to the lining of the stomach, and that in itself can cause nausea. Always take steroid pills with food to prevent stomach irritation.

      Combinations of drugs. As you can tell from the preceding list of medications, different antinausea drugs work in different ways. One drug prevents the chemicals that are released by your body in response to cancer-fighting treatment from affecting the CTZ. Another helps decrease anxiety, making you relaxed and sleepy. Some drugs prevent the immediate nausea associated with treatments, and others are effective in relieving nausea that can occur several days after treatment.

      There are other drugs your doctor may use in combination with those listed above. For instance, antihistamines such as diphenyhydramine (Benadryl®) are useful in preventing nausea associated with motion sickness. When used with other antinausea medications, Benadryl can make them even more effective. Metoclopramide (Reglan®) helps the stomach empty quickly by speeding up the digestive tract. Smoking marijuana or taking the drug dronabinol (Marinol®) (which contains the active ingredient in marijuana) in combination with other antinausea medications can help prevent nausea, as well as stimulate your appetite. Drugs which neutralize or decrease stomach acid (Pepcid®, Prilosec®, Tagamet®, Zantac®, etc.) can also help to prevent or relieve nausea when used with other antinausea drugs.

      Every medicine has potential side effects. To be safe, always consult with your doctor or nurse before taking any new medicines, even ones you can buy without a prescription.

How to Take Antinausea Medicines
Start by taking the medication in the dose and frequency recommended. For instance, your doctor might recommend taking Compazine every four to six hours. Be alert to any side effects that may occur, and notify your doctor or nurse as soon as possible if you are having any problems. Remember, everyone has his or her own unique responses to treatment, and to the antinausea medicines. Your doctor needs your feedback to make adjustments in the plan so that it works for you. You may need to change to a different medication. You may need to change the schedule, the dose, or frequency of the medication, or you may need to add another medication to counteract a bothersome side effect.

Nausea from Anticipation
You may develop nausea that is not directly caused by the chemotherapy or radiation. People who suffer unrelieved nausea from cancer treatments begin to automatically associate the treatments with feeling nauseated. This is a conditioned response to a strongly unpleasant experience. As a result, anything associated with the treatment may trigger this reaction-the ride to the office or hospital, the sight of the nurse, the IV tubing, the smell of alcohol, or entering the dressing room at the radiation therapy department. This phenomenon of feeling nauseated without a physical reason is called anticipatory nausea and vomiting (ANV). The best treatment for ANV is prevention. If you didn't suffer significant nausea with one treatment, then you are not likely to anticipate feeling nauseated with the next one.

      Anxiety also contributes to anticipatory nausea. Some people avoid pretreatment jitters and nausea by taking antinausea medication even before they leave the house. Or, if they have to drive, they may take the pill immediately after arriving for their appointment. The medication that seems to work best for ANV is Ativan, but anything that allows you to relax can help prevent nausea. The following are a few suggestions.

      Progressive muscle relaxation (PMR) is a way of counteracting anxiety. You can learn to relax all the muscles of your body, visualize pleasant scenes, and psychologically remove yourself from a stressful environment. See Chapter 13 ("Relaxation and Stress Reduction") for more information on PMR.

      Systematic desensitization has been used successfully for this problem as well. This technique is a kind of counterconditioning used in the treatment of anxiety and phobia. After you learn to relax your body, various anxiety-provoking scenes associated with chemotherapy are visualized, starting from the least anxiety-provoking to the most. For instance, you might start by visualizing driving to the clinic or doctor's office for your treatment. You learn to relax while visualizing this scene. Then you slowly work up to the scarier scenes (such as having the IV started, or lying on the radiation treatment table). When you learn to relax your body while visualizing the whole procedure from beginning to end, you may find that you are less anxious and less nauseated.

      In addition to PMR and systematic desensitization, other relaxation techniques may prove useful in relieving anticipatory nausea, and are explained in Chapter 13. Deep breathing, relaxation imagery, autogenics, and self-hypnosis are excellent ways to relax. Sometimes just bringing a book or magazine to glance through may distract you. Some people find that bringing a friend to sit and chat, or listening to some music with headphones, is helpful to lower their anxiety and lessen their chances of anticipatory nausea.

The Importance of Fluid
Everything that you take by mouth (food, fluid, medication, and so on) eventually enters your bloodstream, where it circulates through your entire body. It is finally removed from the blood by the liver or kidneys and is eliminated in the urine. Some chemotherapy drugs can cause direct damage to the bladder or kidneys if they are not eliminated fast enough. Dying tumor cells release chemical waste products after chemotherapy or radiation therapy, which can cause nausea. That is why it is so important to drink plenty of fluid after your treatments. The more fluid you take in, the easier it is for your body to break down the chemical by-products and eliminate them.

      One of the dangers of continuous nausea and vomiting is that it makes if difficult to take fluids by mouth. When you are in the hospital or clinic, you will probably receive fluids directly into your bloodstream by IV. But when you are home, after your treatment or after a stay in the hospital, it is especially important to control nausea so that you can drink. If you are too nauseated to drink, you may become dry or dehydrated. When you are dry, the nausea may get worse. The result is a vicious cycle: unrelieved nausea causes dehydration, which intensifies the nausea. Preventing that cycle is essential.

What Is Dehydration?
If you have not been able to drink because of nausea, or if you've been vomiting a great deal, you will feel dry. Your mouth and lips will be dry and may be flaky or cracked. Your blood pressure may be lower than usual, and so you may feel dizzy when first standing up. (Note that since some antinausea medicines can cause dry mouth and slight dizziness, those symptoms may not necessarily mean that you are dehydrated.) When you are dehydrated your body will try to hold onto all the fluid it can, so you will notice that you are urinating less frequently and that the volume of urine is less than usual. Your urine may appear darker because it is more concentrated. You may notice that your weight is down several pounds from before you had your treatment. These are all signs of dehydration.

      Preventing Dehydration

      Here are some suggestions for the hours after your treatment to prevent dehydration:

1. When you first get home, take the antinausea medication at the dose and time recommended. Take it before you experience nausea. That way you can continue to take fluids and eliminate the byproducts of treatment-and feel better sooner.
2. Follow the set schedule of medications as recommended by your doctor or nurse. That will keep you covered during the hours when you're most likely to have problems.
3. If your nausea is not relieved by the medication, or you're having problems with side effects, contact your doctor or nurse. They may advise you to change the dose or frequency of the medication, or add another medication that will relieve your symptoms or counteract side effects. You might need to take a medication by rectal suppository until you're able to keep fluid down.

What to Do If You Are Becoming Dehydrated
Be sure that you are taking the antinausea medication prescribed. If you are vomiting and cannot keep pills down, call your doctor for advice. After taking the medication, wait about half an hour and then try sips of fluid. Any kind of fluid is fine-water, tea, popsicles, or broth. Drink a small amount frequently (try half a cup every half hour). At first you may only be able to tolerate water, but once you feel a little better, try drinking fluids that have calories, such as soda, diluted fruit juice, popsicles, tea with honey, etc. You need some calories or you will feel very weak. Add easily digested solid food cautiously. You may be able to tolerate a little sherbet, applesauce, or toast. See Chapter 7 ("Maintaining Good Nutrition") for more suggestions on how and what to eat when coping with nausea.

      Keep track of how much fluid you are taking and how often you are vomiting, as well as how often you are urinating. If you are still nauseated and think you may be getting dehydrated, call your doctor. Don't wait until you are severely dehydrated to call. Be sure to supply the kind of information that will enable your doctor to accurately evaluate your condition. Tell the doctor:

1. How much fluid you drank in the last twenty-four hours
2. How often and approximately how much you have vomited in the last twenty-four hours
3. What antinausea medicines have been prescribed, whether or not you have taken them, and what problems, if any, they have caused
4. How often and approximately how much you have urinated, and if your urine appears dark. (Some chemotherapy medicines will discolor your urine for a few hours, so it may be difficult to tell if your urine appears darker than normal due to dehydration.)
5. If you have lost weight since getting your treatment (weigh yourself before you call)
6. If your mouth, lips, and skin feel dry
7. If and when you feel dizzy. (Does it happen all the time or just when first rising from a sitting or lying position?)
8. If you have other symptoms that are affecting your condition, such as:
   • If you have a fever (take your temperature before calling)
   • If you have pain-where, how long it lasts, what makes better or worse
   • If you are diabetic (check your blood sugar before calling)
   • If you have missed taking other medications because of the nausea or vomiting (heart or blood pressure medication, anticonvulsants, pain medication, hormones, steroids, etc.)
   • If you have other digestion problems such as diarrhea, heart burn, bloating, etc.

Step-by-Step Hints

      Before Treatment

      It is not necessary to have an empty stomach before getting chemotherapy or radiation therapy. Staying well nourished and well hydrated (drinking lots of fluids) will help you feel stronger and help your body eliminate waste products more quickly. Eat and drink regularly until about two hours before your treatment. Eat foods that are easily digested (high carbohydrate, low fat). Stay away from spicy food or food that will give you a lingering aftertaste that may make you feel nauseated later (onions, garlic, etc.). Your doctor may want you to take antinausea medicine before coming to the clinic or hospital.

      During Treatment

      Do whatever you can to lower your anxiety. Bring a book, a music tape, or a friend to occupy you while you are waiting for treatment. Some antinausea medicine might make you feel sleepy, so sleeping through longer chemotherapy treatments might be possible. Wear comfortable clothes, loosen your belt or tie, and bring a sweater or ask for a blanket if you feel cold. Some chemotherapy drugs leave a metallic or unpleasant taste in your mouth, so sucking on hard candy or chewing gum might help.

      After Treatment

      Medications. Take the antinausea medications as prescribed. Do not wait to feel nauseated to take the medications. Your aim is to get through the high-risk hours and not feel nauseated at all.

      Food and Fluids. Eat small amounts, more frequently. Avoid feeling overfull. Eat bland foods (mashed potatoes, cottage cheese, toast, sherbet, crackers).

      You may be very sensitive to smells of food. Foods that are served cold or at room temperature have less aroma. Stay out of the kitchen as much as possible. Prepare foods for yourself or the family that are quick and easy with minimal sights or smells that may be upsetting to you.

      If you are diabetic, you have to be careful that the medication you take to control your blood sugar is appropriate for how much you are eating. You might need to check your blood sugar several times on the day of your treatment to make sure it is not getting too low or too high. Your doctor may want to adjust your insulin dose or other blood sugar medication until you're able to eat normally.

      Sometimes sweet juices are hard to tolerate after treatment. If that's true for you, try lemonade, broth, club soda, or ice water. Try mixing a little juice with mineral water. You might need to try several different kinds of tastes before you discover what works best.

      It is most important to take fluids. Don't worry if at first you don't feel like eating solid foods. Try popsicles, tea, juices, soup, soda, or ice. Drinking with your meal may make you feel overfull and bloated, so drink fluids before or after eating solid food. Drink small amounts of fluids frequently to avoid feeling too full.

      Rinse your mouth or brush your teeth before and after eating to avoid lingering tastes that may be nauseating.

      Activities. Fresh air and mild physical activity help prevent nausea. Take a walk or sit on the porch or by an open window. Distractions may help. Go to the movies, read a book, talk to a friend, listen to music, play cards, and so on.

      Sleep. Some antinausea medications may make you sleepy. Let yourself sleep through the high-risk hours. If you are supposed to take some medication on a set schedule around the clock, you may want to set the alarm clock so that you can wake up, take the medication, and then go back to sleep. If you are not taking antinausea medication in the middle of the night, then take it when you first wake up-before you get out of bed and start moving around.

      Relaxation. If you are feeling anxious, relaxing may be easier said than done. There are a number of audio and video tapes that you may find useful to help you clear your mind and relax every muscle in your body. You may find that the tension you are holding in your face and jaw or in your shoulders or abdominal muscles is adding to your anxiety or feelings of queasiness. Some tapes provide peaceful and relaxing images and music. After you practice with these tapes for a period of time, you may be able to relax yourself very quickly with or without the tape any time you feel tense or anxious. You can also make your own tape with the relaxation scripts provided in Chapter 14 at the end of this book.

      Self-Talk. The things you say to yourself can either help you cope or cause you more stress. Many of these thoughts are unconscious and so automatic that you may not even be aware of them Pay attention and try to tune into what you may be saying to yourself that is increasing your stress and worries about nausea (or any other scary symptom). It may help to write these thoughts down. This makes them more conscious and more manageable. It also allows you to argue against them and replace these anxiety-provoking thoughts with thoughts that are supportive, accurate, and focused on coping. Your anxiety-producing thoughts may sound like this:

I can't stand it-this is too much.
I feel so helpless, there is nothing I can do.
The antinausea medicine isn't working-nothing will help.
I'll never feel any better.

I can get through this-the discomfort will only last a few hours.
If this medicine isn't working to relieve my nausea, there other medicines that I can try.
The chemotherapy/radiation is effective, no matter how nauseated I feel.
I'm learning how my body reacts to chemotherapy/radiation and to the antinausea medicines.
I am in charge-I can take the medicine that I need in order to feel better.
It's okay to sleep and let the hours pass.
The kids (or husband, or job) are taken care of for now. Right now I can pay attention to me and take care of myself.
I know how to relax, distract myself, and feel better.
I know that ________ is here for me if I need him/her.

      Nausea and vomiting can be very debilitating, both physically and emotionally. Fortunately, there are strong and effective medications and relaxation techniques that really work. Lots of people get through their chemotherapy treatment with minimal nausea or no nausea at all. That is the goal-to get through this time and remain comfortable, well nourished, and able to do the normal activities of your life as soon as possible. Preventing this side effect is very important. If you are able to stay well nourished, feel good, and maintain your activities, you will be more able and willing to complete your treatment. This is possible only if side effects like nausea and vomiting can be controlled.