Nausea and vomiting are common side effects of leukemia treatment. Nausea is the unpleasant sensation that is often described when a person feels as if they are going to be sick to their stomach. Emesis, or vomiting, is the act of throwing up. While the two are often viewed as going hand in hand, one can experience nausea without vomiting, and people can also vomit without feeling nauseated.

Dr. Matt Kalaycio is a professor in the Cleveland Clinic Lerner College of Medicine at Case Western Reserve University. Dr. Kalaycio previously served as chairman of the department of hematology and medical oncology at the Taussig Cancer Institute at Cleveland Clinic. MyLeukemiaTeam sat down with Dr. Kalaycio to discuss nausea and how people living with leukemia can manage this unpleasant symptom.

What Causes Nausea and Vomiting?

Scientists do not fully understand exactly why and how nausea and vomiting occur. Studies suggest that when a person is nauseated, a pathway in the brain is triggered, signaling other parts of the body. Specifically, signals are sent to certain parts of the digestive system — the esophagus, stomach, small intestine, and large intestine.

Causes of nausea range from motion sickness and nervousness to food poisoning and the flu. If the nausea and vomiting last longer than 24 hours, you should consult your health care provider.

What Are Some Consequences of Nausea?

If nausea and vomiting persist, they can seriously affect a person's health and their treatment, both directly and indirectly.

Nausea and vomiting can make it hard to get adequate nutrition. Nausea can make you not want to eat or drink anything, and repeated vomiting can lead to dehydration, weight loss, and loss of appetite.

Throwing up violently can cause broken blood vessels in the face or eyes. Vomiting for lengthy periods of time can also cause fatigue. It can interfere with your ability to take care of yourself, and may negatively affect recovery from cancer or cancer treatment.

Why Does Nausea Occur in Leukemia?

In rare cases, prolonged or recurring nausea can be a symptom of certain leukemia complications. This is especially true when the feelings of sickness keep coming back or are accompanied by other symptoms of leukemia, such as bruising easily or being tired without an obvious reason.

Nausea and vomiting are more likely to be a result of leukemia treatment than they are to be symptoms of cancer.

Nausea and Vomiting Caused by Cancer Treatment

Treatment-related nausea and vomiting, also called chemotherapy-induced nausea and vomiting (CINV), is caused by the cancer treatments themselves. Nausea and vomiting may also be worsened by certain drugs, such as pain medication.

Different treatment regimens bring with them different risks for and severity of CINV. Chemotherapy treatment, radiation therapy, immunotherapy, and targeted therapy have all been known to cause nausea or vomiting.

Different Types of CINV

Various kinds of treatment-related nausea and vomiting exist. They’re named depending on when and why the nausea occurs.

• Acute nausea and vomiting generally happens within minutes to hours of a person undergoing cancer treatment.
• Delayed nausea and vomiting commonly begins 24 hours or more after cancer treatment has been administered.
• Breakthrough nausea and vomiting occurs despite preventative anti-nauseants being administered.
• Refractory vomiting happens when anti-nausea drugs stop working.

CINV is more likely to occur based on several treatment factors.

• Higher doses of cancer-killing drugs, especially chemotherapy and radiation, put a person at high risk for CINV.
• Drugs delivered intravenously are more likely to cause CINV than those taken orally because they are absorbed by the body more quickly.
• Frequent treatments are more likely to cause nausea and vomiting because the body has less time to recover between rounds of medication.

CINV has become much less of a concern due to advancements in existing treatments, development of new treatments, and a wider variety of treatment types. Dr. Kalaycio believes that the best way to manage CINV is to “get away from chemotherapy altogether.”

Regardless of whether or when a person’s nausea and vomiting are likely to occur, it’s important to note that prevention is easier than stopping nausea and vomiting once they have begun.

Individual Factors

In some instances, a person’s biological makeup or psychological response to the stress of a leukemia diagnosis or the resulting treatment may cause nausea or make them more susceptible to vomiting.

Physiological Factors

Not every person will have the same response to a certain type or dose of cancer treatment. In fact, there are several individual factors that may make a person more likely to experience nausea during leukemia treatment. Women are more likely to report nausea and vomiting than men, as are younger people. Other risk factors include:

• Whether a person has had chemotherapy treatment in the past
• If vomiting or nausea is a symptom they commonly experienced when previously sick
• If they are more nervous or anxious about treatment or in general

Psychological Factors

Some leukemia treatments come with a reputation for causing nausea and vomiting. Sometimes this stereotype is enough to induce such anxiety around the treatments that a person may feel nauseated or vomit despite the treatments themselves not being the cause.

“Sometimes people are afraid to get [certain treatments] and they attribute nausea and vomiting to all therapies, even the ones that don't cause nausea and vomiting,” Dr. Kalaycio explained. This conditioned response is known as anticipatory nausea or vomiting.

These pervasive fears can be strong. “Most patients get their chemotherapy in the morning and go to work in the afternoon,” Dr. Kalaycio said. “But a lot of education goes into convincing patients that they're not going to spend all night throwing up after they get this regimen.”

How Can You Manage Nausea?

A cancer care team should be well-versed in the risk of nausea, as well the many other factors that may contribute to a person’s nausea and vomiting. Selecting a regimen of therapeutic drugs for leukemia should be a holistic endeavor, Dr. Kalaycio explained. “The anti-nausea medicines that I prescribe with chemotherapy regimens have been predetermined by a team which includes pharmacists.”

Pharmaceuticals

Antiemetics, or anti-nausea medications, work by blocking different parts of the neural pathways that trigger the urge to throw up. Different classes of antiemetics work in various ways to control, treat, or prevent nausea and vomiting.

Serotonin Antagonists

Serotonin antagonists, also known as 5-hydroxytryptamine type 3 receptor (5-HT3) antagonists, block the effects of serotonin, a substance that commonly triggers nausea and vomiting. This class of drug is effective at controlling acute nausea and vomiting and is usually given before chemotherapy and then for a few days afterward. Examples of 5-HT3 antagonists include Zofran (Ondansetron), Kytril (Granisetron), Anzemet (Dolasetron), and Aloxi (Palonosetron).

NK-1 Receptor Antagonists

Neurokinin-1 (NK-1) receptors help treat delayed nausea and vomiting. The NK-1 receptor is part of the vomiting reflex. NK-1 receptor antagonists are usually prescribed in tandem with 5-HT3 antagonists. Together, these classes of drugs are prescribed to prevent, not treat, nausea and vomiting. They’re often given with other anti-nausea medicines. Examples of NK-1 antagonists include Emend (Aprepitant), Varubi (Rolapitant), and Cinvanti (Fosaprepitant).

Dopamine Antagonists

Dopamine antagonists are often prescribed when other drugs don’t work well to control nausea and vomiting. Examples of dopamine antagonists include Compazine (Prochlorperazine) and Haldol Decanoate (Haloperidol).

Steroids

Steroids are often prescribed alongside other antiemetic drugs to prevent nausea and vomiting. An example of a steroid used as an antiemetic is Ozurdex (Dexamethasone).

Benzodiazepines

Benzodiazepines are commonly used to treat anxiety. They help bring about greater feelings of relaxation. This class of medication is usually utilized in tandem with other treatments and may be more useful in addressing anticipatory nausea and vomiting. Examples of benzodiazepines used as anti-nausea drugs include Ativan (Lorazepam) and Xanax (Alprazolam).

Regardless of the cause of nausea or vomiting, no single anti-nausea therapy works for every person in every scenario. This is because each person responds differently to cancer treatments and to antiemetic therapies. In some cases, your response to treatment may depend on a variety of factors that are specific to your situation.

“Take the anti-nausea medication about 30 minutes before you eat breakfast; then take your Gleevec [Imatinib],” suggested one MyLeukemiaTeam member. While adjusting the timing of medications with meals works for some people, others might find that they aren’t ready to consume full meals at the beginning of treatment, as evidenced by another member’s comment: “Week one of taking Gleevec down: I had nausea on Sunday and Monday, a low grade temperature all day Wednesday — even with taking Tylenol [Acetaminophen]. And I have no appetite.”

Cannabis

Cannabinoids, such as Marinol (Dronabinol) and Cesamet (Nabilone), are drugs that contain ingredients found in cannabis or marijuana. Sometimes cannabinoids are used to treat nausea and vomiting when the usual antiemetic drugs aren’t as effective. Cannabinoids provide the added benefit of being an appetite stimulant in addition to helping combat nausea, stress, and anxiety.

If side effects aren’t easily managed by traditional antiemetics, “We immediately call our palliative care colleagues to help us with any one of a number of interventions that go beyond just pills to try to alleviate the suffering that comes with the therapies — whether that suffering is from nausea, vomiting, or anything else,” Dr. Kalaycio said.

Music Therapy

Dr. Kalaycio has participated in research regarding music therapy and its benefits in helping people with leukemia. “There's something very soothing about sitting and just listening to music,” he said. “When you're concentrating on creating or performing music, you can't be thinking about other things. Much like physical therapy, it's easy for someone to take the lessons learned from music therapy to put into practice at home.”

Reducing anxiety and stress by utilizing alternative, healthier stress-reduction methods and relaxation techniques can be an important part of treatment. Dr. Kalaycio explains that if a person’s primary coping method for dealing with stress is drinking alcohol or smoking cigarettes, risk reduction — that is, reducing the amount consumed or smoked — may be better for them than quitting both or either outright. When facing the inordinate stress brought about by a leukemia diagnosis or treating blood cancer, it may be worthwhile to find ways to:

• Help you feel relaxed
• Distract you from what’s going on (pain, discomfort, fear)
• Help you feel more in control

Anti-Nausea Tips From MyLeukemiaTeam Members

MyLeukemiaTeam is the social network for people living with leukemia and their loved ones. On MyLeukemiaTeam, more than 7,000 members come together to ask questions, give advice, and share their stories with others who understand life with leukemia.

Do you experience nausea or vomiting? Is your nausea related to your leukemia treatment? What has been helpful for you? Share your experience in the comments below or start a conversation by posting on your Activities page.