Chemotherapy-induced nausea and vomiting (CINV) is one of the most distressing side effects of chemotherapy. It can have a negative impact on quality of life and may discourage patients from continuing treatment. Economic impacts include costs of prolonged hospital stays, emergency admissions for dehydration, additional treatments, emotional support and depression. In severe cases, CINV could lead to serious complications and clinical decisions may be made to delay, reduce or stop chemotherapy. It is therefore a priority for pharmacists to optimise antiemetic therapy for better patient outcomes.
Granisetron 3.1mg/24 hours (Sancuso) is the first 5-HT3 receptor antagonist transdermal patch indicated for the prevention of CINV in adults receiving highly emetogenic (HEC) or moderately emetogenic (MEC) chemotherapy for three to five consecutive days and in patients who have difficulty swallowing. The incidence of CINV varies from 70% to 80% in the first 24 hours post treatment with HEC or MEC.
A retrospective analysis was carried out at London Bridge Hospital to investigate the effectiveness of Sancuso with standard antiemetics in HEC and MEC protocols. A cost comparison of Sancuso with other 5-HT3 antagonists was also conducted. Retrospective data were collected for 35 patients from November 2014 to August 2015. Records contained patient history, chemotherapy given, initiation of Sancuso and follow up notes by the multidisciplinary team. The inclusion criteria were patients on HEC and MEC with failed response to standard antiemetics or patients who have difficulty swallowing antiemetics. The exclusion criteria were patients receiving single or low emetogenic chemotherapy or patients who were intolerant or allergic to granisetron.
Complete response rates (i.e. no nausea and vomiting) were seen in 76% of men and 64% of women. A partial response (i.e. some nausea and vomiting) was achieved in 19% of men and 22% of women. Only 5% of men and 14% of women had no response (i.e. nausea and vomiting persisted). The cost of treatment with Sancuso over three to five days of chemotherapy was similar to other 5-HT3 antagonists but cheaper than ondansetron.
Responders had no nausea or breakthrough vomiting and required no additional domperidone or rescue antiemetics. It was safer to use Sancuso in cardiac patients instead of increasing doses of domperidone, which can prolong the QT interval. Partial responders required regular domperidone or rescue antiemetics because of disease progression or comorbidities. Non-responders were either non-compliant, intolerant to Sancuso, or responded to oral granisetron. Only one patient responded to palonosetron. In trials, palonosetron has shown superiority over Sancuso and other 5-HT3 antagonists because of higher affinity for the 5-HT3 receptor.
There were some limitations with using Sancuso. These included patch detachment, application site reactions, degradation by direct exposure to sunlight and slow onset of action (it must be applied at least 24 hours before chemotherapy to be fully effective). The advantages of using this patch included fewer systemic side effects, better suitability for patients unable to swallow or who had a phobia of needles, reduction of anticipatory nausea (application 24 hours before chemotherapy) and no need for repeated dosing of antiemetics. This enhances compliance and reduces pill burden.
We conclude that Sancuso is an effective, well tolerated, cost-effective, non-invasive treatment option for cancer patients. Further use and analysis in the NHS or other practices may help develop new evidence-based antiemetic guidelines for prescribers.
Priya N Patel
Clinical pharmacist, London Bridge Hospital and Leaders in Oncology Care, London
Declarations of interest: ProStraken had no influence on funding, control of data collection or on the results of this analysis.