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Aprepitant was initially developed to prevent chemotherapy-induced nausea and vomiting (CINV). However, its applications have since broadened to include postoperative nausea and vomiting (PONV). Aprepitant belongs to the neurokinin-1 antagonist class of medications and has received approval from the Food and Drug Administration (FDA) for both indications. This activity outlines and reviews the indications, actions, and contraindications of aprepitant as a valuable drug in preventing CINV and PONV. This activity also highlights the mechanism of action, adverse event profile, monitoring, and relevant interactions pertinent for healthcare team members involved in the care of patients undergoing highly emetogenic chemotherapy or general anesthesia. Objectives: Identify appropriate patient candidates for aprepitant therapy based on the risk factors for chemotherapy-induced nausea and vomiting and postoperative nausea and vomiting. Assess and monitor patients for potential adverse events associated with aprepitant therapy and promptly manage any complications. Select appropriate dosing regimens of aprepitant based on the specific chemotherapy or anesthesia regimen. Collaborate with healthcare professionals to ensure proper dosing, monitor drug interactions, and address concerns related to aprepitant for optimal patient outcomes. Access free multiple choice questions on this topic.

Aprepitant has a very high therapeutic index, and case reports of toxicity due to overdose are sparse or nonexistent. No specific antidote exists for aprepitant toxicity.[37] Although serum aminotransferase elevations occur in 6% of treated patients, clinically apparent liver injury is rare.[38] A case report of ifosfamide-induced encephalopathy exists that is associated with aprepitant. The encephalopathy was reversed with supportive treatment and discontinuation of aprepitant.[39] The retrospective case series investigated the prolonged daily use of aprepitant for intractable nausea and vomiting in children in palliative care settings. In comparison with the standard regimen, the mean number of days of aprepitant treatment was 36.5 days, ranging from 6 to 84 days. No adverse events were observed even after prolonged administration of the drug, thereby establishing the safety profile of aprepitant.[40] In the event of an overdose, it is recommended to implement supportive care, consult a medical toxicologist, or contact a poison control center.[41]

CINV and PONV result in decreased patient satisfaction, increased patient stress, and potentially increased admission rates or delayed discharge from healthcare facilities.[42] Emerging as well-tolerated and highly effective novel therapies with minimal adverse effects are evolving. Aprepitant and its IV prodrug, fosaprepitant, belong to a new class of antiemetics known as neurokinin-1 inhibitors. These highly selective medications bind to multiple areas in the brainstem responsible for initiating and coordinating the vomiting reflex.[13][15] Aprepitant binds to NK-1Rs in multiple brainstem areas, exerting its antiemetic effect for up to 48 hours.[16][20] When used as monotherapy or in combination with other antiemetics, aprepitant-fosaprepitant can offer highly effective prophylaxis for CINV and PONV. In cases of CINV refractory to all medical treatments, including aprepitant, further evaluation and workup are necessary to assess for electrolyte abnormalities, intestinal obstruction, and central nervous system metastases.[43] In an interprofessional healthcare team comprising clinicians (MDs, DOs, NPs, and PAs), nursing staff, and pharmacists, awareness of multiple treatment options to prevent nausea and vomiting is crucial.[21] Whether in the cancer center, inpatient, or operative setting, all healthcare team members must leverage their knowledge of antiemetic therapies to mitigate nausea and vomiting rates, thereby reducing adverse effects and fostering positive patient experiences. Forming interprofessional teams to develop evidence-based regimens for the prophylaxis and treatment of CINV and PONV is advisable. The incorporation of aprepitant and fosaprepitant into these regimens can result in a decreased length of hospital stay, enhanced patient satisfaction, and reduced risk of adverse events associated with the vomiting reflex, such as poor nutrition and damage to surgical repairs.[44][45] This may require consulting with a specialized pharmacology pharmacist who can communicate with the rest of the healthcare team regarding appropriate dosing, check for interactions, provide guidance to the nursing staff on administration, and be available for additional input during post-administration monitoring. Nurses should promptly contact the ordering clinician if they observe any adverse events or changes in the patient's status.

Forming interprofessional teams to develop evidence-based regimens for the prophylaxis and treatment of CINV and PONV is advisable. The incorporation of aprepitant and fosaprepitant into these regimens can result in a decreased length of hospital stay, enhanced patient satisfaction, and reduced risk of adverse events associated with the vomiting reflex, such as poor nutrition and damage to surgical repairs.[44][45] This may require consulting with a specialized pharmacology pharmacist who can communicate with the rest of the healthcare team regarding appropriate dosing, check for interactions, provide guidance to the nursing staff on administration, and be available for additional input during post-administration monitoring. Nurses should promptly contact the ordering clinician if they observe any adverse events or changes in the patient's status. Aprepitant and fosaprepitant are relatively novel and expensive therapies compared to older antiemetics. Their use should be guided by risk stratification systems, such as the Apfel and Eberhart scores, when prescribed for PONV and the updated antiemetic guidelines of the Multinational Association of Supportive Care in Cancer (MASCC)/ESMO), ASCO, and NCCN. By evaluating the individual risks of patients for the development of nausea and vomiting, it is possible to optimize the cost-benefit and risk-benefit ratios.[11][18][27][46] As mentioned, a board-certified oncology pharmacist can collaborate with the oncology staff to ensure proper dosing and the lack of drug interactions when choosing chemotherapy-induced antiemetic therapy. The nursing staff should promptly understand the interactions and adverse event profile of these drugs and the chemotherapy to promptly inform the rest of the team if issues arise. These interprofessional strategies aim to maximize therapeutic efficacy, minimize adverse events, and optimize patient outcomes related to aprepitant therapy.