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Long-term aprepitant for nausea and vomiting associated with gastroparesis in hematopoietic stem cell transplantation

Bone Marrow Transplantation volume 53, pages 1372–1374 (2018)Cite this article

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Nausea and vomiting in the course of allogeneic hematopoietic stem cell transplantation (SCT) is common and might persist up to months. Despite modern antiemetic guidelines, control of nausea in children sometimes is not possible [1]. A 3-day regimen of the antiemetic (fos)aprepitant, a neurokinin-1 receptor antagonist, has been licensed for the treatment of chemotherapy-induced nausea and vomiting (CINV) [2]. In this letter, we describe our experience with long-term off-label use of aprepitant to relieve late nausea and vomiting in the course of SCT.

A 15-month-old boy (patient A) with hemophagocytic lymphohistiocytosis was transplanted with bone marrow from a fully matched unrelated donor. Chemotherapeutic conditioning consisted of treosulfan, fludarabine, and alemtuzumab, with methotrexate and cyclosporine as graft versus host disease (GvHD) prophylaxis. Despite several antiemetic regimens (ondansetron, lorazepam, erythromycin, domperidone, alizapride) and a proton pump inhibitor, nausea and vomiting persisted after transplantation. Upper gastrointestinal endoscopy and sigmoidoscopy did not show GvHD or infection (cytomegalovirus, helicobacter pylori, candida). Eventually, he was diagnosed with gastroparesis. Placement of a duodenal feeding tube failed. Introduction of enteral feeding was repeatedly attempted but resulted in recurrence of abdominal pain and vomiting. Two months after transplantation he was discharged with parenteral feeding. After three months without clinical improvement, a trial of aprepitant was considered. After parental consent, aprepitant (1.5 mg/kg once daily, no loading dose) was started during clinical observation. Within 24 h after the start of aprepitant a clear improvement of symptoms was observed. Enteral nasogastric feeding was tolerated and daily aprepitant was continued for four months, without side effects or toxic drug interactions. After one and a half month of treatment with aprepitant, the dosing frequency was decreased for a short period from once daily to once every other day, however, vomiting increased. Eight months after transplantation, aprepitant was successfully discontinued. At this timepoint, the patient resumed oral food intake, and nine months after transplantation the enteral nasogastric feeding could be stopped.

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Acknowledgements

We are indebted to our team involved in the care for these patients.

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Authors and Affiliations

  1. Department of Pediatric Immunology, Infections, Hematology, and Stem Cell Transplantation, Willem-Alexander Children’s Hospital, Leiden University Medical Center, Leiden, The Netherlands

    Justin Jacobse, Harmen Mensink, Wouter J. W. Kollen, Dorine Bresters & Robbert G. M. Bredius

  2. Department of Clinical Pharmacy and Toxicology, Willem-Alexander Children’s Hospital, Leiden University Medical Center, Leiden, The Netherlands

    M. Y. Eileen C. van der Stoep-Yap

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  1. Justin Jacobse
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  2. Harmen Mensink
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  3. M. Y. Eileen C. van der Stoep-Yap
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  4. Wouter J. W. Kollen
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  6. Robbert G. M. Bredius
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Correspondence to Robbert G. M. Bredius.

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Jacobse, J., Mensink, H., van der Stoep-Yap, M.Y.E.C. et al. Long-term aprepitant for nausea and vomiting associated with gastroparesis in hematopoietic stem cell transplantation. Bone Marrow Transplant 53, 1372–1374 (2018). https://doi.org/10.1038/s41409-018-0231-4

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