Nausea when eating during Folfirinox Adjuvant Chemotherapy

Hard to say without a lot more info about the patient, but 6 treatments in with a CA19-9 sounds like a pretty positive and hopeful assessment overall.

Folfirinox can be notoriously hard on any patient -- different impacts for different people -- but nausea is a very common one (before, during, and after eating).

Personally, I think I felt worst between rounds 5 and 6 of my 6-month (12 treatments) regimen of Folfirinox before Whipple. I never reached a point of vomiting, but was close several times. In fact, between my wife's cooking and the common bile duct stent implanted during my EUS, I regained 30 pounds over those 6 months.

Nausea __during__ a meal might warrant some unique thought and treatment distinct from nausea before or after eating.

Some of the nausea might have psychological or sensory roots. A fear of eating, or altered perception of the smell and texture of previously beloved foods __might__ be causing some of it. While on Folfirinox, I was particularly aware of metallic tastes, and learned (on here) that using plastic cutlery instead of metal could reduce that. Dysphagia (difficulty swallowing) is one of the many side effects of oxaliplatin. That, combined with mucus from sinus drainage (fixed with antihistamines during chemo) caused me to experience weird gagging sensations fairly often.

I have zero medical training, and am only a "sample of one" statistically, but some of the things that helped me were conscious relaxation; CBD gummies/oils; thinner and warmer foods; avoiding acidic/spicy foods; plastic forks and spoons; smaller meals and eating them slower. For easy texture and a filling feeling, I liked dipping King's Hawaiian rolls in warm chicken soup, beef broth, or turkey gravy.

Many people have had good luck with THC gummies or medical marijuana. If that's not an option in your state or line of work, there is a federally legal, FDA approved, synthetic THC called Marinol (dronabinol) which you can get by prescription.

Definitely make sure your relative's oncologist is aware of this, and see if they can set you up for consults with a palliative oncologist and/or an oncology-certified dietitian.

Wishing you both the best, and hoping you get through the worst of it quickly!

@kslayer , FWIW, I just typed out a much longer reply which has to be approved by forum moderators before it can appear publicly. I suspect their software detected a magic, naughty keyword.

Anyway, upon a reread of your post, I caught the "adjuvant" portion of your title. Which surgery did your relative have, and when (with respect to commencement of the Folfirinox)?

One justification some oncologists cite for TNT (Total Neoadjuvant Therapy, or 12 rounds of Folfirinox before surgery and none after) is the difficulty many patients have tolerating chemo (especially Folfirinox) after major surgery like Whipple.

Some of the rationale behind that is that given the percentage of patients who are unable to tolerate a full course of adjuvant therapy, TNT ensures they've gotten it beforehand. (I am a living testament, albeit a sample of one, that foregoing adjuvant treatment may not be the best idea... 🙁 but back to your relative's case)...

You asked about the cause of nausea being chemo side effects or progression of disease, but didn't include after-effects or complications of surgery as a possible or sole contributor. Depending on the time passed since surgery and complete healing from it, post-surgical issues might be in play as well. You might need a professional (surgical) diagnosis of whether any leaks, fistulas, pancreatitis/inflammation, or other issues that are exacerbated by eating are involved. GI/exocrine expertise might also help assess what's going on digestively.

One (uneducated) guess that might help narrow it down is what types of food cause the nausea while eating, and how fast it happens. In particular, if there is some kind of leak, I would expect liquids and thinner foods to find their way out of a leak faster.

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Disclaimers:
1) I have zero medical education.
2) If my other post appears after this one, please remember that it was written before it.

That's a lovely CA 19-9 reading! Re the nausea, my guess is that it's due to the chemotherapy. Is your relative getting pre-meds, i.e. medications that are dosed prior to the actual chemo drugs? I assume so, but it's worth asking. I can only speak to my own situation, and I'm only a patient, not a medical professional of any sort. My pre-meds include Zofran, Emend and dexamethasone, and atropine is administered immediately prior to the irinotecan. At home, I was told to alternate between Zofran and Compazine tablets as long as I needed them in order to control nausea. I was also prescribed dexamethasone tablets, but I stopped taking those because the steroid tends to give me hiccups. Also, diet can play a part. Everyone is different, but in general you want to emphasize mild, bland foods that provide as much nutrition as possible but not a lot of spice, fat, etc. that might upset the stomach. Smaller portions consumed more frequently tend to be better than three larger meals a day.

ETA: I just saw markymark's post (the second one, not the first). The "adjuvant" caught my eye too. That's out of my limited realm of expertise, so I'm glad he jumped in to offer some ideas on that.

I don't have experience with having chemo after surgery. I am having chemo before my surgery. I have one more chemo treatment left.
I started with Folfirinox. (as opposed to gem/Abraxane). I experienced a lot of nausea at different times throughout the day. My integrative oncologist okayed the medical marijuana. The medical marijuana really helped me. I live in Iowa. My local oncologist signed my application.
I use a medical marijuana tincture called Harmony. I take 9 drops at night before bed and it has really helped my nausea. Everyone is different. What helps one person may not help another.

Both my posts now appear in order,and it looks like the delayed/moderated one made it through w/ no change in content.

As @ncteacher mentioned, there are also a plethora of anti-nausea meds that could be considered. At home, after chemo, I have prescriptions for Zofran, dexamethasone, and Compazine, but rarely need anything more than Zofran for 2-3 days after my chemo (Gem + Abrax + cisplatin).

One other data point to help with diagnosis of the nausea while eating is whether it is worst immediately after an infusion and gets better over the next two weeks, or whether it's equally bad throughout the period between infusions.

The latter would seem to suggest either 1) some ingredient in the chemo is having a really long lasting negative impact, and might need to be removed; or 2) chemo is not the cause, because most of it should be cleared from the patient's body near the end of that period.

Something else to consider is whether other vitamins/supplements are playing a background role. For example, I was informed by a pharmacist that supplements like Quercitin can inhibit the activity of enzymes 2C8 and 3A4 and prevent the clearance of Abraxane from your body, possibly leading to a toxic buildup. Although Abraxane is not a component of Folfirinox, an eagle-eyed pharmacist might be able to spot something similarly incompatible in your relative's diet/supplement/chemo regimen.

Thank you very much for all the detailed replies . My relative undergone whipple in July last year, and started Folfirinox in late August and 28 courses of radiation therapy in November.

I got through 24 cycles of Folfirinox and 22 cycles of 5-FU/Leucovorin every 15 days over 24 months without interruption using the following proactive methods:

Always kept a small amount of bland food in my stomach such as crackers, low salt pretzels, saltines and bland foods when eating during chemo sessions.

Ate small meals-more like grazing throughout the day.

Used some form of ginger as it is an anti-emetic. Chewing thinly sliced fresh ginger was very effective in quickly knocking down queasiness. Hard ginger candy, sipping room temperature Ginger Ale or drinking warm ginger tea.

Drinking cold water, particularly on an empty stomach would trigger queasiness. I slowly sipped room temp water and always ate a small amount of bland food.

Aroma therapy with essential oils: lavender, citrus (orange) and peppermint were ones I had tried.

There are several pathways that can lead to nausea. There is no single drug developed yet acts on all of the pathways simultaneously. Anticipatory nausea becomes an issue when having experienced queasiness, nausea and vomiting with prior cycles. It will require being proactive in taking a combination of anti-emetics prior to chemo administration. The following is a list of anti-emetic medications:

Drug |Activity |Side Effects
Aloxi, Anzemet, Kytril, Zofran, Ginger (the spice) |
Activity: Serotonin 5-HT3 receptor agonist |
Side effects: Constipation, Dry mouth, Fatigue

Compazine, Motilium, Zyprexa |
Dopamine agonist Targets D2 receptor |
Side effects: Constipation, Dry mouth, Fatigue, Muscle spasms, Tinnitus, restlessness

Emend, Varubi
NK1 receptor agonist
Decrease in urination, Dry mouth, Heartburn

Cannabis, Marinol (Dronabinol), Cesamet (Nabilone) |
Cannabinoid |
Perception, Dizziness

Also, for longer-acting relief, Sustol (aka granisetron, a 5-HT3 receptor antagonist) is a 5-day extended release antiemetic injection to relieve nausea.

https://www.sustol.com/hcp https://www.sustol.com/patient

A couple of links addressing nausea:
https://www.ncoda.org/wp-content/uploads/2021/03/
nauseavomiting_supplemental.pdf

Just a gentle correction.

I've been taking an antipsychotic for over 20 years and have a bit of knowledge about Zyprexa. Zyprexa is an antipsychotic that is a dopamine D2 *antagonist*, not an agonist.

Antagonists decrease dopamine whereas agonists increase dopamine.

Currently my relative seems to be only able to eat blended food like congee or steamed eggs, with other solid food is unable to swallow, does Folfirinox lead to this type of problem ? Thanks a lot.

Hi @katiegrace - My sister is having the same issue (on Folfirinox, Stage IV, major shrinkage of tumor after 8 infusions, CA19-9 now 20). Her oncologist at MSK has adjusted her dose and she is given several anti-nausea meds with varying results. She has Marinol which helps appetite somewhat but it is sporadic. I am wondering if something like the tincture would be more efficacious(?) I will have her ask her doc at next visit. Thank you.