Difference between revisions of "Antiemesis"
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Adapted from the NCCN antiemesis guidelines<ref>[http://www.nccn.org/professionals/physician_gls/pdf/antiemesis.pdf NCCN antiemesis guidelines]</ref>. | Adapted from the NCCN antiemesis guidelines<ref>[http://www.nccn.org/professionals/physician_gls/pdf/antiemesis.pdf NCCN antiemesis guidelines]</ref>. | ||
+ | |||
+ | ==Emetic risk of IV chemotherapy== | ||
+ | ===High emetic risk, >90% frequency of emesis=== | ||
+ | *AC combination (doxorubicin or epirubicin with cyclophosphamide) | ||
+ | *Carmustine >250 mg/m2 | ||
+ | *Cisplatin >=50 mg/m2 | ||
+ | *Cyclophosphamide >1500 mg/m2 | ||
+ | *Dacarbazine | ||
+ | *Doxorubicin >60 mg/m2 | ||
+ | *Epirubicin >90 mg/m2 | ||
+ | *Ifosfamide >= 10 g/m2 | ||
+ | *Mechlorethamine | ||
+ | *Streptozocin | ||
+ | |||
+ | ===Moderate emetic risk, 30-90% frequency of emesis=== | ||
+ | *Aldesleukin >12-15 million international units/m2 | ||
+ | *Amifostine >300 mg/m2 | ||
+ | *Arsenic trioxide | ||
+ | *Azacitadine | ||
+ | *Bendamustine | ||
+ | *Busulfan | ||
+ | *Carboplatin | ||
+ | *Carmustine <=250 mg/m2 | ||
+ | *Cisplatin <50 mg/m2 | ||
+ | *Clofarabine | ||
+ | *Cyclophosphamide <=1500 mg/m2 | ||
+ | *Cytarabine >200 mg/m2 | ||
+ | *Dactinomycin | ||
+ | *Daunorubicin | ||
+ | *Doxorubicin <=60 mg/m2 | ||
+ | *Epirubicin <=90 mg/m2 | ||
+ | *Idarubicin | ||
+ | *Ifosfamide <10 g/m2 | ||
+ | *Interferon alfa >=10 million international units/m2 | ||
+ | *Irinotecan | ||
+ | *Melphalan | ||
+ | *Methotrexate >=250 mg/m2 | ||
+ | *Oxaliplatin | ||
+ | *Temozolomide | ||
+ | |||
+ | ===Low emetic risk, 10-30% frequency of emesis=== | ||
+ | *Amifostine <=300 mg | ||
+ | *Aldesleukin <=12 million international units/m2 | ||
+ | *Cabazitaxel | ||
+ | *Cytarabine (low dose) 100-200 mg/m2 | ||
+ | *Docetaxel | ||
+ | *Doxorubicin (liposomal) | ||
+ | *Eribulin | ||
+ | *Etoposide | ||
+ | *5-Fluorouracil | ||
+ | *Floxuridine | ||
+ | *Gemcitabine | ||
+ | *Interferon alfa >5, <10 million international units/m2 | ||
+ | *Ixabepilone | ||
+ | *Methotrexate >50, <250 mg/m2 | ||
+ | *Mitomycin | ||
+ | *Mitoxantrone | ||
+ | *Paclitaxel | ||
+ | *Paclitaxel (albumin-bound) | ||
+ | *Pemetrexed | ||
+ | *Pentostatin | ||
+ | *Pralatrexate | ||
+ | *Romidepsin | ||
+ | *Thiotepa | ||
+ | *Topotecan | ||
+ | |||
+ | ===Minimal emetic risk, <10% frequency of emesis=== | ||
+ | *Alemtuzumab | ||
+ | *Asparaginase | ||
+ | *Bevacizumab | ||
+ | *Bleomycin | ||
+ | *Bortezomib | ||
+ | *Cetuximab | ||
+ | *Cladribine (2-chlorodeoxyadenosine) | ||
+ | *Cytarabine <100 mg/m2 | ||
+ | *Decitabine | ||
+ | *Denileukin diftitox | ||
+ | *Dexrazoxane | ||
+ | *Fludarabine | ||
+ | *Interferon alpha <=5 million international units/m2 | ||
+ | *Ipilimumab | ||
+ | *Methotrexate <=50 mg/m2 | ||
+ | *Nelarabine | ||
+ | *Ofatumumab | ||
+ | *Panitumumab | ||
+ | *Pegaspargase | ||
+ | *Peginterferon | ||
+ | *Rituximab | ||
+ | *Temsirolimus | ||
+ | *Trastuzumab | ||
+ | *Valrubicin | ||
+ | *Vinblastine | ||
+ | *Vincristine | ||
+ | *Vinorelbine | ||
==High emetic risk IV chemotherapy== | ==High emetic risk IV chemotherapy== | ||
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==Moderate emetic risk IV chemotherapy== | ==Moderate emetic risk IV chemotherapy== | ||
+ | ===Day 1=== | ||
Select one option from each class on day 1: | Select one option from each class on day 1: | ||
− | ===Serotonin (5-HT3) antagonist=== | + | ====Serotonin (5-HT3) antagonist==== |
*Dolasetron 100 mg PO | *Dolasetron 100 mg PO | ||
*Granisetron 2 mg PO or 1 mg PO BID or 0.01 mg/kg (max 1mg) IV day 1 or transdermal patch as 3.1 mg/24H patch (containing 34.3 mg granisetron total dose) applied ~24-48H prior to the first dose of chemotherapy. May use patch up to 7 days. | *Granisetron 2 mg PO or 1 mg PO BID or 0.01 mg/kg (max 1mg) IV day 1 or transdermal patch as 3.1 mg/24H patch (containing 34.3 mg granisetron total dose) applied ~24-48H prior to the first dose of chemotherapy. May use patch up to 7 days. | ||
Line 30: | Line 125: | ||
*Palonosetron 0.25 mg IV day 1 | *Palonosetron 0.25 mg IV day 1 | ||
− | ===Steroid=== | + | ====Steroid==== |
*Dexamethasone 12 mg PO/IV on day 1 | *Dexamethasone 12 mg PO/IV on day 1 | ||
− | ===Optional=== | + | ====Optional==== |
*Aprepitant 125 mg PO day 1 or fosaprepitant 115 mg IV day 1 | *Aprepitant 125 mg PO day 1 or fosaprepitant 115 mg IV day 1 | ||
*Lorazepam 0.5-2 mg PO/IV/sublingual Q4-6H prn nausea days 1-4 | *Lorazepam 0.5-2 mg PO/IV/sublingual Q4-6H prn nausea days 1-4 | ||
Line 79: | Line 174: | ||
==Low to minimal emetic risk PO chemotherapy== | ==Low to minimal emetic risk PO chemotherapy== | ||
*use antiemetics prn first | *use antiemetics prn first | ||
− | ===If nausea/vomiting | + | ===If nausea/vomiting=== |
− | === | ||
− | |||
Start before chemotherapy and continue daily: | Start before chemotherapy and continue daily: | ||
*Metoclopramide 10-40 mg PO/IV x1, then Q4-6H prn nausea | *Metoclopramide 10-40 mg PO/IV x1, then Q4-6H prn nausea |
Revision as of 04:07, 14 November 2011
Adapted from the NCCN antiemesis guidelines[1].
Emetic risk of IV chemotherapy
High emetic risk, >90% frequency of emesis
- AC combination (doxorubicin or epirubicin with cyclophosphamide)
- Carmustine >250 mg/m2
- Cisplatin >=50 mg/m2
- Cyclophosphamide >1500 mg/m2
- Dacarbazine
- Doxorubicin >60 mg/m2
- Epirubicin >90 mg/m2
- Ifosfamide >= 10 g/m2
- Mechlorethamine
- Streptozocin
Moderate emetic risk, 30-90% frequency of emesis
- Aldesleukin >12-15 million international units/m2
- Amifostine >300 mg/m2
- Arsenic trioxide
- Azacitadine
- Bendamustine
- Busulfan
- Carboplatin
- Carmustine <=250 mg/m2
- Cisplatin <50 mg/m2
- Clofarabine
- Cyclophosphamide <=1500 mg/m2
- Cytarabine >200 mg/m2
- Dactinomycin
- Daunorubicin
- Doxorubicin <=60 mg/m2
- Epirubicin <=90 mg/m2
- Idarubicin
- Ifosfamide <10 g/m2
- Interferon alfa >=10 million international units/m2
- Irinotecan
- Melphalan
- Methotrexate >=250 mg/m2
- Oxaliplatin
- Temozolomide
Low emetic risk, 10-30% frequency of emesis
- Amifostine <=300 mg
- Aldesleukin <=12 million international units/m2
- Cabazitaxel
- Cytarabine (low dose) 100-200 mg/m2
- Docetaxel
- Doxorubicin (liposomal)
- Eribulin
- Etoposide
- 5-Fluorouracil
- Floxuridine
- Gemcitabine
- Interferon alfa >5, <10 million international units/m2
- Ixabepilone
- Methotrexate >50, <250 mg/m2
- Mitomycin
- Mitoxantrone
- Paclitaxel
- Paclitaxel (albumin-bound)
- Pemetrexed
- Pentostatin
- Pralatrexate
- Romidepsin
- Thiotepa
- Topotecan
Minimal emetic risk, <10% frequency of emesis
- Alemtuzumab
- Asparaginase
- Bevacizumab
- Bleomycin
- Bortezomib
- Cetuximab
- Cladribine (2-chlorodeoxyadenosine)
- Cytarabine <100 mg/m2
- Decitabine
- Denileukin diftitox
- Dexrazoxane
- Fludarabine
- Interferon alpha <=5 million international units/m2
- Ipilimumab
- Methotrexate <=50 mg/m2
- Nelarabine
- Ofatumumab
- Panitumumab
- Pegaspargase
- Peginterferon
- Rituximab
- Temsirolimus
- Trastuzumab
- Valrubicin
- Vinblastine
- Vincristine
- Vinorelbine
High emetic risk IV chemotherapy
Select one option from each class:
Serotonin (5-HT3) antagonist
- Dolasetron 100 mg PO
- Granisetron 2 mg PO or 1 mg PO BID or 0.01 mg/kg (max 1mg) IV day 1 or transdermal patch as 3.1 mg/24H patch (containing 34.3 mg granisetron total dose) applied ~24-48H prior to the first dose of chemotherapy. May use patch up to 7 days.
- Ondansetron 16-24 mg PO or 8 - 24 mg (max 32 mg/day) IV day 1 (optional: use on day 2-3)
- Palonosetron 0.25 mg IV day 1
Neurokinin 1 antagonist
- Aprepitant 125 mg PO day 1, 80 mg PO daily days 2-3
- Fosaprepitant 150 mg IV day 1
- Fosaprepitant 115 mg IV day 1, then aprepitant 80 mg PO daily days 2-3
Steroid
- If aprepitant 125 mg or fosaprepitant 115mg on day 1: Dexamethasone 12 mg PO/IV on day 1, 8 mg PO daily days 2-4
- If fosaprepitant 150 mg on day 1: dexamethasone 12 mg PO/IV day 1, 8 mg PO day 2, 8 mg PO BID day 3-4
Optional
- Lorazepam 0.5-2 mg PO/IV/sublingual Q4-6H prn nausea days 1-4
- H2 blocker or proton pump inhibitor
Moderate emetic risk IV chemotherapy
Day 1
Select one option from each class on day 1:
Serotonin (5-HT3) antagonist
- Dolasetron 100 mg PO
- Granisetron 2 mg PO or 1 mg PO BID or 0.01 mg/kg (max 1mg) IV day 1 or transdermal patch as 3.1 mg/24H patch (containing 34.3 mg granisetron total dose) applied ~24-48H prior to the first dose of chemotherapy. May use patch up to 7 days.
- Ondansetron 16-24 mg PO or 8 - 24 mg (max 32 mg/day) IV day 1 (optional: use on day 2-3)
- Palonosetron 0.25 mg IV day 1
Steroid
- Dexamethasone 12 mg PO/IV on day 1
Optional
- Aprepitant 125 mg PO day 1 or fosaprepitant 115 mg IV day 1
- Lorazepam 0.5-2 mg PO/IV/sublingual Q4-6H prn nausea days 1-4
- H2 blocker or proton pump inhibitor
Day 2 and 3
Serotonin (5-HT3) antagonist monotherapy
- Dolasetron 100 mg PO daily
- Granisetron 1-2 mg PO daily or 1 mg PO BID or 0.01 mg/kg (max 1mg) IV
- Ondansetron 8 mg PO BID or 16 mg PO daily or 8 mg IV (max 32 mg/day)
Steroid
- Dexamethasone 8 mg PO/IV daily
Neurokinin 1 antagonist +/- steroid if NK-1 used on day 1
- Aprepitant 80 mg PO daily +/- dexamethasone 8 mg PO/IV daily
Optional
- Lorazepam 0.5-2 mg PO/IV/sublingual Q4-6H prn nausea days 1-4
- H2 blocker or proton pump inhibitor
High to moderate emetic risk PO chemotherapy
Start before chemotherapy and continue daily:
Serotonin (5-HT3) antagonist
- Granisetron 2 mg PO daily or 1 mg PO BID
- Ondansetron 16-24 mg PO daily
Optional
- Lorazepam 0.5-2 mg PO/IV/sublingual Q4-6H prn nausea days 1-4
- H2 blocker or proton pump inhibitor
Low emetic risk IV chemotherapy
Repeat daily for multiple day chemotherapy regimens:
- Dexamethasone 12 mg PO/IV daily
- Metoclopramide 10-40 mg PO/IV x1, then Q4-6H prn nausea
- Prochlorperazine 10mg PO/IV x1, then Q4-6H prn nausea
Optional
- Lorazepam 0.5-2 mg PO/IV/sublingual Q4-6H prn nausea days 1-4
- H2 blocker or proton pump inhibitor
Minimal emetic risk chemotherapy
- No routine prophylaxis
Low to minimal emetic risk PO chemotherapy
- use antiemetics prn first
If nausea/vomiting
Start before chemotherapy and continue daily:
- Metoclopramide 10-40 mg PO/IV x1, then Q4-6H prn nausea
- Prochlorperazine 10mg PO/IV x1, then Q4-6H prn nausea
- Haloperidol 0.5-2 mg PO/IV Q4-6H prn nausea (monitor for dystonic reactions)
Optional
- Lorazepam 0.5-2 mg PO/IV/sublingual Q4-6H prn nausea days 1-4
- H2 blocker or proton pump inhibitor
===If continued nausea/vomiting
=
Use serotonin (5-HT3) antagonist:
- Granisetron 2 mg PO daily or 1 mg PO BID
- Ondansetron 16-24 mg PO daily
Breakthrough nausea treatment
Use a medication from a different drug class from the current regimen as a prn medication.
Benzodiazepine
- Lorazepam 0.5-2 mg PO/IV Q4-6H prn nausea
Cannabinoid
- Dronabinol 5-10 mg PO Q3-6H prn nausea
- Nabilone 1-2 mg PO BID prn nausea
Miscellaneous
- Haloperidol 0.5-2 mg PO/IV Q4-6H prn nausea (monitor for dystonic reactions)
- Metoclopramide 10-40 mg PO/IV Q4-6H prn nausea
- Olanzapine 2.5-5 mg PO BID prn nausea
- Scopolamine 1 patch Q72H prn nausea
Phenothiazine
- Prochlorperazine 25 mg suppository PR Q12H or 10mg PO/IV Q4-6H prn nausea
- Promethazine 12.5-25 mg PO/IV Q4H prn nausea
Serotonin 5-HT3 antagonist
- Dolasetron 100 mg PO daily
- Granisetron 1-2 mg PO daily or 1 mg PO BID or 0.01 mg/kg (max 1mg) IV prn nausea
- Ondansetron 16 mg PO/IV daily prn nausea
Steroid
- Dexamethasone 12 mg PO/IV daily