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>. [http://jco.ascopubs.org/content/29/31/4189.full.pdf+html Antiemetics: American Society of Clinical Oncology Clinical Practice Guideline Update (JCO November 1, 2011)]
 
Adapted from the NCCN antiemesis guidelines<ref>[http://www.nccn.org/professionals/physician_gls/pdf/antiemesis.pdf NCCN antiemesis guidelines]</ref>. [http://jco.ascopubs.org/content/29/31/4189.full.pdf+html Antiemetics: American Society of Clinical Oncology Clinical Practice Guideline Update (JCO November 1, 2011)]
  
−
==Emetic risk of IV chemotherapy==
+
==Emetic risk of chemotherapy==
 +
 
 +
{| class="wikitable sortable" border="1" style="text-align:center;"
 +
!Drug
 +
!NCCN emetogenic potential
 +
!ASCO emetogenic potential
 +
!Comment
 +
|-
 +
|align="left" | AC combination ([[Doxorubicin (Adriamycin)]] or [[Epirubicin (Ellence)]] with [[Cyclophosphamide (Cytoxan)]])
 +
|High
 +
|High
 +
|
 +
|-
 +
|align="left" | [[Carmustine (BiCNU)]]
 +
|High: >250 mg/m2<br>Moderate: <=250 mg/m2
 +
|High
 +
|ASCO did not subclassify based on dose
 +
|-
 +
|align="left" | [[Cisplatin (Platinol)]]
 +
|High: >=50 mg/m2<br>Moderate: <50 mg/m2
 +
|High
 +
|ASCO did not subclassify based on dose
 +
|-
 +
|align="left" | [[Cyclophosphamide (Cytoxan)]]
 +
|High: >1500 mg/m2<br>Moderate: <=1500 mg/m2
 +
|High: =>1500 mg/m2<br>Moderate: <1500 mg/m2
 +
|
 +
|-
 +
|align="left" | [[Dacarbazine (DTIC)]]
 +
|High
 +
|High
 +
|
 +
|-
 +
|align="left" | [[Doxorubicin (Adriamycin)]]
 +
|High: >60 mg/m2<br>Moderate: <=60 mg/m2
 +
|Moderate
 +
|ASCO classified as high if combined with [[Cyclophosphamide (Cytoxan)]] but did not subclassify based on dose
 +
|-
 +
|align="left" | [[Epirubicin (Ellence)]]
 +
|High: >90 mg/m2<br>Moderate: <=90 mg/m2
 +
|Moderate
 +
|ASCO classified as high if combined with [[Cyclophosphamide (Cytoxan)]] but did not subclassify based on dose
 +
|-
 +
|align="left" | [[Ifosfamide (Ifex)]]
 +
|High: >=10 g/m2 <br>Moderate: <10 g/m2
 +
|Moderate
 +
|ASCO did not subclassify based on dose
 +
|-
 +
|align="left" | [[Mechlorethamine (Mustargen)]]
 +
|High
 +
|High
 +
|
 +
|-
 +
|align="left" | [[Streptozocin (Zanosar)]]
 +
|High
 +
|High
 +
|
 +
|-
 +
|align="left" | [[Aldesleukin (Proleukin)]]
 +
|Moderate: >12-15 million international units/m2<br>Low: <=12 million international units/m2
 +
|
 +
|
 +
|-
 +
|align="left" | [[Alemtuzumab (Campath)]]
 +
|Minimal
 +
|Moderate
 +
|
 +
|-
 +
|align="left" | [[Amifostine (Ethyol)]]
 +
|Moderate: >300 mg/m2<br>Low: <=300 mg
 +
|
 +
|
 +
|-
 +
|align="left" | [[Arsenic trioxide (Trisenox)]]
 +
|Moderate
 +
|
 +
|
 +
|-
 +
|align="left" | [[Azacitidine (Vidaza)]]
 +
|Moderate
 +
|Moderate
 +
|
 +
|-
 +
|align="left" | [[Bendamustine (Treanda)]]
 +
|Moderate
 +
|Moderate
 +
|
 +
|-
 +
|align="left" | [[Busulfan (Myleran)]]
 +
|Moderate
 +
|Minimal
 +
|
 +
|-
 +
|align="left" | [[Carboplatin (Paraplatin)]]
 +
|Moderate
 +
|Moderate
 +
|
 +
|-
 +
|align="left" | [[Clofarabine (Clolar)]]
 +
|Moderate
 +
|Moderate
 +
|
 +
|-
 +
|align="left" | [[Cytarabine (Cytosar)]]
 +
|Moderate: >200 mg/m2<br>Low: 100-200 mg/m2
 +
|Moderate: >1000 mg/m2<br>Low: <=1000 mg/m2
 +
|
 +
|-
 +
|align="left" | [[Dactinomycin (Cosmegen)]]
 +
|Moderate
 +
|High
 +
|
 +
|-
 +
|align="left" | [[Daunorubicin (Cerubidine)]]
 +
|Moderate
 +
|Moderate
 +
|
 +
|-
 +
|align="left" | [[Idarubicin (Idamycin)]]
 +
|Moderate
 +
|Moderate
 +
|
 +
|-
 +
|align="left" | [[Interferon alfa-2a (Roferon-A)]]
 +
|Moderate: >=10 million international units/m2<br>Low: >5, <10 million international units/m2<br>Minimal: <=5 million international units/m2
 +
|
 +
|NCCN did not specify interferon alfa-2a vs. 2b
 +
|-
 +
|align="left" | [[Interferon alfa-2b (Intron-A)]]
 +
|Moderate: >=10 million international units/m2<br>Low: >5, <10 million international units/m2<br>Minimal: <=5 million international units/m2
 +
|
 +
|NCCN did not specify interferon alfa-2a vs. 2b
 +
|-
 +
|align="left" | [[Irinotecan (Camptosar)]]
 +
|Moderate
 +
|Moderate
 +
|
 +
|-
 +
|align="left" | [[Melphalan (Alkeran)]]
 +
|Moderate
 +
|
 +
|
 +
|-
 +
|align="left" | [[Methotrexate (MTX)]]
 +
|Moderate: >=250 mg/m2<br>Low: >50, <250 mg/m2<br>Minimal: <=50 mg/m2
 +
|Low
 +
|ASCO did not subclassify based on dose
 +
|-
 +
|align="left" | [[Oxaliplatin (Eloxatin)]]
 +
|Moderate
 +
|Moderate
 +
|
 +
|-
 +
|align="left" | [[Ixabepilone (Ixempra)]]
 +
|Low
 +
|Low
 +
|
 +
|-
 +
|align="left" | [[Temozolmide (Temodar)]]
 +
|Moderate
 +
|
 +
|
 +
|-
 +
|align="left" | [[Cabazitaxel (Jevtana)]]
 +
|Low
 +
|Low
 +
|
 +
|-
 +
|align="left" | [[Docetaxel (Taxotere)]]
 +
|Low
 +
|Low
 +
|
 +
|-
 +
|align="left" | [[Doxorubicin liposomal (Doxil)]]
 +
|Low
 +
|Low
 +
|
 +
|-
 +
|align="left" | [[Eribulin (Halaven)]]
 +
|Low
 +
|
 +
|
 +
|-
 +
|align="left" | [[Etoposide (Vepesid)]]
 +
|Low
 +
|Low
 +
|
 +
|-
 +
|align="left" | [[Fluorouracil (5-FU)]]
 +
|Low
 +
|Low
 +
|
 +
|-
 +
|align="left" | [[Gemcitabine (Gemzar)]]
 +
|Low
 +
|Low
 +
|
 +
|-
 +
|align="left" | [[Mitomycin (Mutamycin)]]
 +
|Low
 +
|Low
 +
|
 +
|-
 +
|align="left" | [[Mitoxantrone (Novantrone)]]
 +
|Low
 +
|Low
 +
|
 +
|-
 +
|align="left" | [[Paclitaxel (Taxol)]]
 +
|Low
 +
|Low
 +
|
 +
|-
 +
|align="left" | [[Paclitaxel, nanoparticle albumin-bound (Abraxane)]]
 +
|Low
 +
|
 +
|
 +
|-
 +
|align="left" | [[Pemetrexed (Alimta)]]
 +
|Low
 +
|Low
 +
|
 +
|-
 +
|align="left" | [[Pentostatin (Nipent)]]
 +
|Low
 +
|
 +
|
 +
|-
 +
|align="left" | [[Pralatrexate (Folotyn)]]
 +
|Low
 +
|Minimal
 +
|
 +
|-
 +
|align="left" | [[Romidepsin (Istodax)]]
 +
|Low
 +
|
 +
|
 +
|-
 +
|align="left" | [[Thiotepa (Thioplex)]]
 +
|Low
 +
|
 +
|
 +
|-
 +
|align="left" | [[Topotecan (Hycamtin)]]
 +
|Low
 +
|Low
 +
|
 +
|-
 +
|align="left" | [[Asparaginase (Elspar)]]
 +
|Minimal
 +
|
 +
|
 +
|-
 +
|align="left" | [[Bevacizumab (Avastin)]]
 +
|Minimal
 +
|Minimal
 +
|
 +
|-
 +
|align="left" | [[Bleomycin (Blenoxane)]]
 +
|Minimal
 +
|Minimal
 +
|
 +
|-
 +
|align="left" | [[Bortezomib (Velcade)]]
 +
|Minimal
 +
|Low
 +
|
 +
|-
 +
|align="left" | [[Cetuximab (Erbitux)]]
 +
|Minimal
 +
|Minimal
 +
|
 +
|-
 +
|align="left" | [[Cladribine (Leustatin)]]
 +
|Minimal
 +
|Minimal
 +
|
 +
|-
 +
|align="left" | [[Decitabine (Dacogen)]]
 +
|Minimal
 +
|
 +
|
 +
|-
 +
|align="left" | [[Denileukin diftitox (Ontak)]]
 +
|Minimal
 +
|
 +
|
 +
|-
 +
|align="left" | [[Dexrazoxane (Zinecard)]]
 +
|Minimal
 +
|
 +
|
 +
|-
 +
|align="left" | [[Fludarabine (Fludara)]]
 +
|Minimal
 +
|Minimal
 +
|
 +
|-
 +
|align="left" | [[Ipilimumab (Yervoy)]]
 +
|Minimal
 +
|
 +
|
 +
|-
 +
|align="left" | [[Nelarabine (Arranon)]]
 +
|Minimal
 +
|
 +
|
 +
|-
 +
|align="left" | [[Ofatumumab (Arzzera)]]
 +
|Minimal
 +
|
 +
|
 +
|-
 +
|align="left" | [[Panitumumab (Vectibix)]]
 +
|Minimal
 +
|
 +
|
 +
|-
 +
|align="left" | [[Peg-asparginase (Oncaspar)]]
 +
|Minimal
 +
|
 +
|
 +
|-
 +
|align="left" | [[Peginterferon alfa-2a (Pegasys)]]
 +
|Minimal
 +
|
 +
|NCCN did not specify interferon alfa-2a vs. 2b
 +
|-
 +
|align="left" | [[Peginterferon alfa-2b (PegIntron)]]
 +
|Minimal
 +
|
 +
|NCCN did not specify interferon alfa-2a vs. 2b
 +
|-
 +
|align="left" | [[Rituximab (Rituxan)]]
 +
|Minimal
 +
|Minimal
 +
|
 +
|-
 +
|align="left" | [[Temsirolimus (Torisel)]]
 +
|Minimal
 +
|Low
 +
|
 +
|-
 +
|align="left" | [[Trastuzumab (Herceptin)]]
 +
|Minimal
 +
|Low
 +
|
 +
|-
 +
|align="left" | [[Valrubicin (Valstar)]]
 +
|Minimal
 +
|
 +
|
 +
|-
 +
|align="left" | [[Vinblastine (Velban)]]
 +
|Minimal
 +
|Minimal
 +
|
 +
|-
 +
|align="left" | [[Vincristine (Oncovin)]]
 +
|Minimal
 +
|Minimal
 +
|
 +
|-
 +
|align="left" | [[Vinorelbine (Navelbine)]]
 +
|Minimal
 +
|Minimal
 +
|
 +
|-
 +
|}
 +
 
 
===High emetic risk, >90% frequency of emesis===
 
===High emetic risk, >90% frequency of emesis===
−
*AC combination (doxorubicin or epirubicin with cyclophosphamide)
+
*AC combination ([[Doxorubicin (Adriamycin)]] or [[Epirubicin (Ellence)]] with [[Cyclophosphamide (Cytoxan)]])
−
*Carmustine >250 mg/m2
+
*[[Carmustine (BiCNU)]] >250 mg/m2
−
*Cisplatin >=50 mg/m2
+
*[[Cisplatin (Platinol)]] >=50 mg/m2
−
*Cyclophosphamide >1500 mg/m2
+
*[[Cyclophosphamide (Cytoxan)]] >1500 mg/m2
−
*Dacarbazine
+
*[[Dacarbazine (DTIC)]]
−
*Doxorubicin >60 mg/m2
+
*[[Doxorubicin (Adriamycin)]] >60 mg/m2 -- NCCN classifies as potentially high depending on dose; ASCO classifies it as moderate by itself but high when combined with [[Cyclophosphamide (Cytoxan)]]
−
*Epirubicin >90 mg/m2
+
*[[Epirubicin (Ellence)]] >90 mg/m2 -- NCCN classifies as potentially high depending on dose; ASCO classifies it as moderate by itself but as high when combined with [[Cyclophosphamide (Cytoxan)]]
−
*Ifosfamide >= 10 g/m2
+
*[[Ifosfamide (Ifex)]] >= 10 g/m2 -- NCCN classifies as potentially high depending on dose; ASCO classifies it as moderate
−
*Mechlorethamine
+
*[[Mechlorethamine (Mustargen)]]
−
*Streptozocin
+
*[[Streptozocin (Zanosar)]]
  
 
===Moderate emetic risk, 30-90% frequency of emesis===
 
===Moderate emetic risk, 30-90% frequency of emesis===
−
*Aldesleukin >12-15 million international units/m2
+
*[[Aldesleukin (Proleukin)]] >12-15 million international units/m2
−
*Amifostine >300 mg/m2
+
*[[Alemtuzumab (Campath)]] -- ASCO classifies as moderate; NCCN classifies as minimal
−
*Arsenic trioxide
+
*[[Amifostine (Ethyol)]] >300 mg/m2
−
*Azacitadine
+
*[[Arsenic trioxide (Trisenox)]]
−
*Bendamustine
+
*[[Azacitidine (Vidaza)]]
−
*Busulfan
+
*[[Bendamustine (Treanda)]]
 +
*[[Busulfan (Myleran)]] -- NCCN classifies as moderate; ASCO classifies as
 
*Carboplatin
 
*Carboplatin
 
*Carmustine <=250 mg/m2
 
*Carmustine <=250 mg/m2
Line 67: Line 437:
  
 
===Minimal emetic risk, <10% frequency of emesis===
 
===Minimal emetic risk, <10% frequency of emesis===
−
*Alemtuzumab
+
*[[Alemtuzumab (Campath)]] -- NCCN classifies as minimal; ASCO classifies as moderate
 
*Asparaginase
 
*Asparaginase
 
*Bevacizumab
 
*Bevacizumab
Line 136: Line 506:
 
*Vorinostat
 
*Vorinostat
  
−
==High emetic risk IV chemotherapy==
+
==Antiemetics for highly emetogenic IV chemotherapy==
 
Select one option from each class:
 
Select one option from each class:
 
===Serotonin (5-HT3) antagonist===
 
===Serotonin (5-HT3) antagonist===
−
*Dolasetron 100 mg PO
+
*Dolasetron 100 mg PO day 1
−
*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 (choose one of the options below):
−
*Ondansetron 16-24 mg PO or 8 - 24 mg (max 32 mg/day) IV day 1 (optional: use on day 2-3)
+
**2 mg PO  
−
*Palonosetron 0.25 mg IV day 1
+
**1 mg PO BID  
 +
**0.01 mg/kg (max 1mg) IV day 1  
 +
**transdermal patch as 3.1 mg/24H patch (containing 34.3 mg granisetron total dose) placed ~24-48 hours before the first dose of chemotherapy. May use patch up to 7 days.
 +
*Ondansetron (choose one of the options below):
 +
**16-24 mg PO  
 +
**8-24 mg (max 32 mg/day) IV day 1 (optional: may continue using on day 2-3)
 +
*Palonosetron (choose one of the options below):
 +
**0.25 mg IV day 1
 +
**0.5 mg PO day 1
  
 
===Neurokinin 1 antagonist===
 
===Neurokinin 1 antagonist===
Line 150: Line 528:
  
 
===Steroid===
 
===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 aprepitant 125 mg or fosaprepitant 115mg on day 1: Dexamethasone 12 mg PO/IV on day 1, then 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
+
*If fosaprepitant 150 mg on day 1: dexamethasone 12 mg PO/IV day 1, 8 mg PO day 2, 8 mg PO BID days 3-4
  
 
===Optional===
 
===Optional===
Line 157: Line 535:
 
*H2 blocker or proton pump inhibitor
 
*H2 blocker or proton pump inhibitor
  
−
==Moderate emetic risk IV chemotherapy==
+
==Antiemetics for moderately emetogenic IV chemotherapy==
 
===Day 1===
 
===Day 1===
 
Select one option from each class on day 1:
 
Select one option from each class on day 1:
Line 190: Line 568:
 
*H2 blocker or proton pump inhibitor
 
*H2 blocker or proton pump inhibitor
  
−
==High to moderate emetic risk PO chemotherapy==
+
==Antiemetics for highly to moderately emetogenic PO chemotherapy==
 
Start before chemotherapy and continue daily:
 
Start before chemotherapy and continue daily:
 
===Serotonin (5-HT3) antagonist===
 
===Serotonin (5-HT3) antagonist===
Line 200: Line 578:
 
*H2 blocker or proton pump inhibitor
 
*H2 blocker or proton pump inhibitor
  
−
==Low emetic risk IV chemotherapy==
+
==Antiemetics for low emetic risk IV chemotherapy==
 
Repeat daily for multiple day chemotherapy regimens:
 
Repeat daily for multiple day chemotherapy regimens:
 
*Dexamethasone 12 mg PO/IV daily
 
*Dexamethasone 12 mg PO/IV daily
Line 213: Line 591:
 
*No routine prophylaxis
 
*No routine prophylaxis
  
−
==Low to minimal emetic risk PO chemotherapy==
+
==Antiemetics for low to minimal emetic risk PO chemotherapy==
 
*use antiemetics prn first
 
*use antiemetics prn first
 
===If nausea/vomiting===
 
===If nausea/vomiting===

Revision as of 07:03, 21 February 2012

Adapted from the NCCN antiemesis guidelines[1]. Antiemetics: American Society of Clinical Oncology Clinical Practice Guideline Update (JCO November 1, 2011)

Emetic risk of chemotherapy

Drug NCCN emetogenic potential ASCO emetogenic potential Comment
AC combination (Doxorubicin (Adriamycin) or Epirubicin (Ellence) with Cyclophosphamide (Cytoxan)) High High
Carmustine (BiCNU) High: >250 mg/m2
Moderate: <=250 mg/m2 		High ASCO did not subclassify based on dose
Cisplatin (Platinol) High: >=50 mg/m2
Moderate: <50 mg/m2 		High ASCO did not subclassify based on dose
Cyclophosphamide (Cytoxan) High: >1500 mg/m2
Moderate: <=1500 mg/m2 		High: =>1500 mg/m2
Moderate: <1500 mg/m2
Dacarbazine (DTIC) High High
Doxorubicin (Adriamycin) High: >60 mg/m2
Moderate: <=60 mg/m2 		Moderate ASCO classified as high if combined with Cyclophosphamide (Cytoxan) but did not subclassify based on dose
Epirubicin (Ellence) High: >90 mg/m2
Moderate: <=90 mg/m2 		Moderate ASCO classified as high if combined with Cyclophosphamide (Cytoxan) but did not subclassify based on dose
Ifosfamide (Ifex) High: >=10 g/m2
Moderate: <10 g/m2 		Moderate ASCO did not subclassify based on dose
Mechlorethamine (Mustargen) High High
Streptozocin (Zanosar) High High
Aldesleukin (Proleukin) Moderate: >12-15 million international units/m2
Low: <=12 million international units/m2
Alemtuzumab (Campath) Minimal Moderate
Amifostine (Ethyol) Moderate: >300 mg/m2
Low: <=300 mg
Arsenic trioxide (Trisenox) Moderate
Azacitidine (Vidaza) Moderate Moderate
Bendamustine (Treanda) Moderate Moderate
Busulfan (Myleran) Moderate Minimal
Carboplatin (Paraplatin) Moderate Moderate
Clofarabine (Clolar) Moderate Moderate
Cytarabine (Cytosar) Moderate: >200 mg/m2
Low: 100-200 mg/m2 		Moderate: >1000 mg/m2
Low: <=1000 mg/m2
Dactinomycin (Cosmegen) Moderate High
Daunorubicin (Cerubidine) Moderate Moderate
Idarubicin (Idamycin) Moderate Moderate
Interferon alfa-2a (Roferon-A) Moderate: >=10 million international units/m2
Low: >5, <10 million international units/m2
Minimal: <=5 million international units/m2 		NCCN did not specify interferon alfa-2a vs. 2b
Interferon alfa-2b (Intron-A) Moderate: >=10 million international units/m2
Low: >5, <10 million international units/m2
Minimal: <=5 million international units/m2 		NCCN did not specify interferon alfa-2a vs. 2b
Irinotecan (Camptosar) Moderate Moderate
Melphalan (Alkeran) Moderate
Methotrexate (MTX) Moderate: >=250 mg/m2
Low: >50, <250 mg/m2
Minimal: <=50 mg/m2 		Low ASCO did not subclassify based on dose
Oxaliplatin (Eloxatin) Moderate Moderate
Ixabepilone (Ixempra) Low Low
Temozolmide (Temodar) Moderate
Cabazitaxel (Jevtana) Low Low
Docetaxel (Taxotere) Low Low
Doxorubicin liposomal (Doxil) Low Low
Eribulin (Halaven) Low
Etoposide (Vepesid) Low Low
Fluorouracil (5-FU) Low Low
Gemcitabine (Gemzar) Low Low
Mitomycin (Mutamycin) Low Low
Mitoxantrone (Novantrone) Low Low
Paclitaxel (Taxol) Low Low
Paclitaxel, nanoparticle albumin-bound (Abraxane) Low
Pemetrexed (Alimta) Low Low
Pentostatin (Nipent) Low
Pralatrexate (Folotyn) Low Minimal
Romidepsin (Istodax) Low
Thiotepa (Thioplex) Low
Topotecan (Hycamtin) Low Low
Asparaginase (Elspar) Minimal
Bevacizumab (Avastin) Minimal Minimal
Bleomycin (Blenoxane) Minimal Minimal
Bortezomib (Velcade) Minimal Low
Cetuximab (Erbitux) Minimal Minimal
Cladribine (Leustatin) Minimal Minimal
Decitabine (Dacogen) Minimal
Denileukin diftitox (Ontak) Minimal
Dexrazoxane (Zinecard) Minimal
Fludarabine (Fludara) Minimal Minimal
Ipilimumab (Yervoy) Minimal
Nelarabine (Arranon) Minimal
Ofatumumab (Arzzera) Minimal
Panitumumab (Vectibix) Minimal
Peg-asparginase (Oncaspar) Minimal
Peginterferon alfa-2a (Pegasys) Minimal NCCN did not specify interferon alfa-2a vs. 2b
Peginterferon alfa-2b (PegIntron) Minimal NCCN did not specify interferon alfa-2a vs. 2b
Rituximab (Rituxan) Minimal Minimal
Temsirolimus (Torisel) Minimal Low
Trastuzumab (Herceptin) Minimal Low
Valrubicin (Valstar) Minimal
Vinblastine (Velban) Minimal Minimal
Vincristine (Oncovin) Minimal Minimal
Vinorelbine (Navelbine) Minimal Minimal

High emetic risk, >90% frequency of emesis

Moderate emetic risk, 30-90% frequency of emesis

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 (Campath) -- NCCN classifies as minimal; ASCO classifies as moderate
  • 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

Emetic risk of PO chemotherapy

High to moderate emetic risk

  • Altretamine
  • Busulfan >=4 mg/day
  • Cyclophosphamide >=100 mg/m2/day
  • Estramustine
  • Etoposide
  • Lomustine (single day)
  • Procarbazine
  • Temozolomide >75 mg/m2/day

Low to minimal emetic risk

  • Bexarotene
  • Busulfan <4 mg/day
  • Capecitabine
  • Chlorambucil
  • Cyclophosphamide <100 mg/m2/day
  • Dasatinib
  • Erlotinib
  • Everolimus
  • Fludarabine
  • Gefitinib
  • Hydroxyurea
  • Imatinib
  • Lapatinib
  • Lenalidomide
  • Melphalan
  • Mercaptopurine
  • Methotrexate
  • Nilotinib
  • Pazopanib
  • Sorafenib
  • Sunitinib
  • Temozolomide <75 mg/m2/day
  • Thalidomide
  • Thioguanine
  • Topotecan
  • Tretinoin
  • Vandetanib
  • Vorinostat

Antiemetics for highly emetogenic IV chemotherapy

Select one option from each class:

Serotonin (5-HT3) antagonist

  • Dolasetron 100 mg PO day 1
  • Granisetron (choose one of the options below):
    • 2 mg PO
    • 1 mg PO BID
    • 0.01 mg/kg (max 1mg) IV day 1
    • transdermal patch as 3.1 mg/24H patch (containing 34.3 mg granisetron total dose) placed ~24-48 hours before the first dose of chemotherapy. May use patch up to 7 days.
  • Ondansetron (choose one of the options below):
    • 16-24 mg PO
    • 8-24 mg (max 32 mg/day) IV day 1 (optional: may continue using on day 2-3)
  • Palonosetron (choose one of the options below):
    • 0.25 mg IV day 1
    • 0.5 mg PO 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, then 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 days 3-4

Optional

  • Lorazepam 0.5-2 mg PO/IV/sublingual Q4-6H prn nausea days 1-4
  • H2 blocker or proton pump inhibitor

Antiemetics for moderately emetogenic 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

Antiemetics for highly to moderately emetogenic 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

Antiemetics for 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

Antiemetics for 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

Anticipatory nausea/vomiting

  • Prevent anticipation by optimizing antiemetic therapy for every cycle of chemotherapy
  • Behavioral therapy
    • Relaxation/systemic desensitization
    • Hypnosis/guided imagery
    • Music therapy
  • Acupuncture/acupressure
  • Alprazolam 0.5-2 mg PO TID starting the night before treatment
  • Lorazepam 0.5-2 mg PO the night before and the morning of treatment

Reference

  1. ↑ NCCN antiemesis guidelines
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