Antiemesis

Adapted from the NCCN and ASCO guidelines.

Emetic risk of chemotherapy

Hint: You can sort the table by clicking on the boxes containing arrows at the top of each column.
All drugs are IV route unless otherwise specified.

NCCN categories of emetic risk:

• High: >90% frequency of emesis
• Moderate: 30-90% frequency of emesis
• Low: 10-30% frequency of emesis
• Minimal: <10% frequency of emesis

ASCO guidelines say that in cases of combination chemotherapy regimens, patients should be given antiemetics that are recommended for the individual medication with the highest emetic risk. The exception is with anthracycline and Cyclophosphamide (Cytoxan) combinations as described below.

Drug	NCCN emetogenic potential	ASCO emetogenic potential	Comment
Ado-trastuzumab emtansine (Kadcyla)	Low
Anthracycline (see differences between NCCN & ASCO) & Cyclophosphamide (Cytoxan) combination chemotherapy	High (Doxorubicin (Adriamycin) or Epirubicin (Ellence) with Cyclophosphamide (Cytoxan))	High (Daunorubicin (Cerubidine), Doxorubicin (Adriamycin), Epirubicin (Ellence), or Idarubicin (Idamycin) with Cyclophosphamide (Cytoxan))
Aldesleukin (Proleukin)	Moderate: >12 to 15 million international units/m2 Low: ≤12 million international units/m2
Alemtuzumab (Campath)	Minimal	Moderate
Altretamine (Hexalen) (oral)	High/Moderate		NCCN did not further delineate between degrees of emetic potential
Amifostine (Ethyol)	Moderate: >300 mg/m2 Low: ≤300 mg
Arsenic trioxide (Trisenox)	Moderate
Asparaginase (Elspar)	Minimal
Axitinib (Inlyta) (oral)	Low/Minimal
Azacitidine (Vidaza)	Moderate	Moderate
Bendamustine	Moderate	Moderate
Bevacizumab (Avastin)	Minimal	Minimal
Bexarotene (Targretin) (oral)	Low/Minimal		NCCN did not further delineate between degrees of emetic potential
Bleomycin (Blenoxane)	Minimal	Minimal
Bortezomib (Velcade)	Minimal	Low
Bosutinib (Bosulif) (oral)	Low/Minimal
Brentuximab vedotin (Adcetris)	Low
Busulfan (Myleran)	High/Moderate: ≥4 mg/day Low/Minimal: <4 mg/day	Minimal
Busulfan (Myleran) (oral)	High/Moderate: ≥4 mg/day Low/Minimal: <4 mg/day		NCCN did not further delineate between degrees of emetic potential
Cabazitaxel (Jevtana)	Low	Low
Cabozantinib (Cometriq) (oral)	Low/Minimal
Capecitabine (Xeloda) (oral)	Low/Minimal		NCCN did not further delineate between degrees of emetic potential
Carboplatin (Paraplatin)	High: AUC ≥4 Moderate: AUC <4	Moderate (but recommended to receive 3-drug combo of NK1, 5-HT3, and dexamethasone)
Carfilzomib (Kyprolis)	Low
Carmustine (BiCNU)	High: >250 mg/m2 Moderate: ≤250 mg/m2	High	ASCO did not subclassify based on dose
Catumaxomab (Removab)		Low
Cetuximab (Erbitux)	Minimal	Minimal
Chlorambucil (Leukeran) (oral)	Low/Minimal		NCCN did not further delineate between degrees of emetic potential
Cisplatin (Platinol)	High	High	Some only consider emetogenic potential high when receiving ≥70 mg/m2
Cladribine (Leustatin)	Minimal	Minimal
Clofarabine (Clolar)	Moderate	Moderate
Crizotinib (Xalkori) (oral)	High/Moderate
Cyclophosphamide (Cytoxan)	High: >1500 mg/m2 or when given with certain anthracyclines Moderate: ≤1500 mg/m2	High: ≥1500 mg/m2 or when given with anthracyclines Moderate: <1500 mg/m2
Cyclophosphamide (Cytoxan) (oral)	High/Moderate: ≥100 mg/m2/day Low/Minimal: <100 mg/m2/day		NCCN did not further delineate between degrees of emetic potential
Cytarabine (Cytosar)	Moderate: >200 mg/m2 Low: 100 to 200 mg/m2 Minimal: <100 mg/m2	Moderate: >1000 mg/m2 Low: ≤1000 mg/m2
Dabrafenib (Tafinlar) (oral)	Low/Minimal
Dacarbazine (DTIC)	High	High
Dactinomycin (Cosmegen)	Moderate	High
Dasatinib (Sprycel) (oral)	Low/Minimal		NCCN did not further delineate between degrees of emetic potential
Daunorubicin (Cerubidine)	Moderate	High when given with Cyclophosphamide (Cytoxan) Moderate when used alone
Decitabine (Dacogen)	Minimal
Denileukin diftitox (Ontak)	Minimal
Dexrazoxane (Zinecard)	Minimal
Docetaxel (Taxotere)	Low	Low
Doxorubicin (Adriamycin)	High: ≥60 mg/m2 or when given at any dose with Cyclophosphamide (Cytoxan) Moderate: <60 mg/m2	High when given with Cyclophosphamide (Cytoxan) Moderate when used alone
Pegylated liposomal doxorubicin (Doxil)	Low	Low
Epirubicin (Ellence)	High: >90 mg/m2 or when given at any dose with Cyclophosphamide (Cytoxan) Moderate: ≤90 mg/m2	High when given with Cyclophosphamide (Cytoxan) Moderate when used alone
Eribulin (Halaven)	Low
Erlotinib (Tarceva) (oral)	Low/Minimal		NCCN did not further delineate between degrees of emetic potential
Estramustine (Emcyt) (oral)	High/Moderate		NCCN did not further delineate between degrees of emetic potential
Etoposide (Vepesid)	Low	Low
Etoposide (Vepesid) (oral)	High/Moderate		NCCN did not further delineate between degrees of emetic potential
Everolimus (Afinitor) (oral)	Low/Minimal		NCCN did not further delineate between degrees of emetic potential
Floxuridine (FUDR)	Low
Fludarabine (Fludara)	Minimal	Minimal
Fludarabine (Fludara) (oral)	Low/Minimal		NCCN did not further delineate between degrees of emetic potential
Fluorouracil (5-FU)	Low	Low
Gefitinib (Iressa) (oral)	Low/Minimal		NCCN did not further delineate between degrees of emetic potential
Gemcitabine (Gemzar)	Low	Low
Hydroxyurea (Hydrea) (oral)	Low/Minimal		NCCN did not further delineate between degrees of emetic potential
Idarubicin (Idamycin)	Moderate	High when given with Cyclophosphamide (Cytoxan) Moderate when used alone
Ifosfamide (Ifex)	High: ≥2 g/m2 per dose Moderate: <2 g/m2 per dose	Moderate	ASCO did not subclassify based on dose
Imatinib (Gleevec) (oral)	Low/Minimal		NCCN did not further delineate between degrees of emetic potential
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
Ipilimumab (Yervoy)	Minimal
Irinotecan (Camptosar)	Moderate	Moderate
Ixabepilone (Ixempra)	Low	Low
Lapatinib (Tykerb) (oral)	Low/Minimal		NCCN did not further delineate between degrees of emetic potential
Lenalidomide (Revlimid) (oral)	Low/Minimal		NCCN did not further delineate between degrees of emetic potential
Lomustine (Ceenu) (oral)	High/Moderate (single day)		single day; NCCN did not further delineate between degrees of emetic potential
Mechlorethamine (Mustargen)	High	High
Melphalan (Alkeran)	Moderate
Melphalan (Alkeran) (oral)	Low/Minimal		NCCN did not further delineate between degrees of emetic potential
Mercaptopurine (Purinethol) (oral)	Low/Minimal		NCCN did not further delineate between degrees of emetic potential
Methotrexate (MTX)	Moderate: ≥250 mg/m2 Low: >50, <250 mg/m2 Minimal: ≤50 mg/m2	Low	ASCO did not subclassify based on dose
Methotrexate (MTX) (oral)	Low/Minimal		NCCN did not further delineate between degrees of emetic potential
Mitomycin (Mutamycin)	Low	Low
Mitotane (Lysodren) (oral)	High/Moderate
Mitoxantrone (Novantrone)	Low	Low
Nelarabine (Arranon)	Minimal
Nilotinib (Tasigna) (oral)	Low/Minimal		NCCN did not further delineate between degrees of emetic potential
Ofatumumab (Arzzera)	Minimal
Omacetaxine (Synribo)	Low
Oxaliplatin (Eloxatin)	Moderate	Moderate
Paclitaxel (Taxol)	Low	Low
Paclitaxel, nanoparticle albumin-bound (Abraxane)	Low
Panitumumab (Vectibix)	Minimal
Pazopanib (Votrient) (oral)	Low/Minimal		NCCN did not further delineate between degrees of emetic potential
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
Pemetrexed (Alimta)	Low	Low
Pentostatin (Nipent)	Low
Pertuzumab (Perjeta)	Minimal
Pomalidomide (Pomalyst) (oral)	Low/Minimal
Ponatinib (Iclusig) (oral)	Low/Minimal
Pralatrexate (Folotyn)	Low	Minimal
Procarbazine (Matulane) (oral)	High/Moderate		NCCN did not further delineate between degrees of emetic potential
Regorafenib (Stivarga) (oral)	Low/Minimal
Rituximab (Rituxan)	Minimal	Minimal
Romidepsin (Istodax)	Low
Ruxolitinib (Jakafi) (oral)	Low/Minimal
Sorafenib (Nexavar) (oral)	Low/Minimal		NCCN did not further delineate between degrees of emetic potential
Streptozocin (Zanosar)	High	High
Sunitinib (Sutent) (oral)	Low/Minimal		NCCN did not further delineate between degrees of emetic potential
Temozolmide (Temodar)	Moderate
Temozolmide (Temodar) (oral)	High/Moderate: >75 mg/m2/day Low/Minimal: ≤75 mg/m2/day		NCCN did not further delineate between degrees of emetic potential
Temsirolimus (Torisel)	Minimal	Low
Thalidomide (Thalomid) (oral)	Low/Minimal		NCCN did not further delineate between degrees of emetic potential
Thioguanine (Tabloid) (oral)	Low/Minimal		NCCN did not further delineate between degrees of emetic potential
Thiotepa (Thioplex)	Low
Topotecan (Hycamtin)	Low	Low
Topotecan (Hycamtin) (oral)	Low/Minimal		NCCN did not further delineate between degrees of emetic potential
Trametinib (Mekinist) (oral)	Low/Minimal
Trastuzumab (Herceptin)	Minimal	Low
All-trans retinoic acid (ATRA) (oral)	Low/Minimal		NCCN did not further delineate between degrees of emetic potential
Valrubicin (Valstar)	Minimal
Vandetanib (Caprelsa) (oral)	Low/Minimal		NCCN did not further delineate between degrees of emetic potential
Vemurafenib (Zelboraf) (oral)	Low/Minimal
Vinblastine (Velban)	Minimal	Minimal
Vincristine (Oncovin)	Minimal	Minimal
Vincristine liposomal (Marqibo)	Minimal
Vinorelbine (Navelbine)	Minimal	Minimal
Vismodegib (Erivedge) (oral)	High/Moderate
Vorinostat (Zolinza) (oral)	Low/Minimal		NCCN did not further delineate between degrees of emetic potential
Ziv-aflibercept (Zaltrap)	Low

Antiemetics for highly emetogenic IV chemotherapy

Neurokinin-1 (NK1) antagonist-containing regimen (except netupitant)

Select ONE option from each class:

Neurokinin 1 antagonist

• Aprepitant (Emend) 125 mg PO once on day 1, then 80 mg PO once per day on days 2 & 3
• Fosaprepitant (Emend for Injection) 150 mg IV once on day 1
• Rolapitant (Varubi) 180 mg PO once on day 1

Serotonin (5-HT3) antagonist

• Dolasetron (Anzemet) 100 mg PO once on day 1
• Granisetron (choose one of the options below):
  • 2 mg PO once on day 1
  • 0.01 mg/kg (maximum dose 1 mg) IV once on day 1
  • transdermal patch as 3.1 mg/24H patch (containing 34.3 mg granisetron total dose) placed ~24 to 48 hours before the first dose of chemotherapy. May use patch up to 7 days.
• Ondansetron (Zofran) (choose one of the options below):
  • 16 to 24 mg PO once on day 1
  • 8 to 16 mg IV IV once on day 1
• Palonosetron (Aloxi) 0.25 mg IV once on day 1
• Ramosetron (Iribo) 0.3mg IV day 1
• Tropisetron (Navoban) 5 mg PO/IV day 1

Steroid

Steroids contraindicated for use with interleukin-2 and interferon.

• If Aprepitant (Emend) used:
  • NCCN: Dexamethasone (Decadron) 12 mg PO/IV once on day 1, then 8 mg PO/IV once per day on days 2 to 4
  • ASCO: Dexamethasone (Decadron) 12 mg PO/IV once on day 1, then 8 mg PO/IV once per day on days 2 to 4
• If Fosaprepitant (Emend for Injection) used:
  • NCCN: Dexamethasone (Decadron) 12 mg PO/IV once on day 1, then 8 mg PO/IV once per day on days 2 to 4
  • ASCO: Dexamethasone (Decadron) 12 mg PO/IV once on day 1, then 8 mg PO/IV once on day 2, then 8 mg PO/IV BID on days 3 & 4
• If Rolapitant (Varubi) used:
  • NCCN: Dexamethasone (Decadron) 12 mg PO/IV once on day 1, then 8 mg PO/IV BID on days 2 to 4
  • ASCO: Dexamethasone (Decadron) 12 mg PO/IV once on day 1, then 8 mg PO/IV BID on days 2 to 4

References

1. Grunberg S, Chua D, Maru A, Dinis J, DeVandry S, Boice JA, Hardwick JS, Beckford E, Taylor A, Carides A, Roila F, Herrstedt J. Single-dose fosaprepitant for the prevention of chemotherapy-induced nausea and vomiting associated with cisplatin therapy: randomized, double-blind study protocol--EASE. J Clin Oncol. 2011 Apr 10;29(11):1495-501. Epub 2011 Mar 7. link to original article PubMed

Netupitant-containing regimen

• Netupitant and palonosetron (Akynzeo) 300/0.5 mg PO once on day 1
• Dexamethasone (Decadron) 12 mg PO/IV once on day 1, then 8 mg PO/IV once per day on days 2 to 4

Olanzapine-containing regimen

Note: a 4-drug regimen based on Navari et al. 2016 is likely to be recommended in the next release of the NCCN Guidelines.

• Olanzapine (Zyprexa) 10 mg PO once per day on days 1 to 4
• Palonosetron (Aloxi) 0.25 mg IV once on day 1
• Dexamethasone (Decadron) 20 mg IV once on day 1

Optional

• Lorazepam (Ativan) 0.5 to 2 mg PO/IV/sublingual Q4-6H prn nausea on days 1 to 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

Note: NCCN lists all of the below as potential options, whereas ASCO only lists Palonosetron (Aloxi). Palonosetron (Aloxi) is preferred by the NCCN.

• Dolasetron (Anzemet) 100 mg PO day 1
• Granisetron (choose one of the options below):
  • 2 mg PO day 1
  • 1 mg PO BID day 1
  • 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 to 48 hours before the first dose of chemotherapy. May use patch up to 7 days.
• Ondansetron (Zofran) (choose one of the options below):
  • 16 to 24 mg PO day 1
  • 8 to 16 mg IV day 1 IV day 1
• Palonosetron (Aloxi) (choose one of the options below):
  • 0.25 mg IV day 1
  • 0.5 mg PO day 1

Steroid

Steroids contraindicated for use with interleukin-2 and interferon.

• NCCN: Dexamethasone (Decadron) 12 mg PO/IV day 1
• ASCO: Dexamethasone (Decadron) 8 mg PO/IV day 1

Optional

• Aprepitant (Emend) 125 mg PO day 1 or Fosaprepitant (Emend for Injection) 115 mg IV day 1
• Lorazepam (Ativan) 0.5 to 2 mg PO/IV/sublingual Q4 to 6H prn nausea days 1 to 4
• H2 blocker or proton pump inhibitor

Day 2 and 3

ASCO only recommends Dexamethasone (Decadron), whereas NCCN allows you to choose any one class of medication to use: either a serotonin (5-HT3) antagonist, or steroid, or neurokinin 1 antagonist +/- steroid.

Serotonin (5-HT3) antagonist

• Dolasetron (Anzemet) 100 mg PO daily
• Granisetron (choose one of the options below):
  • 1 to 2 mg PO once per day on days 2 & 3
  • 1 mg PO BID on days 2 & 3
  • 0.01 mg/kg (max 1mg) IV on days 2 & 3
  • continued use of 3.1 mg/24H transdermal patch
• Ondansetron (Zofran) (choose one of the options below):
  • 8 mg PO BID on days 2 & 3
  • 16 mg PO once per day on days 2 & 3
  • 8 to 16 mg IV days 2 to 3

Steroid

Steroids contraindicated for use with interleukin-2 and interferon.

• Dexamethasone (Decadron) 8 mg PO/IV once per day on days 2 & 3

Neurokinin 1 antagonist +/- steroid if NK-1 used on day 1

• Aprepitant (Emend) 80 mg PO once per day on days 2 to 3 +/- Dexamethasone (Decadron) 8 mg PO/IV once per day days 2-3

Optional

• Lorazepam (Ativan) 0.5 to 2 mg PO/IV/sublingual Q4-6H prn nausea
• H2 blocker or proton pump inhibitor

Antiemetics for highly to moderately emetogenic PO chemotherapy

These are NCCN recommendations only. ASCO did not provide separate recommendations for PO vs. IV chemotherapy.
Start before chemotherapy and continue once per day:

Serotonin (5-HT3) antagonist

• Granisetron (choose one of the options below):
  • 2 mg PO once per day
  • 1 mg PO BID
• Ondansetron (Zofran) 16 to 24 mg PO once per day

Optional

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

Antiemetics for low emetic risk IV chemotherapy

Repeat once per day for chemotherapy regimens that last more than one day. ASCO only recommends Dexamethasone (Decadron), whereas NCCN allows you to choose any one medication to use: either Dexamethasone (Decadron), metoclopramide, or prochlorperazine.

• Dexamethasone (Decadron) (contraindicated for use with interleukin-2 and interferon)
  • NCCN: 12 mg PO/IV on the days of chemotherapy
  • ASCO: 8 mg PO/IV on the days of chemotherapy
• Metoclopramide (Reglan) 10-40 mg PO/IV x1, then Q4-6H prn nausea
• Prochlorperazine (Compazine) 10mg PO/IV x1, then Q4-6H prn nausea

Optional

• Lorazepam (Ativan) 0.5 to 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

Choose one of the medications below to start before chemotherapy and continue once per day:

• Metoclopramide (Reglan) 10-40 mg PO/IV x1, then Q4-6H prn nausea
• Prochlorperazine (Compazine) 10mg PO/IV x1, then Q4-6H prn nausea
• Haloperidol (Haldol) 0.5 to 2 mg PO/IV Q4-6H prn nausea (monitor for dystonic reactions)

Optional

• Lorazepam (Ativan) 0.5 to 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 (choose one of the options below):
  • 2 mg PO once per day
  • 1 mg PO BID
• Ondansetron (Zofran) 16 to 24 mg PO once per day

Breakthrough antinausea treatment

Use a medication from a different drug class from the current regimen as a prn medication.

Benzodiazepine

• Lorazepam (Ativan) 0.5 to 2 mg PO/IV Q4-6H prn nausea

Cannabinoid

• Dronabinol (Marinol) 5-10 mg PO Q3-6H prn nausea
• Nabilone (Cesamet) 1-2 mg PO BID prn nausea

Miscellaneous

• Haloperidol (Haldol) 0.5 to 2 mg PO/IV Q4-6H prn nausea (monitor for dystonic reactions)
• Metoclopramide (Reglan) 10-40 mg PO/IV Q4-6H prn nausea
• Olanzapine (Zyprexa) 2.5-5 mg PO BID prn nausea
• Scopolamine (Scopoderm) 1 patch Q72H prn nausea

Phenothiazine

• Prochlorperazine (Compazine) (choose one of the options below):
  • 25 mg suppository PR Q12H prn nausea
  • 10mg PO/IV Q4-6H prn nausea
• Promethazine (Phenergan) 12.5-25 mg PO/IV Q4H prn nausea

Serotonin 5-HT3 antagonist

• Dolasetron (Anzemet) 100 mg PO once per day
• Granisetron (choose one of the options below):
  • 1-2 mg PO once per day
  • 1 mg PO BID
  • 0.01 mg/kg (max 1mg) IV prn nausea
• Ondansetron (Zofran) 16 to 24 mg PO once per day prn nausea

Steroid

Steroids contraindicated for use with interleukin-2 and interferon.

• Dexamethasone (Decadron) 12 mg PO/IV once per day

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 (Xanax) 0.5 to 2 mg PO TID starting the night before treatment
• Lorazepam (Ativan) 0.5 to 2 mg PO the night before and the morning of treatment