Difference between revisions of "Antiemesis"
m (melphalan) Tag: visualeditor |
m (comparative efficacy of 5-HT3; dex beyond day 1; MEC table;) Tag: visualeditor |
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''All drugs are IV route unless otherwise specified.'' | ''All drugs are IV route unless otherwise specified.'' | ||
− | NCCN and MASCC categories of emetic risk in the absence of prophylaxis: | + | NCCN, ASCO and MASCC categories of emetic risk in the absence of prophylaxis: |
*High: >90% frequency of emesis (HEC) | *High: >90% frequency of emesis (HEC) | ||
*Moderate: 30-90% frequency of emesis (MEC) | *Moderate: 30-90% frequency of emesis (MEC) | ||
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==Neurokinin-1 (NK1) antagonist-containing regimen (except netupitant)== | ==Neurokinin-1 (NK1) antagonist-containing regimen (except netupitant)== | ||
− | ===Neurokinin 1 (NK1) antagonist | + | ===Neurokinin 1 (NK1) antagonist === |
*[[Aprepitant (Emend)]] 125 mg PO once on day 1, then 80 mg PO once per day on days 2 & 3 | *[[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 | *[[Fosaprepitant (Emend for Injection)]] 150 mg IV once on day 1 | ||
*[[Rolapitant (Varubi)]] 180 mg PO once on day 1 | *[[Rolapitant (Varubi)]] 180 mg PO once on day 1 | ||
+ | ''Note: All of the above NK1 antagonists are equally effective in IV and PO formulations at recommended doses <ref>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. [http://ascopubs.org/doi/full/10.1200/JCO.2010.31.7859 link to original article] [https://www.ncbi.nlm.nih.gov/pubmed/21383291 PubMed]</ref>'' | ||
===Serotonin (5-HT3) antagonist=== | ===Serotonin (5-HT3) antagonist=== | ||
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**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. | **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): | *[[Ondansetron (Zofran)]] (choose one of the options below): | ||
− | **8 to 16 mg IV<ref name="ondansetron QTc">As of 6/28/2012, the once daily dose of ondansetron (Zofran) 32 mg is no longer recommended due to dose-dependent QTc prolongation. The [http://us.gsk.com/products/assets/us_zofran.pdf Ondansetron (Zofran) package insert] recommends only a maximum of 16 mg per dose, which can be given as often as every 4 hours x up to 3 doses, as detailed in the 6/29/2012 [http://www.fda.gov/Drugs/DrugSafety/ucm310190.htm FDA Drug Safety Communication].</ref> | + | **8 to 16 mg IV<ref name="ondansetron QTc">As of 6/28/2012, the once daily dose of ondansetron (Zofran) 32 mg is no longer recommended due to dose-dependent QTc prolongation. The [http://us.gsk.com/products/assets/us_zofran.pdf Ondansetron (Zofran) package insert] recommends only a maximum of 16 mg per dose, which can be given as often as every 4 hours x up to 3 doses, as detailed in the 6/29/2012 [http://www.fda.gov/Drugs/DrugSafety/ucm310190.htm FDA Drug Safety Communication].</ref> once on day 1 |
*[[Palonosetron (Aloxi)]] 0.25 mg IV once on day 1 | *[[Palonosetron (Aloxi)]] 0.25 mg IV once on day 1 | ||
− | |||
*[[Tropisetron (Navoban)]] 5 mg IV or PO day 1 | *[[Tropisetron (Navoban)]] 5 mg IV or PO day 1 | ||
+ | ''Note: When given at biologically equivalent doses, all of the above 5-HT3 antagonists are equally efficacious and appear to be interchangeable''<ref>Karin Jordan et al. "Comparative activity of antiemetic drugs" | ||
+ | |||
+ | https://www-sciencedirect-com.elibrary.einstein.yu.edu/science/article/pii/S1040842806001661#tbl2 | ||
+ | </ref> | ||
+ | |||
+ | ''Note: Ramosetron is another available 5-HT3, but not approved by FDA'' | ||
===Dexamethasone (DEX)=== | ===Dexamethasone (DEX)=== | ||
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**[[Dexamethasone (Decadron)]] 12 mg IV or PO once on day 1, then 8 mg PO twice per day on days 2 to 4 | **[[Dexamethasone (Decadron)]] 12 mg IV or PO once on day 1, then 8 mg PO twice per day on days 2 to 4 | ||
− | ''Dexamethasone use beyond day 1 might be revised based on the 2018 meta analysis results'' | + | ''Dexamethasone use beyond day 1 might be revised based on the 2018 meta analysis results''<ref name=":1">Ronald CHow et Al. "Efficacy and safety of 1-day versus 3-day dexamethasone for the prophylaxis of chemotherapy-induced nausea and vomiting: a systematic review and meta-analysis of randomized controlled trials" |
+ | |||
+ | http://jhmhp.amegroups.com/article/view/4296 | ||
+ | </ref> | ||
==Netupitant-containing regimen== | ==Netupitant-containing regimen== | ||
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=Antiemetics for moderately emetogenic IV chemotherapy= | =Antiemetics for moderately emetogenic IV chemotherapy= | ||
+ | {| class="wikitable" | ||
+ | | | ||
+ | |Day 1 | ||
+ | |Day 2-4 | ||
+ | |- | ||
+ | |ASCO 2017 | ||
+ | |5-HT3 + DEX | ||
+ | |DEX maybe offered for: oxaliplatin, or anthracycline, or cyclophosphamide | ||
+ | |- | ||
+ | |MASCC 2016 | ||
+ | |5-HT3 + DEX | ||
+ | |DEX can be considered for: oxaliplatin, or anthracycline, or cyclophosphamide | ||
+ | |- | ||
+ | | rowspan="3" |NCCN 2019 | ||
+ | |<nowiki>- 5-HT3 + DEX</nowiki> | ||
+ | |DEX or 5-HT3 | ||
+ | |- | ||
+ | |<nowiki>- NK1 + 5-HT3 + DEX </nowiki> | ||
+ | |||
+ | (for selected patients with additional risk factors or previous Rx failure) | ||
+ | |<nowiki>+/- DEX</nowiki> | ||
+ | |- | ||
+ | |<nowiki>- OLN + 5-HT3 + DEX</nowiki> | ||
+ | |OLN | ||
+ | |} | ||
===Serotonin (5-HT3) antagonist=== | ===Serotonin (5-HT3) antagonist=== | ||
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**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. | **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): | *[[Ondansetron (Zofran)]] (choose one of the options below): | ||
− | **8 to 16 mg IV<ref name="ondansetron QTc">As of 6/28/2012, the once daily dose of ondansetron (Zofran) 32 mg is no longer recommended due to dose-dependent QTc prolongation. The [http://us.gsk.com/products/assets/us_zofran.pdf Ondansetron (Zofran) package insert] recommends only a maximum of 16 mg per dose, which can be given as often as every 4 hours x up to 3 doses, as detailed in the 6/29/2012 [http://www.fda.gov/Drugs/DrugSafety/ucm310190.htm FDA Drug Safety Communication].</ref> | + | **8 to 16 mg IV<ref name="ondansetron QTc">As of 6/28/2012, the once daily dose of ondansetron (Zofran) 32 mg is no longer recommended due to dose-dependent QTc prolongation. The [http://us.gsk.com/products/assets/us_zofran.pdf Ondansetron (Zofran) package insert] recommends only a maximum of 16 mg per dose, which can be given as often as every 4 hours x up to 3 doses, as detailed in the 6/29/2012 [http://www.fda.gov/Drugs/DrugSafety/ucm310190.htm FDA Drug Safety Communication].</ref> once on day 1 |
*[[Palonosetron (Aloxi)]] 0.25 mg IV once on day 1 | *[[Palonosetron (Aloxi)]] 0.25 mg IV once on day 1 | ||
− | |||
*[[Tropisetron (Navoban)]] 5 mg IV or PO day 1 | *[[Tropisetron (Navoban)]] 5 mg IV or PO day 1 | ||
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*If [[Rolapitant (Varubi)]] used: | *If [[Rolapitant (Varubi)]] used: | ||
**[[Dexamethasone (Decadron)]] 12 mg IV or PO once on day 1, then 8 mg PO twice per day on days 2 to 4 | **[[Dexamethasone (Decadron)]] 12 mg IV or PO once on day 1, then 8 mg PO twice per day on days 2 to 4 | ||
− | ''Dexamethasone use beyond day 1 might be revised based on the 2018 meta analysis results | + | ''Dexamethasone use beyond day 1 might be revised based on the 2018 meta analysis results''<ref name=":1" /> |
− | |||
− | = | ||
− | |||
==Netupitant-containing regimen== | ==Netupitant-containing regimen== |
Revision as of 02:19, 29 April 2019
Adapted from the NCCN[1], ASCO[2] and MASCC/ESMO[3]
Emetic risk of chemotherapy, immunotherapy, TKIs and other agents
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, ASCO and MASCC categories of emetic risk in the absence of prophylaxis:
- High: >90% frequency of emesis (HEC)
- Moderate: 30-90% frequency of emesis (MEC)
- 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
(2017) |
MASCC/ESMO emetogenic potential (2016) | 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)) | High | MASCC comment - in patients with breast cancer |
Aldesleukin (Proleukin) | Moderate: >12 to 15 million international units/m2 Low: ≤12 million international units/m2 |
|||
Alemtuzumab (Campath) | Minimal | Moderate | 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 | |||
Atezolizumab | Low | |||
Axitinib (Inlyta) (oral) | Low/Minimal | Low | ||
Azacitidine (Vidaza) | Moderate | Moderate | Moderate | |
Bendamustine | Moderate | Moderate | Moderate | |
Bevacizumab (Avastin) | Minimal | Minimal | Minimal | |
Bexarotene (Targretin) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | ||
Bleomycin (Blenoxane) | Minimal | Minimal | Minimal | |
Blinatumomab | Low | |||
Bortezomib (Velcade) | Minimal | Low | Low | |
Bosutinib (Bosulif) (oral) | Low/Minimal | Moderate | ||
Brentuximab vedotin (Adcetris) | Low | Low | ||
Busulfan (Myleran) | High/Moderate: ≥4 mg/day Low/Minimal: <4 mg/day |
Minimal | 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 | Low | |
Cabozantinib (Cometriq) (oral) | Low/Minimal | |||
Capecitabine (Xeloda) (oral) | Low/Minimal | Low | NCCN did not further delineate between degrees of emetic potential | |
Carboplatin (Paraplatin) | High: AUC ≥4
Moderate: AUC <4 |
Moderate (but recommended triplet combination of NK1, 5-HT3, and Dex if AUC ≥4) | Moderate (but recommended triplet combination of NK1, 5-HT3, and dexamethasone) | MASCC/ESMO did not subclassify based on dose |
Carfilzomib (Kyprolis) | Low | Low | ||
Carmustine (BCNU) | High: >250 mg/m2 Moderate: ≤250 mg/m2 |
High | High | ASCO and MASCC/ESMO did not subclassify based on dose |
Catumaxomab (Removab) | Low | Low | ||
Cetuximab (Erbitux) | Minimal | Minimal | Low | |
Chlorambucil (Leukeran) (oral) | Low/Minimal | Minimal | NCCN did not further delineate between degrees of emetic potential | |
Cisplatin (Platinol) | High | High | High | Some only consider emetogenic potential high when receiving ≥70 mg/m2 |
Cladribine (Leustatin) | Minimal | Minimal | Minimal | |
Clofarabine (Clolar) | Moderate | Moderate | Moderate | |
Crizotinib (Xalkori) (oral) | High/Moderate | 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 |
High: > 1500 mg/m2 or when combined with anthracyclines (in breast cancer patients)
Moderate: < 1500 mg/m2 |
|
Cyclophosphamide (Cytoxan) (oral) | High/Moderate: ≥100 mg/m2/day Low/Minimal: <100 mg/m2/day |
Moderate | NCCN did not further delineate between degrees of emetic potential | |
Cytarabine (Ara-C) | Moderate: >200 mg/m2 Low: 100 to 200 mg/m2 Minimal: <100 mg/m2 |
Moderate: >1000 mg/m2 Low: ≤1000 mg/m2 |
Moderate: > 1000 mg/m2
Low: < 1000 mg/m2 |
|
Dabrafenib (Tafinlar) (oral) | Low/Minimal | Low | ||
Dacarbazine (DTIC) | High | High | High | |
Daratumumab | Minimal | |||
Dactinomycin (Cosmegen) | Moderate | High | ||
Dasatinib (Sprycel) (oral) | Low/Minimal | Low | NCCN did not further delineate between degrees of emetic potential | |
Daunorubicin (Cerubidine) | Moderate | High when given with Cyclophosphamide (Cytoxan) Moderate when used alone |
High: when given with combined with cyclophosphamide (in breast cancer patients)
Moderate: when used alone |
|
Decitabine (Dacogen) | Minimal | |||
Denileukin diftitox (Ontak) | Minimal | |||
Dexrazoxane (Zinecard) | Minimal | |||
Docetaxel (Taxotere) | Low | 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 |
High: when given with combined with cyclophosphamide (in breast cancer patients)
Moderate: when used alone |
|
Pegylated liposomal doxorubicin (Doxil) | Low | 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 |
High: when combined with cyclophosphamide (in breast cancer patients)
Moderate: when used alone |
|
Eribulin (Halaven) | Low | Low | ||
Erlotinib (Tarceva) (oral) | Low/Minimal | 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 | Low | |
Etoposide (Vepesid) (oral) | High/Moderate | Low | NCCN did not further delineate between degrees of emetic potential | |
Everolimus (Afinitor) (oral) | Low/Minimal | Low | NCCN did not further delineate between degrees of emetic potential | |
Floxuridine (FUDR) | Low | |||
Fludarabine (Fludara) | Minimal | Minimal | Minimal | |
Fludarabine (Fludara) (oral) | Low/Minimal | Low | NCCN did not further delineate between degrees of emetic potential | |
Fluorouracil (5-FU) | Low | Low | Low | |
Gefitinib (Iressa) (oral) | Low/Minimal | Minimal | NCCN did not further delineate between degrees of emetic potential | |
Gemcitabine (Gemzar) | Low | Low | Low | |
Hydroxyurea (Hydrea) (oral) | Low/Minimal | Minimal | NCCN did not further delineate between degrees of emetic potential | |
Idarubicin (Idamycin) | Moderate | High when given with Cyclophosphamide (Cytoxan) Moderate when used alone |
High: when combined with cyclophosphamide (in breast cancer patients) Moderate: when used alone | |
Ifosfamide (Ifex) | High: ≥2 g/m2 per dose Moderate: <2 g/m2 per dose |
Moderate | Moderate | ASCO and MASCC did not subclassify based on dose |
Imatinib (Gleevec) (oral) | Low/Minimal | Moderate | 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 | Low | ||
Irinotecan (Camptosar) | Moderate | Moderate | Moderate | |
Ixabepilone (Ixempra) | Low | Low | Low | |
Lapatinib (Tykerb) (oral) | Low/Minimal | Low | NCCN did not further delineate between degrees of emetic potential | |
Lenalidomide (Revlimid) (oral) | Low/Minimal | Low | NCCN did not further delineate between degrees of emetic potential | |
Lomustine (CCNU) (oral) | High/Moderate (single day) | single day; NCCN did not further delineate between degrees of emetic potential | ||
Mechlorethamine (Mustargen) | High | High | High | |
Melphalan (Alkeran) | Moderate | ASCO and MASCC recommend combination of NK1+5-HT3+DEX when melphalan is used at high dose for BMT conditioning. | ||
Melphalan (Alkeran) (oral) | Low/Minimal | Minimal | NCCN did not further delineate between degrees of emetic potential | |
Mercaptopurine (6-MP) (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 | Low | ASCO and MASCC did not subclassify based on dose |
Methotrexate (MTX) (oral) | Low/Minimal | Minimal | NCCN did not further delineate between degrees of emetic potential | |
Mitomycin (Mutamycin) | Low | Low | Low | |
Mitotane (Lysodren) (oral) | High/Moderate | |||
Mitoxantrone (Novantrone) | Low | Low | Low | |
Nelarabine (Arranon) | Minimal | |||
Nilotinib (Tasigna) (oral) | Low/Minimal | Low | NCCN did not further delineate between degrees of emetic potential | |
Ofatumumab (Arzzera) | Minimal | Minimal | ||
Omacetaxine (Synribo) | Low | |||
Oxaliplatin (Eloxatin) | Moderate | Moderate | Moderate | |
Paclitaxel (Taxol) | Low | Low | Low | |
Paclitaxel, nanoparticle albumin-bound (Abraxane) | Low | Low | ||
Panitumumab (Vectibix) | Minimal | |||
Pazopanib (Votrient) (oral) | Low/Minimal | Low | 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 | Low | |
Pentostatin (Nipent) | Low | |||
Pertuzumab (Perjeta) | Minimal | Low | ||
Pomalidomide (Pomalyst) (oral) | Low/Minimal | Minimal | ||
Ponatinib (Iclusig) (oral) | Low/Minimal | Low | ||
Pralatrexate (Folotyn) | Low | Minimal | Minimal | |
Procarbazine (Matulane) (oral) | High/Moderate | High | NCCN did not further delineate between degrees of emetic potential | |
Regorafenib (Stivarga) (oral) | Low/Minimal | Low | ||
Rituximab (Rituxan) | Minimal | Minimal | Minimal | |
Romidepsin (Istodax) | Low | Moderate | ||
Ruxolitinib (Jakafi) (oral) | Low/Minimal | Minimal | ||
Sorafenib (Nexavar) (oral) | Low/Minimal | Minimal | NCCN did not further delineate between degrees of emetic potential | |
Streptozocin (Zanosar) | High | High | High | |
Sunitinib (Sutent) (oral) | Low/Minimal | Low | NCCN did not further delineate between degrees of emetic potential | |
Temozolmide (Temodar) | Moderate | Moderate | MASCC remark: No direct evidence found for temozolomide IV. Classification is based on oral temozolomide, since all sources indicate a
similar safety profile | |
Temozolmide (Temodar) (oral) | High/Moderate: >75 mg/m2/day Low/Minimal: ≤75 mg/m2/day |
Moderate | NCCN did not further delineate between degrees of emetic potential | |
Temsirolimus (Torisel) | Minimal | Low | ||
Thalidomide (Thalomid) (oral) | Low/Minimal | Low | NCCN did not further delineate between degrees of emetic potential | |
Thioguanine (Tabloid) (oral) | Low/Minimal | Minimal | NCCN did not further delineate between degrees of emetic potential | |
Thiotepa (Thioplex) | Low | Moderate | ||
Topotecan (Hycamtin) | Low | 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 | Minimal | |
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 | Low | NCCN did not further delineate between degrees of emetic potential | |
Vemurafenib (Zelboraf) (oral) | Low/Minimal | |||
Vinblastine (Velban) | Minimal | Minimal | Minimal | |
Vincristine (Oncovin) | Minimal | Minimal | Minimal | |
Vincristine liposomal (Marqibo) | Minimal | |||
Vinorelbine (Navelbine) | Minimal | Minimal | Minimal | |
Vismodegib (Erivedge) (oral) | High/Moderate | Minimal | ||
Vorinostat (Zolinza) (oral) | Low/Minimal | Low | NCCN did not further delineate between degrees of emetic potential | |
Ziv-aflibercept (Zaltrap) | Low |
Antiemetics for highly emetogenic IV chemotherapy
Day 1 CINV prophylaxis | Day 2-4 CINV prophylaxis | |
ASCO 2017 | NK1 + 5-HT3 + DEX + OLN | DEX + OLN
(if APR on day 1, then +APR days 2-3) |
MASCC 2016 | NK1 + 5-HT3 + DEX | DEX
(if APR on day 1, then +APR days 2-3) |
NCCN 2019 | - NK1 + 5-HT3 + DEX + OLN | DEX + OLN |
- NK1 + 5-HT3 + DEX | DEX | |
- OLN + 5-HT3 + DEX | OLN |
Neurokinin-1 (NK1) antagonist-containing regimen (except netupitant)
Neurokinin 1 (NK1) 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
Note: All of the above NK1 antagonists are equally effective in IV and PO formulations at recommended doses [4]
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):
- 8 to 16 mg IV[5] once on day 1
- Palonosetron (Aloxi) 0.25 mg IV once on day 1
- Tropisetron (Navoban) 5 mg IV or PO day 1
Note: When given at biologically equivalent doses, all of the above 5-HT3 antagonists are equally efficacious and appear to be interchangeable[6]
Note: Ramosetron is another available 5-HT3, but not approved by FDA
Dexamethasone (DEX)
Steroids contraindicated for use with interleukin-2 and interferon.
- If Aprepitant (Emend) used:
- Dexamethasone (Decadron) 12 mg IV or PO once on day 1, then 8 mg PO once per day on days 2 to 4
- If Fosaprepitant (Emend for Injection) used:
- Dexamethasone (Decadron) 12 mg IV or PO once on day 1, then 8 mg PO once per day on days 2 to 4
- If Rolapitant (Varubi) used:
- Dexamethasone (Decadron) 12 mg IV or PO once on day 1, then 8 mg PO twice per day on days 2 to 4
Dexamethasone use beyond day 1 might be revised based on the 2018 meta analysis results[7]
Netupitant-containing regimen
- Netupitant and palonosetron (Akynzeo) 300/0.5 mg PO once on day 1 as a fixed oral formulation
- Dexamethasone (Decadron) 12 mg PO or IV once on day 1, then 8 mg PO or IV once per day on days 2 to 4
Olanzapine (OLN) containing regimen
Note: a 4-drug regimen based on Navari et al. 2016[8]
- Olanzapine (Zyprexa) 10 mg PO once per day on days 1 to 4
- Aprepitant (Emend) 125 mg PO once on day 1, then 80 mg PO once per day on days 2 & 3, OR Fosaprepitant (Emend for Injection) 150 mg IV once on day 1
- Palonosetron (Aloxi) 0.25 mg IV once on day 1, OR Granisetron 1mg IV or 2mg PO, OR Ondansetron 8 mg PO or IV
- Dexamethasone (Decadron) 12 mg PO on day 1, and 8 mg PO on days 2, 3, and 4
Antiemetics for moderately emetogenic IV chemotherapy
Day 1 | Day 2-4 | |
ASCO 2017 | 5-HT3 + DEX | DEX maybe offered for: oxaliplatin, or anthracycline, or cyclophosphamide |
MASCC 2016 | 5-HT3 + DEX | DEX can be considered for: oxaliplatin, or anthracycline, or cyclophosphamide |
NCCN 2019 | - 5-HT3 + DEX | DEX or 5-HT3 |
- NK1 + 5-HT3 + DEX
(for selected patients with additional risk factors or previous Rx failure) |
+/- DEX | |
- OLN + 5-HT3 + DEX | OLN |
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):
- 8 to 16 mg IV[5] once on day 1
- Palonosetron (Aloxi) 0.25 mg IV once on day 1
- Tropisetron (Navoban) 5 mg IV or PO day 1
Dexamethasone (DEX)
Steroids contraindicated for use with interleukin-2 and interferon.
- If Aprepitant (Emend) used:
- Dexamethasone (Decadron) 12 mg IV or PO once on day 1, then 8 mg PO once per day on days 2 to 4
- If Fosaprepitant (Emend for Injection) used:
- Dexamethasone (Decadron) 12 mg IV or PO once on day 1, then 8 mg PO once per day on days 2 to 4
- If Rolapitant (Varubi) used:
- Dexamethasone (Decadron) 12 mg IV or PO once on day 1, then 8 mg PO twice per day on days 2 to 4
Dexamethasone use beyond day 1 might be revised based on the 2018 meta analysis results[7]
Netupitant-containing regimen
- Netupitant and palonosetron (Akynzeo) 300/0.5 mg PO once on day 1 as a fixed oral formulation
- Dexamethasone (Decadron) 12 mg PO or IV once on day 1, then 8 mg PO or IV once per day on days 2 to 4
Olanzapine (OLN) containing regimen
Note: a 4-drug regimen based on Navari et al. 2016[9]
- Olanzapine (Zyprexa) 10 mg PO once per day on days 1 to 4
- Aprepitant (Emend) 125 mg PO once on day 1, then 80 mg PO once per day on days 2 & 3, OR Fosaprepitant (Emend for Injection) 150 mg IV once on day 1
- Palonosetron (Aloxi) 0.25 mg IV once on day 1, OR Granisetron 1mg IV or 2mg PO, OR Ondansetron 8 mg PO or IV
- Dexamethasone (Decadron) 12 mg PO on day 1, and 8 mg PO on days 2, 3, and 4
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 twice per day 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[5] 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 IV or PO day 1
- ASCO: Dexamethasone (Decadron) 8 mg IV or PO 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 twice per day 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 twice per day on days 2 & 3
- 16 mg PO once per day on days 2 & 3
- 8 to 16 mg IV [5] days 2 to 3
Steroid
Steroids contraindicated for use with interleukin-2 and interferon.
- Dexamethasone (Decadron) 8 mg IV or PO 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 IV or PO 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 twice per day
- 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 IV or PO on the days of chemotherapy
- ASCO: 8 mg IV or PO on the days of chemotherapy
- Metoclopramide (Reglan) 10-40 mg IV or PO x1, then Q4-6H prn nausea
- Prochlorperazine (Compazine) 10mg IV or PO 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 IV or PO x1, then Q4-6H prn nausea
- Prochlorperazine (Compazine) 10mg IV or PO x1, then Q4-6H prn nausea
- Haloperidol (Haldol) 0.5 to 2 mg IV or PO 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 twice per day
- Ondansetron (Zofran) 16 to 24 mg PO once per day
Breakthrough CINV treatment
General Principles
-Use antiemetic from another class than the prophylactic regimen
-Agents which are successful in treating a patient’s breakthrough CINV should be given routinely for a period of time rather than on an as needed basis.
-5-HT3 and NK1 RA are generally not effective or approved for treatment of breakthrough nausea/vomiting (assuming they were used as part of prophylaxis)
Olanzapine
- Olanzapine (Zyprexa) 10 mg PO daily on days 1-3 if CINV develop in the first 24 hours after HEC [10]. Use 5 mg if 10mg is not well tolerated.[11]
Metoclopromide
- Metoclopramide (Reglan) 10 mg PO (IV) every 8 hours on days 1-3 if CINV develop in the first 24 hours after HEC [10].
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 twice per day prn nausea
Other agents
- Haloperidol (Haldol) 0.5 to 2 mg IV or PO Q4-6H prn nausea (monitor for dystonic reactions)
- Scopolamine (Scopoderm) 1 patch Q72H prn nausea
- Prochlorperazine (Compazine) (choose one of the options below):
- 25 mg suppository PR every 12 hours prn nausea
- 10mg IV or PO Q4-6H prn nausea
- Promethazine (Phenergan) 12.5-25 mg IV or PO every 6 hours for 1-3 days
- Dexamethasone (Decadron) 8 mg PO (IV) every 6-8 hours
Serotonin 5-HT3 antagonists
Are generally ineffective for breakthrough CINV (assuming they were used as part of prophylactic regimen).
- Ondansetron (Zofran) 8 to 16 mg PO once per day prn nausea
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 three times per day starting the night before treatment
- Lorazepam (Ativan) 0.5 to 2 mg PO the night before and the morning of treatment
Reference
- ↑ NCCN antiemesis guidelines
- ↑ Antiemetics: American Society of Clinical Oncology Clinical Practice Guideline Update
- ↑ MASCC antiemetic guidlines https://www.mascc.org/antiemetic-guidelines
- ↑ 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
- ↑ 5.0 5.1 5.2 5.3 As of 6/28/2012, the once daily dose of ondansetron (Zofran) 32 mg is no longer recommended due to dose-dependent QTc prolongation. The Ondansetron (Zofran) package insert recommends only a maximum of 16 mg per dose, which can be given as often as every 4 hours x up to 3 doses, as detailed in the 6/29/2012 FDA Drug Safety Communication.
- ↑ Karin Jordan et al. "Comparative activity of antiemetic drugs" https://www-sciencedirect-com.elibrary.einstein.yu.edu/science/article/pii/S1040842806001661#tbl2
- ↑ 7.0 7.1 Ronald CHow et Al. "Efficacy and safety of 1-day versus 3-day dexamethasone for the prophylaxis of chemotherapy-induced nausea and vomiting: a systematic review and meta-analysis of randomized controlled trials" http://jhmhp.amegroups.com/article/view/4296
- ↑ Navari RM, Qin R, Ruddy KJ, Liu H, Powell SF, Bajaj M, Dietrich L, Biggs D, Lafky JM, Loprinzi CL. Olanzapine for the Prevention of Chemotherapy-Induced Nausea and Vomiting. N Engl J Med. 2016 Jul 14;375(2):134-42. link to original article PubMed
- ↑ Navari RM, Qin R, Ruddy KJ, Liu H, Powell SF, Bajaj M, Dietrich L, Biggs D, Lafky JM, Loprinzi CL. Olanzapine for the Prevention of Chemotherapy-Induced Nausea and Vomiting. N Engl J Med. 2016 Jul 14;375(2):134-42. link to original article PubMed
- ↑ 10.0 10.1 R. M. Navari, C. K. Nagy, and S. E. Gray, “The use of olanzapine versus metoclopramide for the treatment of breakthrough chemotherapy-induced nausea and vomiting in patients receiving highly emetogenic chemotherapy,” Supportive Care in Cancer, vol. 21, no. 6, pp. 1655–1663, 2013
- ↑ S. Chanthawong, S. Subongkot, and A. Sookprasert, “Effectiveness of olanzapine for the treatment of breakthrough chemotherapy induced nausea and vomiting,” Journal of the Medical Association of Thailand, vol. 97, pp. 349–355, 2014