Difference between revisions of "Antiemesis"

From HemOnc.org - A Hematology Oncology Wiki
Jump to navigation Jump to search
m (Selinexor added to antiemetic table)
(Added updated NCCN 2022 information for HEC CINV prophylaxis in table and added Cinvanti in NK1 antagonists list)
Tag: visualeditor
Line 1: Line 1:
 
Adapted from the NCCN<ref>[http://www.nccn.org/professionals/physician_gls/pdf/antiemesis.pdf NCCN antiemesis guidelines]</ref>, ASCO<ref>ASCO antiemesis guidelines<nowiki/>https://ascopubs.org/doi/abs/10.1200/JCO.20.01296
 
Adapted from the NCCN<ref>[http://www.nccn.org/professionals/physician_gls/pdf/antiemesis.pdf NCCN antiemesis guidelines]</ref>, ASCO<ref>ASCO antiemesis guidelines<nowiki/>https://ascopubs.org/doi/abs/10.1200/JCO.20.01296
 
</ref> and MASCC/ESMO<ref>MASCC antiemetic guidlines https://www.mascc.org/antiemetic-guidelines</ref>
 
</ref> and MASCC/ESMO<ref>MASCC antiemetic guidlines https://www.mascc.org/antiemetic-guidelines</ref>
−
 
 
=Guidelines=
 
=Guidelines=
 
==ASCO==
 
==ASCO==
−
 
 
*'''2020:''' Hesketh et al. [https://doi.org/10.1200/jco.20.01296 Antiemetics: ASCO Guideline Update]
 
*'''2020:''' Hesketh et al. [https://doi.org/10.1200/jco.20.01296 Antiemetics: ASCO Guideline Update]
−
 
 
=Emetic risk of chemotherapy, immunotherapy, TKIs and other agents=
 
=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.'''<br>
 
'''Hint: You can sort the table by clicking on the boxes containing arrows at the top of each column.'''<br>
Line 12: Line 9:
  
 
NCCN, ASCO 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)
 
*Low: 10-30% frequency of emesis
 
*Low: 10-30% frequency of emesis
 
*Minimal: <10% 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.
−
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.
 
−
 
 
 
{| class="wikitable sortable" border="1" style="text-align:center;"
 
{| class="wikitable sortable" border="1" style="text-align:center;"
 
!Drug
 
!Drug
Line 261: Line 255:
 
|Moderate: >200 mg/m<sup>2</sup><br>Low: 100 to 200 mg/m<sup>2</sup><br>Minimal: <100 mg/m<sup>2</sup>
 
|Moderate: >200 mg/m<sup>2</sup><br>Low: 100 to 200 mg/m<sup>2</sup><br>Minimal: <100 mg/m<sup>2</sup>
 
|Moderate: >1000 mg/m<sup>2</sup><br>Low: ≤1000 mg/m<sup>2</sup>
 
|Moderate: >1000 mg/m<sup>2</sup><br>Low: ≤1000 mg/m<sup>2</sup>
−
|Moderate: > 1000 mg/m2  
+
|Moderate: > 1000 mg/m2
 
Low: < 1000 mg/m2
 
Low: < 1000 mg/m2
 
|
 
|
Line 299: Line 293:
 
|High when given with [[Cyclophosphamide (Cytoxan)]]<br>Moderate when used alone
 
|High when given with [[Cyclophosphamide (Cytoxan)]]<br>Moderate when used alone
 
|High: when given with combined with cyclophosphamide (in breast cancer patients)
 
|High: when given with combined with cyclophosphamide (in breast cancer patients)
−
 
 
Moderate: when used alone
 
Moderate: when used alone
 
|
 
|
Line 331: Line 324:
 
|High when given with [[Cyclophosphamide (Cytoxan)]]<br>Moderate when used alone
 
|High when given with [[Cyclophosphamide (Cytoxan)]]<br>Moderate when used alone
 
|High: when given with combined with cyclophosphamide (in breast cancer patients)
 
|High: when given with combined with cyclophosphamide (in breast cancer patients)
−
 
 
Moderate: when used alone
 
Moderate: when used alone
 
|
 
|
Line 345: Line 337:
 
|High when given with [[Cyclophosphamide (Cytoxan)]]<br>Moderate when used alone
 
|High when given with [[Cyclophosphamide (Cytoxan)]]<br>Moderate when used alone
 
|High: when combined with cyclophosphamide (in breast cancer patients)
 
|High: when combined with cyclophosphamide (in breast cancer patients)
−
 
 
Moderate: when used alone
 
Moderate: when used alone
 
|
 
|
Line 896: Line 887:
 
|
 
|
 
|}
 
|}
−
 
 
=Highly emetogenic IV chemotherapy (HEC)=
 
=Highly emetogenic IV chemotherapy (HEC)=
 
{| class="wikitable"
 
{| class="wikitable"
 
|
 
|
 
|'''Day 1 CINV prophylaxis'''
 
|'''Day 1 CINV prophylaxis'''
−
|'''Day 2-4 CINV prophylaxis'''
+
|'''Day 2-4 CINV prophylaxis'''
 
|-
 
|-
 
|ASCO 2017
 
|ASCO 2017
−
|NK1 + 5-HT3 + DEX + OLN
+
|NK1 + 5-HT3 + DEX + OLN
 
|DEX + OLN
 
|DEX + OLN
−
 
+
''(if APR on day 1, then + APR days 2-3)''
−
''(if APR on day 1, then + APR days 2-3)''
 
 
|-
 
|-
 
|MASCC 2019
 
|MASCC 2019
−
|NK1 + 5-HT3 + DEX +/- OLN
+
|NK1 + 5-HT3 + DEX +/- OLN
 
|DEX +/- OLN
 
|DEX +/- OLN
−
 
+
''(if APR on day 1, then + APR days 2-3)''
−
''(if APR on day 1, then + APR days 2-3)''
 
 
|-
 
|-
−
| rowspan="3" |NCCN 2019
+
| rowspan="3" |NCCN 2022
−
|<nowiki>- NK1 + 5-HT3 + DEX + OLN</nowiki>
+
|<nowiki>- NK1 + 5-HT3 + DEX + OLN</nowiki>
 
|DEX + OLN
 
|DEX + OLN
 +
''(if po APR on day 1, then + APR days 2-3)''
 
|-
 
|-
−
|<nowiki>- NK1 + 5-HT3 + DEX</nowiki>
+
|<nowiki>- NK1 + 5-HT3 + DEX</nowiki>
 
|DEX
 
|DEX
 +
''(if po APR on day 1, then + APR days 2-3)''
 
|-
 
|-
−
|<nowiki>- OLN + 5-HT3  + DEX</nowiki>
+
| - OLN + Palonosetron + DEX
 
|OLN
 
|OLN
 
|}
 
|}
−
 
 
==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
 +
*Aprepitant injectable emulsion (Cinvanti) 130 mg IV once on day 1
 
*[[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. [https://doi.org/10.1200/JCO.2010.31.7859 link to original article] [https://pubmed.ncbi.nlm.nih.gov/21383291 PubMed]</ref>''
 
''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. [https://doi.org/10.1200/JCO.2010.31.7859 link to original article] [https://pubmed.ncbi.nlm.nih.gov/21383291 PubMed]</ref>''
−
 
 
===Serotonin (5-HT3) antagonist===
 
===Serotonin (5-HT3) antagonist===
−
 
 
*[[Dolasetron (Anzemet)]] 100 mg PO once on day 1
 
*[[Dolasetron (Anzemet)]] 100 mg PO once on day 1
 
*[[Granisetron]] (choose one of the options below):
 
*[[Granisetron]] (choose one of the options below):
Line 943: Line 929:
 
**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> once on day 1
+
**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"
 
''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
 
https://www-sciencedirect-com.elibrary.einstein.yu.edu/science/article/pii/S1040842806001661#tbl2
 
</ref>
 
</ref>
  
 
''Note: Ramosetron is another available 5-HT3, but not approved by FDA''
 
''Note: Ramosetron is another available 5-HT3, but not approved by FDA''
−
 
 
===Dexamethasone (DEX)===
 
===Dexamethasone (DEX)===
 
''Steroids contraindicated for use with interleukin-2 and interferon.''
 
''Steroids contraindicated for use with interleukin-2 and interferon.''
−
 
+
*If [[Aprepitant (Emend)]] used:
−
*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
 
**[[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:
 
*If [[Fosaprepitant (Emend for Injection)]] used:
Line 963: Line 945:
 
*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''<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"
 
''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
 
http://jhmhp.amegroups.com/article/view/4296
−
</ref>  
+
</ref>
−
 
 
 
==Netupitant-containing regimen==
 
==Netupitant-containing regimen==
−
 
 
*[[Netupitant and palonosetron (Akynzeo)]] 300/0.5 mg PO once on day 1 as a fixed oral formulation
 
*[[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
 
*[[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==
 
==Olanzapine (OLN) containing regimen==
−
 
 
*[[Olanzapine (Zyprexa)]] 10 mg PO once per day on days 1 to 4
 
*[[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
 
*[[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
+
*[[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
 
*[[Dexamethasone (Decadron)]] 12 mg PO on day 1, and 8 mg PO on days 2, 3, and 4
−
 
 
Reference:  
 
Reference:  
−
 
 
#''[https://www.nejm.org/doi/full/10.1056/NEJMoa1515725 Navari et al. 2016]<ref name=":3">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. [https://www.nejm.org/doi/full/10.1056/NEJMoa1515725 link to original article] [https://pubmed.ncbi.nlm.nih.gov/27410922 PubMed]</ref>''<br />
 
#''[https://www.nejm.org/doi/full/10.1056/NEJMoa1515725 Navari et al. 2016]<ref name=":3">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. [https://www.nejm.org/doi/full/10.1056/NEJMoa1515725 link to original article] [https://pubmed.ncbi.nlm.nih.gov/27410922 PubMed]</ref>''<br />
−
 
 
=Moderately emetogenic IV chemotherapy (MEC)=
 
=Moderately emetogenic IV chemotherapy (MEC)=
 
{| class="wikitable"
 
{| class="wikitable"
Line 992: Line 965:
 
|-
 
|-
 
|ASCO 2017
 
|ASCO 2017
−
|5-HT3 + DEX
+
|5-HT3 + DEX
−
|DEX maybe offered for: oxaliplatin, or anthracycline, or cyclophosphamide
+
|DEX maybe offered for: oxaliplatin, or anthracycline, or cyclophosphamide
 
|-
 
|-
 
|MASCC 2016
 
|MASCC 2016
−
|5-HT3 + DEX
+
|5-HT3 + DEX
−
|DEX can be considered for: oxaliplatin, or anthracycline, or cyclophosphamide
+
|DEX can be considered for: oxaliplatin, or anthracycline, or cyclophosphamide
 
|-
 
|-
 
| rowspan="3" |NCCN 2019
 
| rowspan="3" |NCCN 2019
−
|<nowiki>- 5-HT3 + DEX</nowiki>
+
|<nowiki>- 5-HT3 + DEX</nowiki>
 
|DEX or 5-HT3
 
|DEX or 5-HT3
 
|-
 
|-
−
|<nowiki>- NK1 + 5-HT3 + DEX </nowiki>
+
|<nowiki>- NK1 + 5-HT3 + DEX </nowiki>
−
 
+
(for selected patients with additional risk factors or previous Rx failure)
−
(for selected patients with additional risk factors or previous Rx failure)
 
 
|<nowiki>+/- DEX</nowiki>
 
|<nowiki>+/- DEX</nowiki>
 
|-
 
|-
−
|<nowiki>- OLN + 5-HT3 + DEX</nowiki>
+
|<nowiki>- OLN + 5-HT3 + DEX</nowiki>
 
|OLN
 
|OLN
 
|}
 
|}
−
 
 
===Serotonin (5-HT3) antagonist===
 
===Serotonin (5-HT3) antagonist===
−
 
 
*[[Dolasetron (Anzemet)]] 100 mg PO once on day 1
 
*[[Dolasetron (Anzemet)]] 100 mg PO once on day 1
 
*[[Granisetron]] (choose one of the options below):
 
*[[Granisetron]] (choose one of the options below):
Line 1,023: Line 993:
 
*[[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
−
 
 
===Dexamethasone (DEX)===
 
===Dexamethasone (DEX)===
 
''Steroids contraindicated for use with interleukin-2 and interferon.''
 
''Steroids contraindicated for use with interleukin-2 and interferon.''
−
 
+
*If [[Aprepitant (Emend)]] used:
−
*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
 
**[[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:
 
*If [[Fosaprepitant (Emend for Injection)]] used:
Line 1,033: Line 1,001:
 
*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''<ref name=":1" />
 
''Dexamethasone use beyond day 1 might be revised based on the 2018 meta analysis results''<ref name=":1" />
−
 
 
==Netupitant-containing regimen==
 
==Netupitant-containing regimen==
−
 
 
*[[Netupitant and palonosetron (Akynzeo)]] 300/0.5 mg PO once on day 1 as a fixed oral formulation
 
*[[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
 
*[[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==
 
==Olanzapine (OLN) containing regimen==
 
''Note: a 4-drug regimen based on [https://www.nejm.org/doi/full/10.1056/NEJMoa1515725 Navari et al. 2016]<ref>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. [https://www.nejm.org/doi/full/10.1056/NEJMoa1515725 link to original article] [https://pubmed.ncbi.nlm.nih.gov/27410922 PubMed]</ref>''
 
''Note: a 4-drug regimen based on [https://www.nejm.org/doi/full/10.1056/NEJMoa1515725 Navari et al. 2016]<ref>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. [https://www.nejm.org/doi/full/10.1056/NEJMoa1515725 link to original article] [https://pubmed.ncbi.nlm.nih.gov/27410922 PubMed]</ref>''
−
 
 
*[[Olanzapine (Zyprexa)]] 10 mg PO once per day on days 1 to 4
 
*[[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
 
*[[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
+
*[[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
 
*[[Dexamethasone (Decadron)]] 12 mg PO on day 1, and 8 mg PO on days 2, 3, and 4
−
 
 
=Carboplatin based chemotherapy=
 
=Carboplatin based chemotherapy=
 
{| class="wikitable"
 
{| class="wikitable"
Line 1,056: Line 1,018:
 
|-
 
|-
 
|ASCO 2017 (MEC)
 
|ASCO 2017 (MEC)
−
 
 
AUC ≥ 4
 
AUC ≥ 4
−
|NK1 + 5-HT3 + DEX
+
|NK1 + 5-HT3 + DEX
 
|NONE
 
|NONE
−
 
+
(if APR on day 1, then +APR days 2-3)
−
(if APR on day 1, then +APR days 2-3)
 
 
|-
 
|-
 
|MASCC 2019 (MEC)
 
|MASCC 2019 (MEC)
−
 
 
(doesn’t specify AUC)
 
(doesn’t specify AUC)
−
|NK1 + 5-HT3 + DEX
+
|NK1 + 5-HT3 + DEX
 
|NONE
 
|NONE
−
 
+
(if APR on day 1, then +APR days 2-3)
−
(if APR on day 1, then +APR days 2-3)
 
 
|-
 
|-
 
| rowspan="2" |NCCN 2019
 
| rowspan="2" |NCCN 2019
−
 
 
AUC ≥ 4 (HEC)
 
AUC ≥ 4 (HEC)
  
 
AUC < 4 (MEC)
 
AUC < 4 (MEC)
−
|NK1 + 5-HT3 + DEX
+
|NK1 + 5-HT3 + DEX
 
|DEX
 
|DEX
 
|-
 
|-
−
|5-HT3 + DEX
+
|5-HT3 + DEX
 
|
 
|
 
|}
 
|}
−
Recommendation to add NK1 is largely based on 2 phase III studies<ref name=":2">Yahata H, Kobayashi H, Sonoda K, et al: Effi- cacy of aprepitant for the prevention of chemotherapy- induced nausea and vomiting with a moderately emetogenic chemotherapy regimen: A multicenter, placebo-controlled, double-blind, randomized study in patients with gynecologic cancer receiving pac- litaxel and carboplatin. Int J Clin Oncol 21:491-497, 2016  
+
Recommendation to add NK1 is largely based on 2 phase III studies<ref name=":2">Yahata H, Kobayashi H, Sonoda K, et al: Effi- cacy of aprepitant for the prevention of chemotherapy- induced nausea and vomiting with a moderately emetogenic chemotherapy regimen: A multicenter, placebo-controlled, double-blind, randomized study in patients with gynecologic cancer receiving pac- litaxel and carboplatin. Int J Clin Oncol 21:491-497, 2016
−
 
 
 
https://pubmed.ncbi.nlm.nih.gov/26662632
 
https://pubmed.ncbi.nlm.nih.gov/26662632
 
</ref><ref>Hesketh PJ, Schnadig ID, Schwartzberg LS, et al: Efficacy of the neurokinin-1 receptor antagonist rolapitant in preventing nausea and vomiting in pa- tients receiving carboplatin-based chemotherapy. Cancer 122:2418-2425, 2016<nowiki/>https://pubmed.ncbi.nlm.nih.gov/27176138</ref>. One of them was conducted in female patients with GYN malignancy only. <ref name=":2" /> 5-HT3 used in those trials was either granisetron or ondansetron.  
 
</ref><ref>Hesketh PJ, Schnadig ID, Schwartzberg LS, et al: Efficacy of the neurokinin-1 receptor antagonist rolapitant in preventing nausea and vomiting in pa- tients receiving carboplatin-based chemotherapy. Cancer 122:2418-2425, 2016<nowiki/>https://pubmed.ncbi.nlm.nih.gov/27176138</ref>. One of them was conducted in female patients with GYN malignancy only. <ref name=":2" /> 5-HT3 used in those trials was either granisetron or ondansetron.  
−
 
 
=Bone marrow transplant (BMT) conditioning regimens=
 
=Bone marrow transplant (BMT) conditioning regimens=
−
''Note: Day 0 is the day of BMT, days with "-" in front are days prior to transplant, days with "+" afterwards are days after transplant''  
+
''Note: Day 0 is the day of BMT, days with "-" in front are days prior to transplant, days with "+" afterwards are days after transplant''
−
 
 
 
=Allogeneic BMT conditioning regimens=
 
=Allogeneic BMT conditioning regimens=
 
{| class="wikitable"
 
{| class="wikitable"
Line 1,096: Line 1,050:
 
|-
 
|-
 
|FMT (fludarabine, melphalan, thiotepa)
 
|FMT (fludarabine, melphalan, thiotepa)
−
| - NK1 on day -7
+
| - NK1 on day -7
−
 
 
 
- 5-HT3 on days -7 to -1
 
- 5-HT3 on days -7 to -1
 
|-
 
|-
 
|Flu/Mel (fludarabine, melphalan)
 
|Flu/Mel (fludarabine, melphalan)
−
| - NK1 on day -2
+
| - NK1 on day -2
 
- 5-HT3 on days -6 to -1
 
- 5-HT3 on days -6 to -1
  
Line 1,110: Line 1,063:
 
|-
 
|-
 
|Cy/TBI (cyclophosphamide, total body irradiation)
 
|Cy/TBI (cyclophosphamide, total body irradiation)
−
| - NK1 on day -6
+
| - NK1 on day -6
−
 
 
 
- 5-HT3 on days -6 to -1
 
- 5-HT3 on days -6 to -1
  
Line 1,122: Line 1,074:
 
|
 
|
 
|}
 
|}
−
 
 
==Autologous BMT conditioning regimens==
 
==Autologous BMT conditioning regimens==
 
{| class="wikitable"
 
{| class="wikitable"
Line 1,129: Line 1,080:
 
|-
 
|-
 
|High dose melphalan<ref>{{#pmid:25225424}}</ref>
 
|High dose melphalan<ref>{{#pmid:25225424}}</ref>
−
| - NK1 on days -3 to 0
+
| - NK1 on days -3 to 0
−
 
 
 
- 5-HT3 on days -3 to 0
 
- 5-HT3 on days -3 to 0
  
Line 1,142: Line 1,092:
 
|}<br />
 
|}<br />
 
=Highly to moderately emetogenic PO chemotherapy=
 
=Highly to moderately emetogenic PO chemotherapy=
−
'''These are NCCN recommendations only. ASCO did not provide separate antiemetic recommendations for PO vs. IV chemotherapy.'''<br>
+
'''These are NCCN recommendations only. ASCO did not provide separate antiemetic recommendations for PO vs. IV chemotherapy.'''<br>
 
Start before chemotherapy and continue once per day:
 
Start before chemotherapy and continue once per day:
 
==Serotonin (5-HT3) antagonist==
 
==Serotonin (5-HT3) antagonist==
−
 
 
*[[Granisetron]] (choose one of the options below):
 
*[[Granisetron]] (choose one of the options below):
 
**2 mg PO once per day
 
**2 mg PO once per day
 
**1 mg PO twice per day
 
**1 mg PO twice per day
 
*[[Ondansetron (Zofran)]] 16 to 24 mg PO once per day
 
*[[Ondansetron (Zofran)]] 16 to 24 mg PO once per day
−
 
 
==Optional==
 
==Optional==
−
 
 
*[[Lorazepam (Ativan)]] 0.5 to 2 mg PO/IV/sublingual Q4-6H prn nausea on days 1 to 4
 
*[[Lorazepam (Ativan)]] 0.5 to 2 mg PO/IV/sublingual Q4-6H prn nausea on days 1 to 4
 
*[[:Category:H2-receptor antagonists|H2 blocker]] or [[:Category:Proton pump inhibitors|proton pump inhibitor]]
 
*[[:Category:H2-receptor antagonists|H2 blocker]] or [[:Category:Proton pump inhibitors|proton pump inhibitor]]
−
 
 
=Low emetic risk IV chemotherapy=
 
=Low emetic risk IV chemotherapy=
 
{| class="wikitable"
 
{| class="wikitable"
Line 1,163: Line 1,109:
 
|-
 
|-
 
|ASCO 2017
 
|ASCO 2017
−
|Single dose 5-HT3 or DEX 8mg
+
|Single dose 5-HT3 or DEX 8mg
 
|No routine prophylaxis
 
|No routine prophylaxis
 
|-
 
|-
 
|MASCC 2016
 
|MASCC 2016
−
|5-HT3 or DEX or Dopamine RA
+
|5-HT3 or DEX or Dopamine RA
 
|No routine prophylaxis
 
|No routine prophylaxis
 
|-
 
|-
 
|NCCN 2019
 
|NCCN 2019
−
|5-HT3 or DEX or Dopamine RA
+
|5-HT3 or DEX or Dopamine RA
−
 
+
5-HT3 other than palonosetrone
−
5-HT3 other than palonosetrone
 
 
|No routine prophylaxis
 
|No routine prophylaxis
 
|}
 
|}
−
'''Repeat once per day for chemotherapy regimens that last more than one day.'''
+
'''Repeat once per day for chemotherapy regimens that last more than one day.'''
−
 
+
*[[Dexamethasone (Decadron)]]
−
*[[Dexamethasone (Decadron)]]  
 
 
**NCCN: 12 mg IV or PO on the days of chemotherapy
 
**NCCN: 12 mg IV or PO on the days of chemotherapy
 
**ASCO: 8 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
 
*[[Metoclopramide (Reglan)]] 10-40 mg IV or PO x1, then Q4-6H prn nausea
 
*[[Prochlorperazine (Compazine)]] 10 mg IV or PO x1, then Q4-6H prn nausea
 
*[[Prochlorperazine (Compazine)]] 10 mg IV or PO x1, then Q4-6H prn nausea
−
 
 
=Minimal emetic risk chemotherapy=
 
=Minimal emetic risk chemotherapy=
−
 
 
*No routine prophylaxis recommended by all 3 guideline groups. Assess patient prior to cycle 2 and add single agent prophylactic antiemetic if patient had emesis with cycle 1.
 
*No routine prophylaxis recommended by all 3 guideline groups. Assess patient prior to cycle 2 and add single agent prophylactic antiemetic if patient had emesis with cycle 1.
−
 
 
=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==
 
Choose one of the medications below to start before chemotherapy and continue once per day:
 
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
 
*[[Metoclopramide (Reglan)]] 10-40 mg IV or PO x1, then Q4-6H prn nausea
 
*[[Prochlorperazine (Compazine)]] 10 mg IV or PO x1, then Q4-6H prn nausea
 
*[[Prochlorperazine (Compazine)]] 10 mg 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)
 
*[[Haloperidol (Haldol)]] 0.5 to 2 mg IV or PO Q4-6H prn nausea (monitor for dystonic reactions)
−
 
 
==Optional==
 
==Optional==
−
 
 
*[[Lorazepam (Ativan)]] 0.5 to 2 mg PO/IV/sublingual Q4-6H prn nausea days 1-4
 
*[[Lorazepam (Ativan)]] 0.5 to 2 mg PO/IV/sublingual Q4-6H prn nausea days 1-4
 
*[[:Category:H2-receptor antagonists|H2 blocker]] or [[:Category:Proton pump inhibitors|proton pump inhibitor]]
 
*[[:Category:H2-receptor antagonists|H2 blocker]] or [[:Category:Proton pump inhibitors|proton pump inhibitor]]
−
 
 
==If continued nausea/vomiting==
 
==If continued nausea/vomiting==
 
Use serotonin (5-HT3) antagonist:
 
Use serotonin (5-HT3) antagonist:
−
 
 
*[[Granisetron]] (choose one of the options below):
 
*[[Granisetron]] (choose one of the options below):
 
**2 mg PO once per day
 
**2 mg PO once per day
 
**1 mg PO twice per day
 
**1 mg PO twice per day
 
*[[Ondansetron (Zofran)]] 16 to 24 mg PO once per day
 
*[[Ondansetron (Zofran)]] 16 to 24 mg PO once per day
−
 
 
=Breakthrough CINV treatment=
 
=Breakthrough CINV treatment=
 
General Principles
 
General Principles
Line 1,221: Line 1,154:
 
-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)
 
-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==
−
 
 
*[[Olanzapine (Zyprexa)]] 10 mg PO daily on days 1-3 if CINV develop in the first 24 hours after HEC <ref name=":0">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</ref>. Use 5 mg if 10 mg is not well tolerated.<ref>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</ref>
 
*[[Olanzapine (Zyprexa)]] 10 mg PO daily on days 1-3 if CINV develop in the first 24 hours after HEC <ref name=":0">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</ref>. Use 5 mg if 10 mg is not well tolerated.<ref>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</ref>
−
 
 
==Metoclopromide==
 
==Metoclopromide==
−
 
+
*[[Metoclopramide (Reglan)]] 10 mg PO (IV) every 8 hours on days 1-3 if CINV develop in the first 24 hours after HEC <ref name=":0" />.
−
*[[Metoclopramide (Reglan)]] 10 mg PO (IV) every 8 hours on days 1-3 if CINV develop in the first 24 hours after HEC <ref name=":0" />.
 
−
 
 
 
==Benzodiazepine==
 
==Benzodiazepine==
−
 
 
*[[Lorazepam (Ativan)]] 0.5 to 2 mg PO (IV) Q4-6H prn nausea
 
*[[Lorazepam (Ativan)]] 0.5 to 2 mg PO (IV) Q4-6H prn nausea
−
 
 
==Cannabinoid==
 
==Cannabinoid==
−
 
 
*[[Dronabinol (Marinol)]] 5-10 mg PO Q3-6H prn nausea
 
*[[Dronabinol (Marinol)]] 5-10 mg PO Q3-6H prn nausea
 
*[[Nabilone (Cesamet)]] 1-2 mg PO twice per day prn nausea
 
*[[Nabilone (Cesamet)]] 1-2 mg PO twice per day prn nausea
−
 
 
==Other agents==
 
==Other agents==
−
 
 
*[[Haloperidol (Haldol)]] 0.5 to 2 mg IV or PO Q4-6H prn nausea (monitor for dystonic reactions)
 
*[[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
 
*[[Scopolamine (Scopoderm)]] 1 patch Q72H prn nausea
Line 1,247: Line 1,171:
 
*[[Promethazine (Phenergan)]] 12.5-25 mg IV or PO every 6 hours for 1-3 days
 
*[[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
 
*[[Dexamethasone (Decadron)]] 8 mg PO (IV) every 6-8 hours
−
 
 
==Serotonin 5-HT3 antagonists==
 
==Serotonin 5-HT3 antagonists==
 
Are generally ineffective for breakthrough CINV (assuming they were used as part of prophylactic regimen).  
 
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
 
*[[Ondansetron (Zofran)]] 8 to 16 mg PO once per day prn nausea
−
 
 
=Anticipatory nausea/vomiting=
 
=Anticipatory nausea/vomiting=
−
 
 
*Prevent anticipation by optimizing antiemetic therapy for every cycle of chemotherapy
 
*Prevent anticipation by optimizing antiemetic therapy for every cycle of chemotherapy
 
*Behavioral therapy
 
*Behavioral therapy
Line 1,263: Line 1,183:
 
*[[Alprazolam (Xanax)]] 0.5 to 2 mg PO three times per day starting the night before treatment
 
*[[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
 
*[[Lorazepam (Ativan)]] 0.5 to 2 mg PO the night before and the morning of treatment
−
 
 
=Reference=
 
=Reference=
 
<references />
 
<references />
−
 
 
[[Category:General reference pages]]
 
[[Category:General reference pages]]
 
[[Category:Supportive medications]]
 
[[Category:Supportive medications]]
 
[[Category:Clinical pharmacology]]
 
[[Category:Clinical pharmacology]]

Revision as of 23:16, 10 April 2022

Adapted from the NCCN[1], ASCO[2] and MASCC/ESMO[3]

Guidelines

ASCO

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 (2021) ASCO emetogenic potential

(2020)

MASCC/ESMO emetogenic potential (2019) Comment
Ado-trastuzumab emtansine (Kadcyla) Low Low 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) or Hexamethylmelamine (oral) Moderate/High Moderate/High NCCN and ASCO did not further delineate between degrees of emetic potential
Amifostine (Ethyol) Moderate: >300 mg/m2
Low: ≤300 mg/m2
Arsenic trioxide (Trisenox) Low Moderate
Asparaginase (Elspar) Minimal
Atezolizumab (Tecentriq) Minimal Minimal
Axitinib (Inlyta) (oral) Minimal/Low Minimal/Low Low
Azacitidine (Vidaza) Moderate Moderate Moderate
Bendamustine Moderate Moderate Moderate
Belinostat (Beleodaq) Low
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 (Blincyto) Low Low
Bortezomib (Velcade) Minimal Low Low
Bosutinib (Bosulif) (oral) Low/Minimal Moderate 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 Moderate
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
Ceritinib (Zykadia) Moderate
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 dose ≥70 mg/m2
Cladribine (Leustatin) Minimal Minimal Minimal
Clofarabine (Clolar) Moderate Moderate Moderate
Crizotinib (Xalkori) (oral) High/Moderate 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 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 (Darzalex) 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 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
Lenvatinib (Lenvima) (oral) Moderate
Lomustine (CCNU) (oral) High/Moderate (single day) single day; NCCN did not further delineate between degrees of emetic potential
Lurbinectedin (Zepzelca) Moderate
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
Niraparib (Zejula) (oral) Moderate to high NCCN did not further delineate between degrees of emetic potential (>30%)
Ofatumumab (Arzzera) Minimal Minimal
Omacetaxine (Synribo) Low
Olaparib (Lynparza) (oral) Moderate to high NCCN did not further delineate between degrees of emetic potential (>30%)
Oxaliplatin (Eloxatin) Moderate Moderate Moderate
Paclitaxel (Taxol) Low Low Low
Paclitaxel, nanoparticle albumin-bound (Abraxane) Low Low
Panitumumab (Vectibix) Minimal Low
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
Pembrolizumab (Keytruda) Minimal
Pemetrexed (Alimta) Low Low Low
Pentostatin (Nipent) Low
Pertuzumab (Perjeta) Minimal Low
Pixantrone (Pixuvri) Minimal
Pomalidomide (Pomalyst) (oral) Low/Minimal Minimal
Ponatinib (Iclusig) (oral) Low/Minimal Low
Pralatrexate (Folotyn) Low Minimal Minimal
Procarbazine (Matulane) (oral) High/Moderate High 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
Rucaparib (Rubraca) Moderate to high NCCN did not further delineate between degrees of emetic potential (>30%)
Ruxolitinib (Jakafi) (oral) Low/Minimal Minimal
Selinexor (Xpovio) (oral) Moderate/High Moderate/High NCCN and ASCO did not further delineate between degrees of emetic potential
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 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
Trabectedin (Yondelis) Moderate
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
Vinflunine (Javlor) Low
Vinorelbine (Navelbine) Minimal Minimal Minimal
Vinorelbine (oral) Moderate
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 Low

Highly emetogenic IV chemotherapy (HEC)

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 2019 NK1 + 5-HT3 + DEX +/- OLN DEX +/- OLN

(if APR on day 1, then + APR days 2-3)

NCCN 2022 - NK1 + 5-HT3 + DEX + OLN DEX + OLN

(if po APR on day 1, then + APR days 2-3)

- NK1 + 5-HT3 + DEX DEX

(if po APR on day 1, then + APR days 2-3)

- OLN + Palonosetron + DEX OLN

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

Neurokinin 1 (NK1) antagonist

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.

Dexamethasone use beyond day 1 might be revised based on the 2018 meta analysis results[7]

Netupitant-containing regimen

Olanzapine (OLN) containing regimen

Reference:

  1. Navari et al. 2016[8]

Moderately emetogenic IV chemotherapy (MEC)

Day 1 CINV prophylaxis Day 2-4 CINV prophylaxis
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.

Dexamethasone use beyond day 1 might be revised based on the 2018 meta analysis results[7]

Netupitant-containing regimen

Olanzapine (OLN) containing regimen

Note: a 4-drug regimen based on Navari et al. 2016[9]

Carboplatin based chemotherapy

Guideline and emetic risk Day 1 CINV prophylaxis Day 2-4 CINV prophylaxis
ASCO 2017 (MEC)

AUC ≥ 4

NK1 + 5-HT3 + DEX NONE

(if APR on day 1, then +APR days 2-3)

MASCC 2019 (MEC)

(doesn’t specify AUC)

NK1 + 5-HT3 + DEX NONE

(if APR on day 1, then +APR days 2-3)

NCCN 2019

AUC ≥ 4 (HEC)

AUC < 4 (MEC)

NK1 + 5-HT3 + DEX DEX
5-HT3 + DEX

Recommendation to add NK1 is largely based on 2 phase III studies[10][11]. One of them was conducted in female patients with GYN malignancy only. [10] 5-HT3 used in those trials was either granisetron or ondansetron.

Bone marrow transplant (BMT) conditioning regimens

Note: Day 0 is the day of BMT, days with "-" in front are days prior to transplant, days with "+" afterwards are days after transplant

Allogeneic BMT conditioning regimens

Conditioning regimen CINV prophylaxis
FMT (fludarabine, melphalan, thiotepa) - NK1 on day -7

- 5-HT3 on days -7 to -1

Flu/Mel (fludarabine, melphalan) - NK1 on day -2

- 5-HT3 on days -6 to -1

- DEX on days -6 to -1

Flu/Cy/TBI (fludarabine, cyclophosphamide, total body irradiation)
Cy/TBI (cyclophosphamide, total body irradiation) - NK1 on day -6

- 5-HT3 on days -6 to -1

- DEX on days -6 to -4

Bu/Flu (bufulfan, fludarabine)
Bu/Cy (busulfan, cyclophosphamide)

Autologous BMT conditioning regimens

Conditioning regimen CINV prophylaxis
High dose melphalan[12] - NK1 on days -3 to 0

- 5-HT3 on days -3 to 0

- DEX on days -3 to -1

BEAM (busulfan, etoposide, cytarabine, melphalan)
TBC (thiotepa, busulfan, cyclophosphamide)


Highly to moderately emetogenic PO chemotherapy

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

Serotonin (5-HT3) antagonist

Optional

Low emetic risk IV chemotherapy

Day 1 Day 2-4
ASCO 2017 Single dose 5-HT3 or DEX 8mg No routine prophylaxis
MASCC 2016 5-HT3 or DEX or Dopamine RA No routine prophylaxis
NCCN 2019 5-HT3 or DEX or Dopamine RA

5-HT3 other than palonosetrone

No routine prophylaxis

Repeat once per day for chemotherapy regimens that last more than one day.

Minimal emetic risk chemotherapy

  • No routine prophylaxis recommended by all 3 guideline groups. Assess patient prior to cycle 2 and add single agent prophylactic antiemetic if patient had emesis with cycle 1.

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:

Optional

If continued nausea/vomiting

Use serotonin (5-HT3) antagonist:

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 [13]. Use 5 mg if 10 mg is not well tolerated.[14]

Metoclopromide

Benzodiazepine

Cannabinoid

Other agents

Serotonin 5-HT3 antagonists

Are generally ineffective for breakthrough CINV (assuming they were used as part of prophylactic regimen).

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

  1. ↑ NCCN antiemesis guidelines
  2. ↑ ASCO antiemesis guidelineshttps://ascopubs.org/doi/abs/10.1200/JCO.20.01296
  3. ↑ MASCC antiemetic guidlines https://www.mascc.org/antiemetic-guidelines
  4. ↑ 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. ↑ 5.0 5.1 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. Cite error: Invalid <ref> tag; name "ondansetron QTc" defined multiple times with different content
  6. ↑ Karin Jordan et al. "Comparative activity of antiemetic drugs" https://www-sciencedirect-com.elibrary.einstein.yu.edu/science/article/pii/S1040842806001661#tbl2
  7. ↑ 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
  8. ↑ 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
  9. ↑ 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. ↑ 10.0 10.1 Yahata H, Kobayashi H, Sonoda K, et al: Effi- cacy of aprepitant for the prevention of chemotherapy- induced nausea and vomiting with a moderately emetogenic chemotherapy regimen: A multicenter, placebo-controlled, double-blind, randomized study in patients with gynecologic cancer receiving pac- litaxel and carboplatin. Int J Clin Oncol 21:491-497, 2016 https://pubmed.ncbi.nlm.nih.gov/26662632
  11. ↑ Hesketh PJ, Schnadig ID, Schwartzberg LS, et al: Efficacy of the neurokinin-1 receptor antagonist rolapitant in preventing nausea and vomiting in pa- tients receiving carboplatin-based chemotherapy. Cancer 122:2418-2425, 2016https://pubmed.ncbi.nlm.nih.gov/27176138
  12. ↑ . Aprepitant, granisetron, and dexamethasone for prevention of chemotherapy-induced nausea and vomiting after high-dose melphalan in autologous transplantation for multiple myeloma: results of a randomized, placebo-controlled phase III trial. J Clin Oncol. 2014;32:3413-20. PubMed ID 25225424.
  13. ↑ 13.0 13.1 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
  14. ↑ 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
Retrieved from "https://hemonc.org/w/index.php?title=Antiemesis&oldid=55497"