Difference between revisions of "Antiemesis"
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− | Adapted from the NCCN<ref>[http://www.nccn.org/professionals/physician_gls/pdf/antiemesis.pdf NCCN antiemesis guidelines version | + | Adapted from the NCCN<ref>[http://www.nccn.org/professionals/physician_gls/pdf/antiemesis.pdf NCCN antiemesis guidelines version 2.2014]</ref> and ASCO guidelines.<ref>[http://www.asco.org/ASCOv2/Practice+%26+Guidelines/Guidelines/Clinical+Practice+Guidelines/Antiemetics%3A+American+Society+of+Clinical+Oncology+Clinical+Practice+Guideline+Update Antiemetics: American Society of Clinical Oncology Clinical Practice Guideline Update (2011)]</ref><ref>[http://www.asco.org/ASCOv2/Department%20Content/Cancer%20Policy%20and%20Clinical%20Affairs/Downloads/Guideline%20Tools%20and%20Resources/Antiemetics/2011/Antiemetics%20Full%20Guideline%2010.14.11.pdf ASCO 2011 antiemetics guideline PDF]</ref><ref>[http://www.asco.org/ASCOv2/Department%20Content/Cancer%20Policy%20and%20Clinical%20Affairs/Downloads/Guideline%20Tools%20and%20Resources/Antiemetics/2011/Antiemetic%20Dosing%20Clinical%20Tool_9.21.11.pdf ASCO 2011 antiemetics table]</ref> |
==Emetic risk of chemotherapy== | ==Emetic risk of chemotherapy== | ||
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!ASCO emetogenic potential | !ASCO emetogenic potential | ||
!Comment | !Comment | ||
+ | |- | ||
+ | |align="left" | [[Ado-trastuzumab emtansine (Kadcyla)]] | ||
+ | |Low | ||
+ | | | ||
+ | | | ||
|- | |- | ||
|align="left" | Anthracycline (see differences between NCCN & ASCO) & [[Cyclophosphamide (Cytoxan)]] combination chemotherapy | |align="left" | Anthracycline (see differences between NCCN & ASCO) & [[Cyclophosphamide (Cytoxan)]] combination chemotherapy | ||
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|- | |- | ||
|align="left" | [[Aldesleukin (Proleukin)]] | |align="left" | [[Aldesleukin (Proleukin)]] | ||
− | |Moderate: >12 | + | |Moderate: >12 to 15 million international units/m2<br>Low: ≤12 million international units/m2 |
| | | | ||
| | | | ||
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|- | |- | ||
|align="left" | [[Amifostine (Ethyol)]] | |align="left" | [[Amifostine (Ethyol)]] | ||
− | |Moderate: >300 mg/m2<br>Low: | + | |Moderate: >300 mg/m2<br>Low: ≤300 mg |
| | | | ||
| | | | ||
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|align="left" | [[Asparaginase (Elspar)]] | |align="left" | [[Asparaginase (Elspar)]] | ||
|Minimal | |Minimal | ||
+ | | | ||
+ | | | ||
+ | |- | ||
+ | |align="left" | [[Axitinib (Inlyta)]] (oral) | ||
+ | |Low/Minimal | ||
| | | | ||
| | | | ||
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|Minimal | |Minimal | ||
|Low | |Low | ||
+ | | | ||
+ | |- | ||
+ | |align="left" | [[Bosutinib (Bosulif)]] (oral) | ||
+ | |Low/Minimal | ||
+ | | | ||
+ | | | ||
+ | |- | ||
+ | |align="left" | [[Brentuximab vedotin (Adcetris)]] | ||
+ | |Low | ||
+ | | | ||
| | | | ||
|- | |- | ||
|align="left" | [[Busulfan (Myleran)]] | |align="left" | [[Busulfan (Myleran)]] | ||
− | |Moderate | + | |High/Moderate: ≥4 mg/day <br> Low/Minimal: <4 mg/day |
|Minimal | |Minimal | ||
| | | | ||
|- | |- | ||
|align="left" | [[Busulfan (Myleran)]] (oral) | |align="left" | [[Busulfan (Myleran)]] (oral) | ||
− | |High/Moderate: | + | |High/Moderate: ≥4 mg/day<br>Low/Minimal: <4 mg/day |
| | | | ||
|NCCN did not further delineate between degrees of emetic potential | |NCCN did not further delineate between degrees of emetic potential | ||
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|Low | |Low | ||
|Low | |Low | ||
+ | | | ||
+ | |- | ||
+ | |align="left" | [[Cabozantinib (Cometriq)]] (oral) | ||
+ | |Low/Minimal | ||
+ | | | ||
| | | | ||
|- | |- | ||
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|Moderate | |Moderate | ||
|Moderate | |Moderate | ||
+ | | | ||
+ | |- | ||
+ | |align="left" | [[Carfilzomib (Kyprolis)]] | ||
+ | |Low | ||
+ | | | ||
| | | | ||
|- | |- | ||
|align="left" | [[Carmustine (BiCNU)]] | |align="left" | [[Carmustine (BiCNU)]] | ||
− | |High: >250 mg/m2<br>Moderate: | + | |High: >250 mg/m2<br>Moderate: ≤250 mg/m2 |
|High | |High | ||
|ASCO did not subclassify based on dose | |ASCO did not subclassify based on dose | ||
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|- | |- | ||
|align="left" | [[Cisplatin (Platinol)]] | |align="left" | [[Cisplatin (Platinol)]] | ||
− | |||
|High | |High | ||
− | | | + | |High |
+ | | | ||
|- | |- | ||
|align="left" | [[Cladribine (Leustatin)]] | |align="left" | [[Cladribine (Leustatin)]] | ||
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|Moderate | |Moderate | ||
|Moderate | |Moderate | ||
+ | | | ||
+ | |- | ||
+ | |align="left" | [[Crizotinib (Xalkori)]] (oral) | ||
+ | |High/Moderate | ||
+ | | | ||
| | | | ||
|- | |- | ||
|align="left" | [[Cyclophosphamide (Cytoxan)]] | |align="left" | [[Cyclophosphamide (Cytoxan)]] | ||
− | |High: >1500 mg/m2 or [[#Emetic_risk_of_chemotherapy|when given with certain anthracyclines]]<br>Moderate: | + | |High: >1500 mg/m2 or [[#Emetic_risk_of_chemotherapy|when given with certain anthracyclines]]<br>Moderate: ≤1500 mg/m2 |
− | |High: | + | |High: ≥1500 mg/m2 or [[#Emetic_risk_of_chemotherapy|when given with anthracyclines]]<br>Moderate: <1500 mg/m2 |
| | | | ||
|- | |- | ||
|align="left" | [[Cyclophosphamide (Cytoxan)]] (oral) | |align="left" | [[Cyclophosphamide (Cytoxan)]] (oral) | ||
− | |High/Moderate: | + | |High/Moderate: ≥100 mg/m2/day<br>Low/Minimal: <100 mg/m2/day |
| | | | ||
|NCCN did not further delineate between degrees of emetic potential | |NCCN did not further delineate between degrees of emetic potential | ||
|- | |- | ||
|align="left" | [[Cytarabine (Cytosar)]] | |align="left" | [[Cytarabine (Cytosar)]] | ||
− | |Moderate: >200 mg/m2<br>Low: 100 | + | |Moderate: >200 mg/m2<br>Low: 100 to 200 mg/m2<br>Minimal: <100 mg/m2 |
− | |Moderate: >1000 mg/m2<br>Low: | + | |Moderate: >1000 mg/m2<br>Low: ≤1000 mg/m2 |
+ | | | ||
+ | |- | ||
+ | |align="left" | [[Dabrafenib (Tafinlar)]] (oral) | ||
+ | |Low/Minimal | ||
+ | | | ||
| | | | ||
|- | |- | ||
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|- | |- | ||
|align="left" | [[Doxorubicin (Adriamycin)]] | |align="left" | [[Doxorubicin (Adriamycin)]] | ||
− | |High: | + | |High: ≥60 mg/m2 or when given with [[Cyclophosphamide (Cytoxan)]]<br>Moderate: <60 mg/m2 |
|High when given with [[Cyclophosphamide (Cytoxan)]]<br>Moderate when used alone | |High when given with [[Cyclophosphamide (Cytoxan)]]<br>Moderate when used alone | ||
| | | | ||
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|- | |- | ||
|align="left" | [[Epirubicin (Ellence)]] | |align="left" | [[Epirubicin (Ellence)]] | ||
− | |High: >90 mg/m2 or when given with [[Cyclophosphamide (Cytoxan)]]<br>Moderate: | + | |High: >90 mg/m2 or when given with [[Cyclophosphamide (Cytoxan)]]<br>Moderate: ≤90 mg/m2 |
|High when given with [[Cyclophosphamide (Cytoxan)]]<br>Moderate when used alone | |High when given with [[Cyclophosphamide (Cytoxan)]]<br>Moderate when used alone | ||
| | | | ||
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| | | | ||
|NCCN did not further delineate between degrees of emetic potential | |NCCN did not further delineate between degrees of emetic potential | ||
+ | |- | ||
+ | |align="left" | [[Floxuridine (FUDR)]] | ||
+ | |Low | ||
+ | | | ||
+ | | | ||
|- | |- | ||
|align="left" | [[Fludarabine (Fludara)]] | |align="left" | [[Fludarabine (Fludara)]] | ||
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|- | |- | ||
|align="left" | [[Ifosfamide (Ifex)]] | |align="left" | [[Ifosfamide (Ifex)]] | ||
− | |High: | + | |High: ≥2 g/m2 per dose <br> Moderate: <2 g/m2 per dose |
|Moderate | |Moderate | ||
|ASCO did not subclassify based on dose | |ASCO did not subclassify based on dose | ||
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|- | |- | ||
|align="left" | [[Interferon alfa-2a (Roferon-A)]] | |align="left" | [[Interferon alfa-2a (Roferon-A)]] | ||
− | |Moderate: | + | |Moderate: ≥10 million international units/m2<br>Low: >5, <10 million international units/m2<br>Minimal: ≤5 million international units/m2 |
| | | | ||
|NCCN did not specify interferon alfa-2a vs. 2b | |NCCN did not specify interferon alfa-2a vs. 2b | ||
|- | |- | ||
|align="left" | [[Interferon alfa-2b (Intron-A)]] | |align="left" | [[Interferon alfa-2b (Intron-A)]] | ||
− | |Moderate: | + | |Moderate: ≥10 million international units/m2<br>Low: >5, <10 million international units/m2<br>Minimal: ≤5 million international units/m2 |
| | | | ||
|NCCN did not specify interferon alfa-2a vs. 2b | |NCCN did not specify interferon alfa-2a vs. 2b | ||
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|- | |- | ||
|align="left" | [[Lomustine (Ceenu)]] (oral) | |align="left" | [[Lomustine (Ceenu)]] (oral) | ||
− | |High/Moderate | + | |High/Moderate (single day) |
| | | | ||
|single day; NCCN did not further delineate between degrees of emetic potential | |single day; NCCN did not further delineate between degrees of emetic potential | ||
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|- | |- | ||
|align="left" | [[Methotrexate (MTX)]] | |align="left" | [[Methotrexate (MTX)]] | ||
− | |Moderate: | + | |Moderate: ≥250 mg/m2<br>Low: >50, <250 mg/m2<br>Minimal: ≤50 mg/m2 |
|Low | |Low | ||
|ASCO did not subclassify based on dose | |ASCO did not subclassify based on dose | ||
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|Low | |Low | ||
|Low | |Low | ||
+ | | | ||
+ | |- | ||
+ | |align="left" | [[Mitotane (Lysodren)]] (oral) | ||
+ | |High/Moderate | ||
+ | | | ||
| | | | ||
|- | |- | ||
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|align="left" | [[Ofatumumab (Arzzera)]] | |align="left" | [[Ofatumumab (Arzzera)]] | ||
|Minimal | |Minimal | ||
+ | | | ||
+ | | | ||
+ | |- | ||
+ | |align="left" | [[Omacetaxine (Synribo)]] | ||
+ | |Low | ||
| | | | ||
| | | | ||
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|align="left" | [[Pentostatin (Nipent)]] | |align="left" | [[Pentostatin (Nipent)]] | ||
|Low | |Low | ||
+ | | | ||
+ | | | ||
+ | |- | ||
+ | |align="left" | [[Pertuzumab (Perjeta)]] | ||
+ | |Minimal | ||
+ | | | ||
+ | | | ||
+ | |- | ||
+ | |align="left" | [[Pomalidomide (Pomalyst)]] (oral) | ||
+ | |Low/Minimal | ||
+ | | | ||
+ | | | ||
+ | |- | ||
+ | |align="left" | [[Ponatinib (Iclusig))]] (oral) | ||
+ | |Low/Minimal | ||
| | | | ||
| | | | ||
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| | | | ||
|NCCN did not further delineate between degrees of emetic potential | |NCCN did not further delineate between degrees of emetic potential | ||
+ | |- | ||
+ | |align="left" | [[Regorafenib (Stivarga)]] (oral) | ||
+ | |Low/Minimal | ||
+ | | | ||
+ | | | ||
|- | |- | ||
|align="left" | [[Rituximab (Rituxan)]] | |align="left" | [[Rituximab (Rituxan)]] | ||
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|align="left" | [[Romidepsin (Istodax)]] | |align="left" | [[Romidepsin (Istodax)]] | ||
|Low | |Low | ||
+ | | | ||
+ | | | ||
+ | |- | ||
+ | |align="left" | [[Ruxolitinib (Jakafi)]] (oral) | ||
+ | |Low/Minimal | ||
| | | | ||
| | | | ||
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|- | |- | ||
|align="left" | [[Temozolmide (Temodar)]] (oral) | |align="left" | [[Temozolmide (Temodar)]] (oral) | ||
− | |High/Moderate: >75 mg/m2/day<br>Low/Minimal: | + | |High/Moderate: >75 mg/m2/day<br>Low/Minimal: ≤75 mg/m2/day |
| | | | ||
|NCCN did not further delineate between degrees of emetic potential | |NCCN did not further delineate between degrees of emetic potential | ||
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| | | | ||
|NCCN did not further delineate between degrees of emetic potential | |NCCN did not further delineate between degrees of emetic potential | ||
+ | |- | ||
+ | |align="left" | [[Trametinib (Mekinist)]] (oral) | ||
+ | |Low/Minimal | ||
+ | | | ||
+ | | | ||
|- | |- | ||
|align="left" | [[Trastuzumab (Herceptin)]] | |align="left" | [[Trastuzumab (Herceptin)]] | ||
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| | | | ||
|NCCN did not further delineate between degrees of emetic potential | |NCCN did not further delineate between degrees of emetic potential | ||
+ | |- | ||
+ | |align="left" | [[Vemurafenib (Zelboraf)]] (oral) | ||
+ | |Low/Minimal | ||
+ | | | ||
+ | | | ||
|- | |- | ||
|align="left" | [[Vinblastine (Velban)]] | |align="left" | [[Vinblastine (Velban)]] | ||
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|Minimal | |Minimal | ||
|Minimal | |Minimal | ||
+ | | | ||
+ | |- | ||
+ | |align="left" | [[Vincristine liposomal (Marqibo)]] | ||
+ | |Minimal | ||
+ | | | ||
| | | | ||
|- | |- | ||
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|Minimal | |Minimal | ||
|Minimal | |Minimal | ||
+ | | | ||
+ | |- | ||
+ | |align="left" | [[Vismodegib (Erivedge)]] (oral) | ||
+ | |High/Moderate | ||
+ | | | ||
| | | | ||
|- | |- | ||
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| | | | ||
|NCCN did not further delineate between degrees of emetic potential | |NCCN did not further delineate between degrees of emetic potential | ||
+ | |- | ||
+ | |align="left" | [[Ziv-aflibercept (Zaltrap)]] | ||
+ | |Low | ||
+ | | | ||
+ | | | ||
|- | |- | ||
|} | |} | ||
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*[[Ondansetron (Zofran)]] (choose one of the options below): | *[[Ondansetron (Zofran)]] (choose one of the options below): | ||
**16-24 mg PO day 1 | **16-24 mg PO day 1 | ||
− | **8- | + | **8-16 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> IV day 1 (optional: may continue using on day 2-3) |
*[[Palonosetron (Aloxi)]] (choose one of the options below): | *[[Palonosetron (Aloxi)]] (choose one of the options below): | ||
**0.25 mg IV day 1 | **0.25 mg IV day 1 | ||
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===Steroid=== | ===Steroid=== | ||
''Steroids contraindicated for use with interleukin-2 and interferon.'' | ''Steroids contraindicated for use with interleukin-2 and interferon.'' | ||
− | *If [[Aprepitant (Emend)]] 125 mg or [[Fosaprepitant (Emend for Injection)]] | + | *If [[Aprepitant (Emend)]] 125 mg or [[Fosaprepitant (Emend for Injection)]] 115 mg on day 1: |
**NCCN: [[Dexamethasone (Decadron)]] 12 mg PO/IV on day 1, then 8 mg PO once per day on days 2 to 4 | **NCCN: [[Dexamethasone (Decadron)]] 12 mg PO/IV on day 1, then 8 mg PO once per day on days 2 to 4 | ||
**ASCO: [[Dexamethasone (Decadron)]] 12 mg PO/IV day 1, 8 mg PO/IV once per day on days 2 & 3 or 2 to 4 | **ASCO: [[Dexamethasone (Decadron)]] 12 mg PO/IV day 1, 8 mg PO/IV once per day on days 2 & 3 or 2 to 4 | ||
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===Optional=== | ===Optional=== | ||
*[[Lorazepam (Ativan)]] 0.5-2 mg PO/IV/sublingual Q4-6H prn nausea on days 1 to 4 | *[[Lorazepam (Ativan)]] 0.5-2 mg PO/IV/sublingual Q4-6H prn nausea on days 1 to 4 | ||
− | *H2 blocker or proton pump inhibitor | + | *[[:Category:H2-receptor antagonists|H2 blocker]] or [[:Category:Proton pump inhibitors|proton pump inhibitor]] |
==Antiemetics for moderately emetogenic IV chemotherapy== | ==Antiemetics for moderately emetogenic IV chemotherapy== | ||
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*[[Ondansetron (Zofran)]] (choose one of the options below): | *[[Ondansetron (Zofran)]] (choose one of the options below): | ||
**16 to 24 mg PO day 1 | **16 to 24 mg PO day 1 | ||
− | **8 to | + | **8 to 16 mg IV day 1<ref name="ondansetron QTc"></ref> IV day 1 |
*[[Palonosetron (Aloxi)]] (choose one of the options below): | *[[Palonosetron (Aloxi)]] (choose one of the options below): | ||
**0.25 mg IV day 1 | **0.25 mg IV day 1 | ||
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*[[Aprepitant (Emend)]] 125 mg PO day 1 or [[Fosaprepitant (Emend for Injection)]] 115 mg IV day 1 | *[[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 | *[[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 | + | *[[:Category:H2-receptor antagonists|H2 blocker]] or [[:Category:Proton pump inhibitors|proton pump inhibitor]] |
===Day 2 and 3=== | ===Day 2 and 3=== | ||
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**8 mg PO BID on days 2 & 3 | **8 mg PO BID on days 2 & 3 | ||
**16 mg PO once per day on days 2 & 3 | **16 mg PO once per day on days 2 & 3 | ||
− | **8 mg IV | + | **8 to 16 mg IV <ref name="ondansetron QTc"></ref> days 2 to 3 |
====Steroid==== | ====Steroid==== | ||
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====Optional==== | ====Optional==== | ||
*[[Lorazepam (Ativan)]] 0.5-2 mg PO/IV/sublingual Q4-6H prn nausea | *[[Lorazepam (Ativan)]] 0.5-2 mg PO/IV/sublingual Q4-6H prn nausea | ||
− | *H2 blocker or proton pump inhibitor | + | *[[:Category:H2-receptor antagonists|H2 blocker]] or [[:Category:Proton pump inhibitors|proton pump inhibitor]] |
==Antiemetics for highly to moderately emetogenic PO chemotherapy== | ==Antiemetics for highly to moderately emetogenic PO chemotherapy== | ||
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===Optional=== | ===Optional=== | ||
*[[Lorazepam (Ativan)]] 0.5-2 mg PO/IV/sublingual Q4-6H prn nausea on days 1 to 4 | *[[Lorazepam (Ativan)]] 0.5-2 mg PO/IV/sublingual Q4-6H prn nausea on days 1 to 4 | ||
− | *H2 blocker or proton pump inhibitor | + | *[[:Category:H2-receptor antagonists|H2 blocker]] or [[:Category:Proton pump inhibitors|proton pump inhibitor]] |
==Antiemetics for low emetic risk IV chemotherapy== | ==Antiemetics for low emetic risk IV chemotherapy== | ||
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===Optional=== | ===Optional=== | ||
*[[Lorazepam (Ativan)]] 0.5-2 mg PO/IV/sublingual Q4-6H prn nausea days 1-4 | *[[Lorazepam (Ativan)]] 0.5-2 mg PO/IV/sublingual Q4-6H prn nausea days 1-4 | ||
− | *H2 blocker or proton pump inhibitor | + | *[[:Category:H2-receptor antagonists|H2 blocker]] or [[:Category:Proton pump inhibitors|proton pump inhibitor]] |
==Minimal emetic risk chemotherapy== | ==Minimal emetic risk chemotherapy== | ||
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===Optional=== | ===Optional=== | ||
*[[Lorazepam (Ativan)]] 0.5-2 mg PO/IV/sublingual Q4-6H prn nausea days 1-4 | *[[Lorazepam (Ativan)]] 0.5-2 mg PO/IV/sublingual Q4-6H prn nausea days 1-4 | ||
− | *H2 blocker or 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=== |
Revision as of 08:57, 2 March 2015
Adapted from the NCCN[1] and ASCO guidelines.[2][3][4]
Emetic risk of chemotherapy
Hint: You can sort the table by clicking on the boxes containing arrows at the top of each column.
All drugs are IV route unless otherwise specified.
NCCN categories of emetic risk:
- High: >90% frequency of emesis
- Moderate: 30-90% frequency of emesis
- Low: 10-30% frequency of emesis
- Minimal: <10% frequency of emesis
ASCO guidelines say that in cases of combination chemotherapy regimens, patients should be given antiemetics that are recommended for the individual medication with the highest emetic risk. The exception is with anthracycline and Cyclophosphamide (Cytoxan) combinations as described below.
Drug | NCCN emetogenic potential | ASCO emetogenic potential | Comment |
---|---|---|---|
Ado-trastuzumab emtansine (Kadcyla) | Low | ||
Anthracycline (see differences between NCCN & ASCO) & Cyclophosphamide (Cytoxan) combination chemotherapy | High (Doxorubicin (Adriamycin) or Epirubicin (Ellence) with Cyclophosphamide (Cytoxan)) | High (Daunorubicin (Cerubidine), Doxorubicin (Adriamycin), Epirubicin (Ellence), or Idarubicin (Idamycin) with Cyclophosphamide (Cytoxan)) | |
Aldesleukin (Proleukin) | Moderate: >12 to 15 million international units/m2 Low: ≤12 million international units/m2 |
||
Alemtuzumab (Campath) | Minimal | Moderate | |
Altretamine (Hexalen) (oral) | High/Moderate | NCCN did not further delineate between degrees of emetic potential | |
Amifostine (Ethyol) | Moderate: >300 mg/m2 Low: ≤300 mg |
||
Arsenic trioxide (Trisenox) | Moderate | ||
Asparaginase (Elspar) | Minimal | ||
Axitinib (Inlyta) (oral) | Low/Minimal | ||
Azacitidine (Vidaza) | Moderate | Moderate | |
Bendamustine (Treanda) | Moderate | Moderate | |
Bevacizumab (Avastin) | Minimal | Minimal | |
Bexarotene (Targretin) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | |
Bleomycin (Blenoxane) | Minimal | Minimal | |
Bortezomib (Velcade) | Minimal | Low | |
Bosutinib (Bosulif) (oral) | Low/Minimal | ||
Brentuximab vedotin (Adcetris) | Low | ||
Busulfan (Myleran) | High/Moderate: ≥4 mg/day Low/Minimal: <4 mg/day |
Minimal | |
Busulfan (Myleran) (oral) | High/Moderate: ≥4 mg/day Low/Minimal: <4 mg/day |
NCCN did not further delineate between degrees of emetic potential | |
Cabazitaxel (Jevtana) | Low | Low | |
Cabozantinib (Cometriq) (oral) | Low/Minimal | ||
Capecitabine (Xeloda) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | |
Carboplatin (Paraplatin) | Moderate | Moderate | |
Carfilzomib (Kyprolis) | Low | ||
Carmustine (BiCNU) | High: >250 mg/m2 Moderate: ≤250 mg/m2 |
High | ASCO did not subclassify based on dose |
Catumaxomab (Removab) | Low | ||
Cetuximab (Erbitux) | Minimal | Minimal | |
Chlorambucil (Leukeran) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | |
Cisplatin (Platinol) | High | High | |
Cladribine (Leustatin) | Minimal | Minimal | |
Clofarabine (Clolar) | Moderate | Moderate | |
Crizotinib (Xalkori) (oral) | High/Moderate | ||
Cyclophosphamide (Cytoxan) | High: >1500 mg/m2 or when given with certain anthracyclines Moderate: ≤1500 mg/m2 |
High: ≥1500 mg/m2 or when given with anthracyclines Moderate: <1500 mg/m2 |
|
Cyclophosphamide (Cytoxan) (oral) | High/Moderate: ≥100 mg/m2/day Low/Minimal: <100 mg/m2/day |
NCCN did not further delineate between degrees of emetic potential | |
Cytarabine (Cytosar) | Moderate: >200 mg/m2 Low: 100 to 200 mg/m2 Minimal: <100 mg/m2 |
Moderate: >1000 mg/m2 Low: ≤1000 mg/m2 |
|
Dabrafenib (Tafinlar) (oral) | Low/Minimal | ||
Dacarbazine (DTIC) | High | High | |
Dactinomycin (Cosmegen) | Moderate | High | |
Dasatinib (Sprycel) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | |
Daunorubicin (Cerubidine) | Moderate | High when given with Cyclophosphamide (Cytoxan) Moderate when used alone |
|
Decitabine (Dacogen) | Minimal | ||
Denileukin diftitox (Ontak) | Minimal | ||
Dexrazoxane (Zinecard) | Minimal | ||
Docetaxel (Taxotere) | Low | Low | |
Doxorubicin (Adriamycin) | High: ≥60 mg/m2 or when given with Cyclophosphamide (Cytoxan) Moderate: <60 mg/m2 |
High when given with Cyclophosphamide (Cytoxan) Moderate when used alone |
|
Doxorubicin liposomal (Doxil) | Low | Low | |
Epirubicin (Ellence) | High: >90 mg/m2 or when given with Cyclophosphamide (Cytoxan) Moderate: ≤90 mg/m2 |
High when given with Cyclophosphamide (Cytoxan) Moderate when used alone |
|
Eribulin (Halaven) | Low | ||
Erlotinib (Tarceva) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | |
Estramustine (Emcyt) (oral) | High/Moderate | NCCN did not further delineate between degrees of emetic potential | |
Etoposide (Vepesid) | Low | Low | |
Etoposide (Vepesid) (oral) | High/Moderate | NCCN did not further delineate between degrees of emetic potential | |
Everolimus (Afinitor) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | |
Floxuridine (FUDR) | Low | ||
Fludarabine (Fludara) | Minimal | Minimal | |
Fludarabine (Fludara) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | |
Fluorouracil (5-FU) | Low | Low | |
Gefitinib (Iressa) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | |
Gemcitabine (Gemzar) | Low | Low | |
Hydroxyurea (Hydrea) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | |
Idarubicin (Idamycin) | Moderate | High when given with Cyclophosphamide (Cytoxan) Moderate when used alone |
|
Ifosfamide (Ifex) | High: ≥2 g/m2 per dose Moderate: <2 g/m2 per dose |
Moderate | ASCO did not subclassify based on dose |
Imatinib (Gleevec) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | |
Interferon alfa-2a (Roferon-A) | Moderate: ≥10 million international units/m2 Low: >5, <10 million international units/m2 Minimal: ≤5 million international units/m2 |
NCCN did not specify interferon alfa-2a vs. 2b | |
Interferon alfa-2b (Intron-A) | Moderate: ≥10 million international units/m2 Low: >5, <10 million international units/m2 Minimal: ≤5 million international units/m2 |
NCCN did not specify interferon alfa-2a vs. 2b | |
Ipilimumab (Yervoy) | Minimal | ||
Irinotecan (Camptosar) | Moderate | Moderate | |
Ixabepilone (Ixempra) | Low | Low | |
Lapatinib (Tykerb) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | |
Lenalidomide (Revlimid) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | |
Lomustine (Ceenu) (oral) | High/Moderate (single day) | single day; NCCN did not further delineate between degrees of emetic potential | |
Mechlorethamine (Mustargen) | High | High | |
Melphalan (Alkeran) | Moderate | ||
Melphalan (Alkeran) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | |
Mercaptopurine (Purinethol) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | |
Methotrexate (MTX) | Moderate: ≥250 mg/m2 Low: >50, <250 mg/m2 Minimal: ≤50 mg/m2 |
Low | ASCO did not subclassify based on dose |
Methotrexate (MTX) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | |
Mitomycin (Mutamycin) | Low | Low | |
Mitotane (Lysodren) (oral) | High/Moderate | ||
Mitoxantrone (Novantrone) | Low | Low | |
Nelarabine (Arranon) | Minimal | ||
Nilotinib (Tasigna) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | |
Ofatumumab (Arzzera) | Minimal | ||
Omacetaxine (Synribo) | Low | ||
Oxaliplatin (Eloxatin) | Moderate | Moderate | |
Paclitaxel (Taxol) | Low | Low | |
Paclitaxel, nanoparticle albumin-bound (Abraxane) | Low | ||
Panitumumab (Vectibix) | Minimal | ||
Pazopanib (Votrient) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | |
Peg-asparginase (Oncaspar) | Minimal | ||
Peginterferon alfa-2a (Pegasys) | Minimal | NCCN did not specify interferon alfa-2a vs. 2b | |
Peginterferon alfa-2b (PegIntron) | Minimal | NCCN did not specify interferon alfa-2a vs. 2b | |
Pemetrexed (Alimta) | Low | Low | |
Pentostatin (Nipent) | Low | ||
Pertuzumab (Perjeta) | Minimal | ||
Pomalidomide (Pomalyst) (oral) | Low/Minimal | ||
Ponatinib (Iclusig)) (oral) | Low/Minimal | ||
Pralatrexate (Folotyn) | Low | Minimal | |
Procarbazine (Matulane) (oral) | High/Moderate | NCCN did not further delineate between degrees of emetic potential | |
Regorafenib (Stivarga) (oral) | Low/Minimal | ||
Rituximab (Rituxan) | Minimal | Minimal | |
Romidepsin (Istodax) | Low | ||
Ruxolitinib (Jakafi) (oral) | Low/Minimal | ||
Sorafenib (Nexavar) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | |
Streptozocin (Zanosar) | High | High | |
Sunitinib (Sutent) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | |
Temozolmide (Temodar) | Moderate | ||
Temozolmide (Temodar) (oral) | High/Moderate: >75 mg/m2/day Low/Minimal: ≤75 mg/m2/day |
NCCN did not further delineate between degrees of emetic potential | |
Temsirolimus (Torisel) | Minimal | Low | |
Thalidomide (Thalomid) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | |
Thioguanine (Tabloid) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | |
Thiotepa (Thioplex) | Low | ||
Topotecan (Hycamtin) | Low | Low | |
Topotecan (Hycamtin) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | |
Trametinib (Mekinist) (oral) | Low/Minimal | ||
Trastuzumab (Herceptin) | Minimal | Low | |
Tretinoin (Vesanoid) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | |
Valrubicin (Valstar) | Minimal | ||
Vandetanib (Caprelsa) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | |
Vemurafenib (Zelboraf) (oral) | Low/Minimal | ||
Vinblastine (Velban) | Minimal | Minimal | |
Vincristine (Oncovin) | Minimal | Minimal | |
Vincristine liposomal (Marqibo) | Minimal | ||
Vinorelbine (Navelbine) | Minimal | Minimal | |
Vismodegib (Erivedge) (oral) | High/Moderate | ||
Vorinostat (Zolinza) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | |
Ziv-aflibercept (Zaltrap) | Low |
Antiemetics for highly emetogenic IV chemotherapy
Select one option from each class:
Serotonin (5-HT3) antagonist
- Dolasetron (Anzemet) 100 mg PO day 1
- Granisetron (Kytril) (choose one of the options below):
- 2 mg PO day 1
- 1 mg PO BID day 1
- 0.01 mg/kg (max 1mg) IV day 1
- transdermal patch as 3.1 mg/24H patch (containing 34.3 mg granisetron total dose) placed ~24-48 hours before the first dose of chemotherapy. May use patch up to 7 days.
- Ondansetron (Zofran) (choose one of the options below):
- 16-24 mg PO day 1
- 8-16 mg IV[5] IV day 1 (optional: may continue using on day 2-3)
- Palonosetron (Aloxi) (choose one of the options below):
- 0.25 mg IV day 1
- 0.5 mg PO day 1
- Ramosetron 0.3mg IV day 1
- Tropisetron 5 mg PO/IV day 1
Neurokinin 1 antagonist
- Aprepitant (Emend) 125 mg PO day 1, 80 mg PO once per day on days 2 & 3
- Fosaprepitant (Emend for Injection) 150 mg IV day 1
- Fosaprepitant (Emend for Injection) 115 mg IV day 1, then Aprepitant (Emend) 80 mg PO once per day on days 2 & 3
Steroid
Steroids contraindicated for use with interleukin-2 and interferon.
- If Aprepitant (Emend) 125 mg or Fosaprepitant (Emend for Injection) 115 mg on day 1:
- NCCN: Dexamethasone (Decadron) 12 mg PO/IV on day 1, then 8 mg PO once per day on days 2 to 4
- ASCO: Dexamethasone (Decadron) 12 mg PO/IV day 1, 8 mg PO/IV once per day on days 2 & 3 or 2 to 4
- If Fosaprepitant (Emend for Injection) 150 mg on day 1:
- NCCN: Dexamethasone (Decadron) 12 mg PO/IV day 1, 8 mg PO day 2, 8 mg PO BID on days 3 & 4
- ASCO: Dexamethasone (Decadron) 12 mg PO/IV day 1, 8 mg PO/IV once per day on days 2 & 3 or 2 to 4
Optional
- Lorazepam (Ativan) 0.5-2 mg PO/IV/sublingual Q4-6H prn nausea on days 1 to 4
- H2 blocker or proton pump inhibitor
Antiemetics for moderately emetogenic IV chemotherapy
Day 1
Select one option from each class on day 1:
Serotonin (5-HT3) antagonist
Note: NCCN lists all of the below as potential options, whereas ASCO only lists Palonosetron (Aloxi). Palonosetron (Aloxi) is preferred by the NCCN.
- Dolasetron (Anzemet) 100 mg PO day 1
- Granisetron (Kytril) (choose one of the options below):
- 2 mg PO day 1
- 1 mg PO BID day 1
- 0.01 mg/kg (max 1mg) IV day 1
- transdermal patch as 3.1 mg/24H patch (containing 34.3 mg Granisetron (Kytril) 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 PO/IV day 1
- ASCO: Dexamethasone (Decadron) 8 mg PO/IV day 1
Optional
- Aprepitant (Emend) 125 mg PO day 1 or Fosaprepitant (Emend for Injection) 115 mg IV day 1
- Lorazepam (Ativan) 0.5 to 2 mg PO/IV/sublingual Q4 to 6H prn nausea days 1 to 4
- H2 blocker or proton pump inhibitor
Day 2 and 3
ASCO only recommends Dexamethasone (Decadron), whereas NCCN allows you to choose any one class of medication to use: either a serotonin (5-HT3) antagonist, or steroid, or neurokinin 1 antagonist +/- steroid.
Serotonin (5-HT3) antagonist
- Dolasetron (Anzemet) 100 mg PO daily
- Granisetron (Kytril) (choose one of the options below):
- 1 to 2 mg PO once per day on days 2 & 3
- 1 mg PO BID on days 2 & 3
- 0.01 mg/kg (max 1mg) IV on days 2 & 3
- continued use of 3.1 mg/24H transdermal patch
- Ondansetron (Zofran) (choose one of the options below):
- 8 mg PO BID on days 2 & 3
- 16 mg PO once per day on days 2 & 3
- 8 to 16 mg IV [5] days 2 to 3
Steroid
Steroids contraindicated for use with interleukin-2 and interferon.
- Dexamethasone (Decadron) 8 mg PO/IV once per day on days 2 & 3
Neurokinin 1 antagonist +/- steroid if NK-1 used on day 1
- Aprepitant (Emend) 80 mg PO once per day on days 2-3 +/- Dexamethasone (Decadron) 8 mg PO/IV once per day days 2-3
Optional
- Lorazepam (Ativan) 0.5-2 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 (Kytril) (choose one of the options below):
- 2 mg PO once per day
- 1 mg PO BID
- Ondansetron (Zofran) 16-24 mg PO once per day
Optional
- Lorazepam (Ativan) 0.5-2 mg PO/IV/sublingual Q4-6H prn nausea on days 1 to 4
- H2 blocker or proton pump inhibitor
Antiemetics for low emetic risk IV chemotherapy
Repeat once per day for chemotherapy regimens that last more than one day. ASCO only recommends Dexamethasone (Decadron), whereas NCCN allows you to choose any one medication to use: either Dexamethasone (Decadron), metoclopramide, or prochlorperazine.
- Dexamethasone (Decadron) (contraindicated for use with interleukin-2 and interferon)
- NCCN: 12 mg PO/IV on the days of chemotherapy
- ASCO: 8 mg PO/IV on the days of chemotherapy
- Metoclopramide (Reglan) 10-40 mg PO/IV x1, then Q4-6H prn nausea
- Prochlorperazine (Compazine) 10mg PO/IV x1, then Q4-6H prn nausea
Optional
- Lorazepam (Ativan) 0.5-2 mg PO/IV/sublingual Q4-6H prn nausea days 1-4
- H2 blocker or proton pump inhibitor
Minimal emetic risk chemotherapy
- No routine prophylaxis
Antiemetics for low to minimal emetic risk PO chemotherapy
- use antiemetics prn first
If nausea/vomiting
Choose one of the medications below to start before chemotherapy and continue once per day:
- Metoclopramide (Reglan) 10-40 mg PO/IV x1, then Q4-6H prn nausea
- Prochlorperazine (Compazine) 10mg PO/IV x1, then Q4-6H prn nausea
- Haloperidol (Haldol) 0.5-2 mg PO/IV Q4-6H prn nausea (monitor for dystonic reactions)
Optional
- Lorazepam (Ativan) 0.5-2 mg PO/IV/sublingual Q4-6H prn nausea days 1-4
- H2 blocker or proton pump inhibitor
If continued nausea/vomiting
Use serotonin (5-HT3) antagonist:
- Granisetron (Kytril) (choose one of the options below):
- 2 mg PO once per day
- 1 mg PO BID
- Ondansetron (Zofran) 16-24 mg PO once per day
Breakthrough antinausea treatment
Use a medication from a different drug class from the current regimen as a prn medication.
Benzodiazepine
- Lorazepam (Ativan) 0.5-2 mg PO/IV Q4-6H prn nausea
Cannabinoid
- Dronabinol (Marinol) 5-10 mg PO Q3-6H prn nausea
- Nabilone (Cesamet) 1-2 mg PO BID prn nausea
Miscellaneous
- Haloperidol (Haldol) 0.5-2 mg PO/IV Q4-6H prn nausea (monitor for dystonic reactions)
- Metoclopramide (Reglan) 10-40 mg PO/IV Q4-6H prn nausea
- Olanzapine (Zyprexa) 2.5-5 mg PO BID prn nausea
- Scopolamine (Scopoderm) 1 patch Q72H prn nausea
Phenothiazine
- Prochlorperazine (Compazine) (choose one of the options below):
- 25 mg suppository PR Q12H prn nausea
- 10mg PO/IV Q4-6H prn nausea
- Promethazine (Phenergan) 12.5-25 mg PO/IV Q4H prn nausea
Serotonin 5-HT3 antagonist
- Dolasetron (Anzemet) 100 mg PO once per day
- Granisetron (Kytril) (choose one of the options below):
- 1-2 mg PO once per day
- 1 mg PO BID
- 0.01 mg/kg (max 1mg) IV prn nausea
- Ondansetron (Zofran) 16-24 mg PO once per day prn nausea
Steroid
Steroids contraindicated for use with interleukin-2 and interferon.
- Dexamethasone (Decadron) 12 mg PO/IV once per day
Anticipatory nausea/vomiting
- Prevent anticipation by optimizing antiemetic therapy for every cycle of chemotherapy
- Behavioral therapy
- Relaxation/systemic desensitization
- Hypnosis/guided imagery
- Music therapy
- Acupuncture/acupressure
- Alprazolam (Xanax) 0.5-2 mg PO TID starting the night before treatment
- Lorazepam (Ativan) 0.5-2 mg PO the night before and the morning of treatment
Reference
- ↑ NCCN antiemesis guidelines version 2.2014
- ↑ Antiemetics: American Society of Clinical Oncology Clinical Practice Guideline Update (2011)
- ↑ ASCO 2011 antiemetics guideline PDF
- ↑ ASCO 2011 antiemetics table
- ↑ 5.0 5.1 5.2 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.