Antiemesis

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

Emetic risk of chemotherapy

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

High emetic risk, >90% frequency of emesis

• AC combination (Doxorubicin (Adriamycin) or Epirubicin (Ellence) with Cyclophosphamide (Cytoxan))
• Carmustine (BiCNU) >250 mg/m2
• Cisplatin (Platinol) >=50 mg/m2
• Cyclophosphamide (Cytoxan) >1500 mg/m2
• Dacarbazine (DTIC)
• Doxorubicin (Adriamycin) >60 mg/m2 -- NCCN classifies as potentially high depending on dose; ASCO classifies it as moderate by itself but high when combined with Cyclophosphamide (Cytoxan)
• Epirubicin (Ellence) >90 mg/m2 -- NCCN classifies as potentially high depending on dose; ASCO classifies it as moderate by itself but as high when combined with Cyclophosphamide (Cytoxan)
• Ifosfamide (Ifex) >= 10 g/m2 -- NCCN classifies as potentially high depending on dose; ASCO classifies it as moderate
• Mechlorethamine (Mustargen)
• Streptozocin (Zanosar)

Moderate emetic risk, 30-90% frequency of emesis

• Aldesleukin (Proleukin) >12-15 million international units/m2
• Alemtuzumab (Campath) -- ASCO classifies as moderate; NCCN classifies as minimal
• Amifostine (Ethyol) >300 mg/m2
• Arsenic trioxide (Trisenox)
• Azacitidine (Vidaza)
• Bendamustine (Treanda)
• Busulfan (Myleran) -- NCCN classifies as moderate; ASCO classifies as
• Carboplatin
• Carmustine <=250 mg/m2
• Cisplatin <50 mg/m2
• Clofarabine
• Cyclophosphamide <=1500 mg/m2
• Cytarabine >200 mg/m2
• Dactinomycin
• Daunorubicin
• Doxorubicin <=60 mg/m2
• Epirubicin <=90 mg/m2
• Idarubicin
• Ifosfamide <10 g/m2
• Interferon alfa >=10 million international units/m2
• Irinotecan
• Melphalan
• Methotrexate >=250 mg/m2
• Oxaliplatin
• Temozolomide

Low emetic risk, 10-30% frequency of emesis

• Amifostine <=300 mg
• Aldesleukin <=12 million international units/m2
• Cabazitaxel
• Cytarabine (low dose) 100-200 mg/m2
• Docetaxel
• Doxorubicin (liposomal)
• Eribulin
• Etoposide
• 5-Fluorouracil
• Floxuridine
• Gemcitabine
• Interferon alfa >5, <10 million international units/m2
• Ixabepilone
• Methotrexate >50, <250 mg/m2
• Mitomycin
• Mitoxantrone
• Paclitaxel
• Paclitaxel (albumin-bound)
• Pemetrexed
• Pentostatin
• Pralatrexate
• Romidepsin
• Thiotepa
• Topotecan

Minimal emetic risk, <10% frequency of emesis

• Alemtuzumab (Campath) -- NCCN classifies as minimal; ASCO classifies as moderate
• Asparaginase
• Bevacizumab
• Bleomycin
• Bortezomib
• Cetuximab
• Cladribine (2-chlorodeoxyadenosine)
• Cytarabine <100 mg/m2
• Decitabine
• Denileukin diftitox
• Dexrazoxane
• Fludarabine
• Interferon alpha <=5 million international units/m2
• Ipilimumab
• Methotrexate <=50 mg/m2
• Nelarabine
• Ofatumumab
• Panitumumab
• Pegaspargase
• Peginterferon
• Rituximab
• Temsirolimus
• Trastuzumab
• Valrubicin
• Vinblastine
• Vincristine
• Vinorelbine

Emetic risk of PO chemotherapy

High to moderate emetic risk

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

Low to minimal emetic risk

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

Antiemetics for highly emetogenic IV chemotherapy

Select one option from each class:

Serotonin (5-HT3) antagonist

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

Neurokinin 1 antagonist

• Aprepitant 125 mg PO day 1, 80 mg PO daily days 2-3
• Fosaprepitant 150 mg IV day 1
• Fosaprepitant 115 mg IV day 1, then aprepitant 80 mg PO daily days 2-3

Steroid

• If aprepitant 125 mg or fosaprepitant 115mg on day 1: Dexamethasone 12 mg PO/IV on day 1, then 8 mg PO daily days 2-4
• If fosaprepitant 150 mg on day 1: dexamethasone 12 mg PO/IV day 1, 8 mg PO day 2, 8 mg PO BID days 3-4

Optional

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

Antiemetics for moderately emetogenic IV chemotherapy

Day 1

Select one option from each class on day 1:

Serotonin (5-HT3) antagonist

• Dolasetron 100 mg PO
• Granisetron 2 mg PO or 1 mg PO BID or 0.01 mg/kg (max 1mg) IV day 1 or transdermal patch as 3.1 mg/24H patch (containing 34.3 mg granisetron total dose) applied ~24-48H prior to the first dose of chemotherapy. May use patch up to 7 days.
• Ondansetron 16-24 mg PO or 8 - 24 mg (max 32 mg/day) IV day 1 (optional: use on day 2-3)
• Palonosetron 0.25 mg IV day 1

Steroid

• Dexamethasone 12 mg PO/IV on day 1

Optional

• Aprepitant 125 mg PO day 1 or fosaprepitant 115 mg IV day 1
• Lorazepam 0.5-2 mg PO/IV/sublingual Q4-6H prn nausea days 1-4
• H2 blocker or proton pump inhibitor

Day 2 and 3

Serotonin (5-HT3) antagonist monotherapy

• Dolasetron 100 mg PO daily
• Granisetron 1-2 mg PO daily or 1 mg PO BID or 0.01 mg/kg (max 1mg) IV
• Ondansetron 8 mg PO BID or 16 mg PO daily or 8 mg IV (max 32 mg/day)

Steroid

• Dexamethasone 8 mg PO/IV daily

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

• Aprepitant 80 mg PO daily +/- dexamethasone 8 mg PO/IV daily

Optional

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

Antiemetics for highly to moderately emetogenic PO chemotherapy

Start before chemotherapy and continue daily:

Serotonin (5-HT3) antagonist

• Granisetron 2 mg PO daily or 1 mg PO BID
• Ondansetron 16-24 mg PO daily

Optional

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

Antiemetics for low emetic risk IV chemotherapy

Repeat daily for multiple day chemotherapy regimens:

• Dexamethasone 12 mg PO/IV daily
• Metoclopramide 10-40 mg PO/IV x1, then Q4-6H prn nausea
• Prochlorperazine 10mg PO/IV x1, then Q4-6H prn nausea

Optional

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

Minimal emetic risk chemotherapy

• No routine prophylaxis

Antiemetics for low to minimal emetic risk PO chemotherapy

• use antiemetics prn first

If nausea/vomiting

Start before chemotherapy and continue daily:

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

Optional

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

If continued nausea/vomiting

Use serotonin (5-HT3) antagonist:

• Granisetron 2 mg PO daily or 1 mg PO BID
• Ondansetron 16-24 mg PO daily

Breakthrough nausea treatment

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

Benzodiazepine

• Lorazepam 0.5-2 mg PO/IV Q4-6H prn nausea

Cannabinoid

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

Miscellaneous

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

Phenothiazine

• Prochlorperazine 25 mg suppository PR Q12H or 10mg PO/IV Q4-6H prn nausea
• Promethazine 12.5-25 mg PO/IV Q4H prn nausea

Serotonin 5-HT3 antagonist

• Dolasetron 100 mg PO daily
• Granisetron 1-2 mg PO daily or 1 mg PO BID or 0.01 mg/kg (max 1mg) IV prn nausea
• Ondansetron 16 mg PO/IV daily prn nausea

Steroid

• Dexamethasone 12 mg PO/IV daily

Anticipatory nausea/vomiting

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