Antiemesis

Adapted from the NCCN, ASCO and MASCC/ESMO

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 (2019)	ASCO emetogenic potential (2017)	MASCC/ESMO emetogenic potential (2016)	Comment
Ado-trastuzumab emtansine (Kadcyla)	Low
Anthracycline (see differences between NCCN & ASCO) & Cyclophosphamide (Cytoxan) combination chemotherapy	High (Doxorubicin (Adriamycin) or Epirubicin (Ellence) with Cyclophosphamide (Cytoxan))	High (Daunorubicin (Cerubidine), Doxorubicin (Adriamycin), Epirubicin (Ellence), or Idarubicin (Idamycin) with Cyclophosphamide (Cytoxan))	High	MASCC comment - in patients with breast cancer
Aldesleukin (Proleukin)	Moderate: >12 to 15 million international units/m2 Low: ≤12 million international units/m2
Alemtuzumab (Campath)	Minimal	Moderate	Moderate
Altretamine (Hexalen) or Hexamethylmelamine (oral)	High/Moderate	High		NCCN did not further delineate between degrees of emetic potential
Amifostine (Ethyol)	Moderate: >300 mg/m2 Low: ≤300 mg
Arsenic trioxide (Trisenox)	Moderate
Asparaginase (Elspar)	Minimal
Atezolizumab		Low
Axitinib (Inlyta) (oral)	Low/Minimal		Low
Azacitidine (Vidaza)	Moderate	Moderate	Moderate
Bendamustine	Moderate	Moderate	Moderate
Bevacizumab (Avastin)	Minimal	Minimal	Minimal
Bexarotene (Targretin) (oral)	Low/Minimal			NCCN did not further delineate between degrees of emetic potential
Bleomycin (Blenoxane)	Minimal	Minimal	Minimal
Blinatumomab		Low
Bortezomib (Velcade)	Minimal	Low	Low
Bosutinib (Bosulif) (oral)	Low/Minimal	Moderate	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		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		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		Moderate
Lomustine (CCNU) (oral)	High/Moderate (single day)			single day; NCCN did not further delineate between degrees of emetic potential
Mechlorethamine (Mustargen)	High	High	High
Melphalan (Alkeran)	Moderate			ASCO and MASCC recommend combination of NK1+5-HT3+DEX when melphalan is used at high dose for BMT conditioning.
Melphalan (Alkeran) (oral)	Low/Minimal		Minimal	NCCN did not further delineate between degrees of emetic potential
Mercaptopurine (6-MP) (oral)	Low/Minimal			NCCN did not further delineate between degrees of emetic potential
Methotrexate (MTX)	Moderate: ≥250 mg/m2 Low: >50, <250 mg/m2 Minimal: ≤50 mg/m2	Low	Low	ASCO and MASCC did not subclassify based on dose
Methotrexate (MTX) (oral)	Low/Minimal		Minimal	NCCN did not further delineate between degrees of emetic potential
Mitomycin (Mutamycin)	Low	Low	Low
Mitotane (Lysodren) (oral)	High/Moderate
Mitoxantrone (Novantrone)	Low	Low	Low
Nelarabine (Arranon)	Minimal
Nilotinib (Tasigna) (oral)	Low/Minimal		Low	NCCN did not further delineate between degrees of emetic potential
Ofatumumab (Arzzera)	Minimal		Minimal
Omacetaxine (Synribo)	Low
Oxaliplatin (Eloxatin)	Moderate	Moderate	Moderate
Paclitaxel (Taxol)	Low	Low	Low
Paclitaxel, nanoparticle albumin-bound (Abraxane)	Low		Low
Panitumumab (Vectibix)	Minimal
Pazopanib (Votrient) (oral)	Low/Minimal		Low	NCCN did not further delineate between degrees of emetic potential
Peg-asparginase (Oncaspar)	Minimal
Peginterferon alfa-2a (Pegasys)	Minimal			NCCN did not specify interferon alfa-2a vs. 2b
Peginterferon alfa-2b (PegIntron)	Minimal			NCCN did not specify interferon alfa-2a vs. 2b
Pemetrexed (Alimta)	Low	Low	Low
Pentostatin (Nipent)	Low
Pertuzumab (Perjeta)	Minimal		Low
Pomalidomide (Pomalyst) (oral)	Low/Minimal		Minimal
Ponatinib (Iclusig) (oral)	Low/Minimal		Low
Pralatrexate (Folotyn)	Low	Minimal	Minimal
Procarbazine (Matulane) (oral)	High/Moderate	High	High	NCCN did not further delineate between degrees of emetic potential
Regorafenib (Stivarga) (oral)	Low/Minimal		Low
Rituximab (Rituxan)	Minimal	Minimal	Minimal
Romidepsin (Istodax)	Low		Moderate
Ruxolitinib (Jakafi) (oral)	Low/Minimal		Minimal
Sorafenib (Nexavar) (oral)	Low/Minimal		Minimal	NCCN did not further delineate between degrees of emetic potential
Streptozocin (Zanosar)	High	High	High
Sunitinib (Sutent) (oral)	Low/Minimal		Low	NCCN did not further delineate between degrees of emetic potential
Temozolmide (Temodar)	Moderate		Moderate	MASCC remark: No direct evidence found for temozolomide IV. Classification is based on oral temozolomide, since all sources indicate a similar safety profile
Temozolmide (Temodar) (oral)	High/Moderate: >75 mg/m2/day Low/Minimal: ≤75 mg/m2/day	Moderate	Moderate	NCCN did not further delineate between degrees of emetic potential
Temsirolimus (Torisel)	Minimal	Low
Thalidomide (Thalomid) (oral)	Low/Minimal		Low	NCCN did not further delineate between degrees of emetic potential
Thioguanine (Tabloid) (oral)	Low/Minimal		Minimal	NCCN did not further delineate between degrees of emetic potential
Thiotepa (Thioplex)	Low		Moderate
Topotecan (Hycamtin)	Low	Low	Low
Topotecan (Hycamtin) (oral)	Low/Minimal			NCCN did not further delineate between degrees of emetic potential
Trametinib (Mekinist) (oral)	Low/Minimal
Trastuzumab (Herceptin)	Minimal	Low	Minimal
All-trans retinoic acid (ATRA) (oral)	Low/Minimal			NCCN did not further delineate between degrees of emetic potential
Valrubicin (Valstar)	Minimal
Vandetanib (Caprelsa) (oral)	Low/Minimal		Low	NCCN did not further delineate between degrees of emetic potential
Vemurafenib (Zelboraf) (oral)	Low/Minimal
Vinblastine (Velban)	Minimal	Minimal	Minimal
Vincristine (Oncovin)	Minimal	Minimal	Minimal
Vincristine liposomal (Marqibo)	Minimal
Vinorelbine (Navelbine)	Minimal	Minimal	Minimal
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

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 2016	NK1  + 5-HT3  + DEX	DEX (if APR on day 1, then +APR days 2-3)
NCCN 2019	- NK1  + 5-HT3  + DEX + OLN	DEX + OLN
	- NK1  + 5-HT3  + DEX	DEX
	- OLN + 5-HT3  + DEX	OLN

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

Neurokinin 1 (NK1) antagonist

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

Note: All of the above NK1 antagonists are equally effective in IV and PO formulations at recommended doses

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 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

Note: Ramosetron is another available 5-HT3, but not approved by FDA

Dexamethasone (DEX)

Steroids contraindicated for use with interleukin-2 and interferon.

• If Aprepitant (Emend) used:
  • Dexamethasone (Decadron) 12 mg IV or PO once on day 1, then 8 mg PO once per day on days 2 to 4
• If Fosaprepitant (Emend for Injection) used:
  • Dexamethasone (Decadron) 12 mg IV or PO once on day 1, then 8 mg PO once per day on days 2 to 4
• If Rolapitant (Varubi) used:
  • Dexamethasone (Decadron) 12 mg IV or PO once on day 1, then 8 mg PO twice per day on days 2 to 4

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

Netupitant-containing regimen

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

Olanzapine (OLN) containing regimen

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

• Olanzapine (Zyprexa) 10 mg PO once per day on days 1 to 4
• Aprepitant (Emend) 125 mg PO once on day 1, then 80 mg PO once per day on days 2 & 3, OR Fosaprepitant (Emend for Injection) 150 mg IV once on day 1
• Palonosetron (Aloxi) 0.25 mg IV once on day 1, OR Granisetron 1mg IV or 2mg PO, OR Ondansetron 8 mg PO or IV
• Dexamethasone (Decadron) 12 mg PO on day 1, and 8 mg PO on days 2, 3, and 4

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 once on day 1
• Palonosetron (Aloxi) 0.25 mg IV once on day 1
• Tropisetron (Navoban) 5 mg IV or PO day 1

Dexamethasone (DEX)

Steroids contraindicated for use with interleukin-2 and interferon.

• If Aprepitant (Emend) used:
  • Dexamethasone (Decadron) 12 mg IV or PO once on day 1, then 8 mg PO once per day on days 2 to 4
• If Fosaprepitant (Emend for Injection) used:
  • Dexamethasone (Decadron) 12 mg IV or PO once on day 1, then 8 mg PO once per day on days 2 to 4
• If Rolapitant (Varubi) used:
  • Dexamethasone (Decadron) 12 mg IV or PO once on day 1, then 8 mg PO twice per day on days 2 to 4

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

Netupitant-containing regimen

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

Olanzapine (OLN) containing regimen

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

• Olanzapine (Zyprexa) 10 mg PO once per day on days 1 to 4
• Aprepitant (Emend) 125 mg PO once on day 1, then 80 mg PO once per day on days 2 & 3, OR Fosaprepitant (Emend for Injection) 150 mg IV once on day 1
• Palonosetron (Aloxi) 0.25 mg IV once on day 1, OR Granisetron 1mg IV or 2mg PO, OR Ondansetron 8 mg PO or IV
• Dexamethasone (Decadron) 12 mg PO on day 1, and 8 mg PO on days 2, 3, and 4

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 2016 (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. One of them for done in female patients with GYN malignancy only. 5-HT3 used in those trials was either granisetron or ondansetron.

Bone marrow transplant (BMT) conditioning regimens

Allogeneic BMT conditioning regimens

Conditioning regimen	CINV prophylaxis
FMT (fludarabine, melphalan, thiotepa)	- Fosaprepitant on day -7 - Ondansetron on days -7 to -1
Flu/Mel (fludarabine, melphalan)	- Fosaprepitant on day -2 - Ondansetron on days -6 to -1 - Dexamethasone on days -6 to -1
Flu/Cy/TBI (fludarabine, cyclophosphamide, total body irradiation)
Cy/TBI (cyclophosphamide, total body irradiation)	- Fosaprepitant on day -6 - Ondansetron on days -6 to -1 - Dexamethasone on days -6 to -4
Bu/Flu (bufulfan, fludarabine)
Bu/Cy (busulfan, cyclophosphamide)

Autologous BMT conditioning regimens

Conditioning regimen	CINV prophylaxis
High dose melphalan
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

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

Optional

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

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.

• Dexamethasone (Decadron)
  • NCCN: 12 mg IV or PO on the days of chemotherapy
  • ASCO: 8 mg IV or PO on the days of chemotherapy
• Metoclopramide (Reglan) 10-40 mg IV or PO x1, then Q4-6H prn nausea
• Prochlorperazine (Compazine) 10mg IV or PO x1, then Q4-6H prn nausea

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:

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

Optional

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

If continued nausea/vomiting

Use serotonin (5-HT3) antagonist:

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

Breakthrough CINV treatment

General Principles

-Use antiemetic from another class than the prophylactic regimen

-Agents which are successful in treating a patient’s breakthrough CINV should be given routinely for a period of time rather than on an as needed basis.

-5-HT3 and NK1 RA are generally not effective or approved for treatment of breakthrough nausea/vomiting (assuming they were used as part of prophylaxis)

Olanzapine

• Olanzapine (Zyprexa) 10 mg PO daily on days 1-3 if CINV develop in the first 24 hours after HEC . Use 5 mg if 10mg is not well tolerated.

Metoclopromide

• Metoclopramide (Reglan) 10 mg PO (IV) every 8 hours on days 1-3 if CINV develop in the first 24 hours after HEC .

Benzodiazepine

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

Cannabinoid

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

Other agents

• Haloperidol (Haldol) 0.5 to 2 mg IV or PO Q4-6H prn nausea (monitor for dystonic reactions)
• Scopolamine (Scopoderm) 1 patch Q72H prn nausea

• Prochlorperazine (Compazine) (choose one of the options below):
  • 25 mg suppository PR every 12 hours prn nausea
  • 10mg IV or PO Q4-6H prn nausea
• Promethazine (Phenergan) 12.5-25 mg IV or PO every 6 hours for 1-3 days
• Dexamethasone (Decadron) 8 mg PO (IV) every 6-8 hours

Serotonin 5-HT3 antagonists

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

• Ondansetron (Zofran) 8 to 16 mg PO once per day prn nausea

Anticipatory nausea/vomiting

• Prevent anticipation by optimizing antiemetic therapy for every cycle of chemotherapy
• Behavioral therapy
  • Relaxation/systemic desensitization
  • Hypnosis/guided imagery
  • Music therapy
• Acupuncture/acupressure
• Alprazolam (Xanax) 0.5 to 2 mg PO three times per day starting the night before treatment
• Lorazepam (Ativan) 0.5 to 2 mg PO the night before and the morning of treatment