Antiemesis

Adapted from the NCCN antiemesis guidelines.

High emetic risk IV chemotherapy

Select one option from each class:

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

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, 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 day 3-4

Optional

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

Moderate emetic risk IV chemotherapy

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

High to moderate emetic risk 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

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

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