Antiemesis
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 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
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 | |
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 | ||
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 | |
Busulfan (Myleran) | Moderate | 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 | |
Capecitabine (Xeloda) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | |
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 | |
Chlorambucil (Leukeran) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | |
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 |
|
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: 100-200 mg/m2 |
Moderate: >1000 mg/m2 Low: <=1000 mg/m2 |
|
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 | 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 | ||
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 | |
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 | Moderate | |
Ifosfamide (Ifex) | High: >=10 g/m2 Moderate: <10 g/m2 |
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; 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 | |
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 | ||
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 | ||
Pralatrexate (Folotyn) | Low | Minimal | |
Procarbazine (Matulane) (oral) | High/Moderate | NCCN did not further delineate between degrees of emetic potential | |
Rituximab (Rituxan) | Minimal | Minimal | |
Romidepsin (Istodax) | Low | ||
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 | |
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 | |
Vinblastine (Velban) | Minimal | Minimal | |
Vincristine (Oncovin) | Minimal | Minimal | |
Vinorelbine (Navelbine) | Minimal | Minimal | |
Vorinostat (Zolinza) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential |
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 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 (choose one of the options below):
- 16-24 mg PO day 1
- 8-24 mg (max 32 mg/day)[5] 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
- Ramosetron 0.3mg IV day 1
- Tropisetron 5 mg PO/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
Steroids contraindicated for use with interleukin-2 and interferon.
- If aprepitant 125 mg or fosaprepitant 115mg on day 1:
- NCCN: Dexamethasone 12 mg PO/IV on day 1, then 8 mg PO daily days 2-4
- ASCO: Dexamethasone 12 mg PO/IV day 1, 8 mg PO/IV daily on days 2-3 or 2-4
- If fosaprepitant 150 mg on day 1:
- NCCN: Dexamethasone 12 mg PO/IV day 1, 8 mg PO day 2, 8 mg PO BID days 3-4
- ASCO: Dexamethasone 12 mg PO/IV day 1, 8 mg PO/IV daily on days 2-3 or 2-4
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
Note: NCCN lists all of the below as potential options, whereas ASCO only lists palonosetron. Palonosetron is preferred by the NCCN.
- Dolasetron 100 mg PO day 1
- Granisetron (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 (choose one of the options below):
- 16-24 mg PO day 1
- 8-24 mg (max 32 mg/day)[5] IV day 1
- Palonosetron (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 12 mg PO/IV day 1
- ASCO: Dexamethasone 8 mg PO/IV 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
ASCO only recommends dexamethasone, 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 100 mg PO daily
- Granisetron (choose one of the options below):
- 1-2 mg PO daily days 2-3
- 1 mg PO BID days 2-3
- 0.01 mg/kg (max 1mg) IV days 2-3
- continued use of 3.1 mg/24H transdermal patch
- Ondansetron (choose one of the options below):
- 8 mg PO BID days 2-3
- 16 mg PO daily days 2-3
- 8 mg IV (up to 32 mg/day[5]) days 2-3
Steroid
Steroids contraindicated for use with interleukin-2 and interferon.
- Dexamethasone 8 mg PO/IV daily days 2-3
Neurokinin 1 antagonist +/- steroid if NK-1 used on day 1
- Aprepitant 80 mg PO daily days 2-3 +/- dexamethasone 8 mg PO/IV daily days 2-3
Optional
- Lorazepam 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 daily:
Serotonin (5-HT3) antagonist
- Granisetron (choose one of the options below):
- 2 mg PO daily
- 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 chemotherapy regimens that last more than one day. ASCO only recommends dexamethasone, whereas NCCN allows you to choose any one medication to use: either dexamethasone, metoclopramide, or prochlorperazine.
- Dexamethasone (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 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
Choose one of the medications below to 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 (choose one of the options below):
- 2 mg PO daily
- 1 mg PO BID
- Ondansetron 16-24 mg PO daily
Breakthrough antinausea 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 (choose one of the options below):
- 25 mg suppository PR Q12H prn nausea
- 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 (choose one of the options below):
- 1-2 mg PO daily
- 1 mg PO BID
- 0.01 mg/kg (max 1mg) IV prn nausea
- Ondansetron 16-24 mg PO daily prn nausea
Steroid
Steroids contraindicated for use with interleukin-2 and interferon.
- 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
Reference
- ↑ NCCN antiemesis guidelines
- ↑ 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.