Antiemesis

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Adapted from the NCCN antiemesis guidelines[1].

Emetic risk of IV chemotherapy

High emetic risk, >90% frequency of emesis

  • AC combination (doxorubicin or epirubicin with cyclophosphamide)
  • Carmustine >250 mg/m2
  • Cisplatin >=50 mg/m2
  • Cyclophosphamide >1500 mg/m2
  • Dacarbazine
  • Doxorubicin >60 mg/m2
  • Epirubicin >90 mg/m2
  • Ifosfamide >= 10 g/m2
  • Mechlorethamine
  • Streptozocin

Moderate emetic risk, 30-90% frequency of emesis

  • Aldesleukin >12-15 million international units/m2
  • Amifostine >300 mg/m2
  • Arsenic trioxide
  • Azacitadine
  • Bendamustine
  • Busulfan
  • 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
  • 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

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

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

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

Reference

  1. ↑ NCCN antiemesis guidelines
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