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
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
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
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