Antiemesis

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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, ZD6474) (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) 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) 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) 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

  1. ↑ NCCN antiemesis guidelines
  2. ↑ Antiemetics: American Society of Clinical Oncology Clinical Practice Guideline Update (2011)
  3. ↑ ASCO 2011 antiemetics guideline PDF
  4. ↑ ASCO 2011 antiemetics table
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