Antiemesis
Guidelines
Given the rapid change in evidence in many areas of hematology/oncology, readers are encouraged to consider any guideline published 5+ years ago to be for historical purposes, only.
ASCO
- 2020: Hesketh et al. Antiemetics: ASCO Guideline Update PubMed
- 2017: Hesketh et al. Antiemetics: American Society of Clinical Oncology Clinical Practice Guideline Update PubMed
- 2015: Hesketh et al. Antiemetics: American Society of Clinical Oncology Focused Guideline Update PubMed
- 2011: Basch et al. Antiemetics: American Society of Clinical Oncology clinical practice guideline update PubMed
- 2006: Kris et al. American Society of Clinical Oncology guideline for antiemetics in oncology: update 2006 PubMed
ESMO
- 2009: Herrstedt & Roila. Chemotherapy-induced nausea and vomiting: ESMO clinical recommendations for prophylaxis PubMed
- 2008: Herrstedt & Roila. Chemotherapy-induced nausea and vomiting: ESMO clinical recommendations for prophylaxis PubMed
- 2007: Herrstedt. Chemotherapy-induced nausea and vomiting: ESMO clinical recommendations for prophylaxis PubMed
- 2005: Herrstedt et al. ESMO Minimum Clinical Recommendations for prophylaxis of chemotherapy-induced nausea and vomiting (NV) PubMed
- 2001: ESMO Recommendations for prophylaxis of chemotherapy-induced nausea and vomiting (NV) PubMed
MASCC/ESMO
- 2023: Herrstedt et al. 2023 MASCC and ESMO guideline update for the prevention of chemotherapy- and radiotherapy-induced nausea and vomiting PubMed
- 2016: Herrstedt et al. 2016 Updated MASCC/ESMO Consensus Recommendations: Prevention of Nausea and Vomiting Following High Emetic Risk Chemotherapy PubMed
- 2016: Einhorn et al. 2016 updated MASCC/ESMO consensus recommendations: prevention of nausea and vomiting following multiple-day chemotherapy, high-dose chemotherapy, and breakthrough nausea and vomiting PubMed
- 2016: Roila et al. 2016 updated MASCC/ESMO consensus recommendations: Prevention of nausea and vomiting following moderately emetogenic chemotherapy PubMed
- 2016: Olver et al. 2016 Updated MASCC/ESMO Consensus Recommendations: Controlling nausea and vomiting with chemotherapy of low or minimal emetic potential PubMed
- 2016: Dupuis et al. 2016 updated MASCC/ESMO consensus recommendations: Prevention of acute chemotherapy-induced nausea and vomiting in children PubMed
NCCN
- NCCN Guidelines - Antiemesis
- 2012: Ettinger et al. Antiemesis. PubMed
- 2009: Ettinger et al. Antiemesis. Clinical Practice Guidelines in Oncology. PubMed
- 2007: Ettinger et al. Antiemesis. PubMed
- 2004: Ettinger et al. Antiemesis clinical practice guidelines in oncology. PubMed
Children's Oncology Group (COG)
Emetic risk of chemotherapy, immunotherapy, TKIs and other agents
Hint: You can sort the table by clicking on the boxes containing arrows at the top of each column.
All drugs are IV route unless otherwise specified.
NCCN, ASCO and MASCC categories of emetic risk in the absence of prophylaxis:
- High: >90% frequency of emesis (HEC)
- Moderate: 30-90% frequency of emesis (MEC)
- Low: 10-30% frequency of emesis
- Minimal: less than 10% frequency of emesis
ASCO guidelines say that in cases of combination chemotherapy regimens, patients should be given antiemetics that are recommended for the individual medication with the highest emetic risk. The exception is with anthracycline and Cyclophosphamide (Cytoxan) combinations as described below.
Drug | NCCN emetogenic potential (2021) | ASCO emetogenic potential
(2020) |
MASCC/ESMO emetogenic potential (2019) | Comment |
---|---|---|---|---|
Trastuzumab emtansine (Kadcyla) | Low | Low | Low | |
Anthracycline (see differences between NCCN & ASCO) & Cyclophosphamide (Cytoxan) combination chemotherapy | High (Doxorubicin (Adriamycin) or Epirubicin (Ellence) with Cyclophosphamide (Cytoxan)) | High (Daunorubicin (Cerubidine), Doxorubicin (Adriamycin), Epirubicin (Ellence), or Idarubicin (Idamycin) with Cyclophosphamide (Cytoxan)) | High | MASCC comment - in patients with breast cancer |
Aldesleukin (Proleukin) | Moderate: >12 to 15 million international units/m2 Low: ≤12 million international units/m2 |
|||
Alemtuzumab (Campath) | Minimal | Moderate | Moderate | |
Altretamine (Hexalen) or Hexamethylmelamine (oral) | Moderate/High | Moderate/High | NCCN and ASCO did not further delineate between degrees of emetic potential | |
Amifostine (Ethyol) | Moderate: >300 mg/m2 Low: ≤300 mg/m2 |
|||
Arsenic trioxide (Trisenox) | Low | Moderate | ||
Asparaginase (Elspar) | Minimal | |||
Atezolizumab (Tecentriq) | Minimal | Minimal | ||
Axitinib (Inlyta) (oral) | Minimal/Low | Minimal/Low | Low | |
Azacitidine (Vidaza) | Moderate | Moderate | Moderate | |
Bendamustine | Moderate | Moderate | Moderate | |
Belinostat (Beleodaq) | Low | |||
Bevacizumab (Avastin) | Minimal | Minimal | Minimal | |
Bexarotene (Targretin) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | ||
Bleomycin (Blenoxane) | Minimal | Minimal | Minimal | |
Blinatumomab (Blincyto) | Low | Low | ||
Bortezomib (Velcade) | Minimal | Low | Low | |
Bosutinib (Bosulif) (oral) | Low/Minimal | Moderate | Moderate | |
Brentuximab vedotin (Adcetris) | Low | Low | ||
Busulfan (Myleran) | High/Moderate: at least 4 mg/day Low/Minimal: less than 4 mg/day |
Minimal | Minimal | |
Busulfan (Myleran) (oral) | High/Moderate: at least 4 mg/day Low/Minimal: less than 4 mg/day |
NCCN did not further delineate between degrees of emetic potential | ||
Cabazitaxel (Jevtana) | Low | Low | Low | |
Cabozantinib (Cometriq) (oral) | Low/Minimal | Moderate | ||
Capecitabine (Xeloda) (oral) | Low/Minimal | Low | NCCN did not further delineate between degrees of emetic potential | |
Carboplatin (Paraplatin) | High: AUC 4 or more
Moderate: AUC less than 4 |
Moderate (but recommended triplet combination of NK1, 5-HT3, and Dex if AUC 4 or more) | Moderate (but recommended triplet combination of NK1, 5-HT3, and dexamethasone) | MASCC/ESMO did not subclassify based on dose |
Carfilzomib (Kyprolis) | Low | Low | ||
Carmustine (BCNU) | High: >250 mg/m2 Moderate: ≤250 mg/m2 |
High | High | ASCO and MASCC/ESMO did not subclassify based on dose |
Catumaxomab (Removab) | Low | Low | ||
Cetuximab (Erbitux) | Minimal | Minimal | Low | |
Ceritinib (Zykadia) | Moderate | |||
Chlorambucil (Leukeran) (oral) | Low/Minimal | Minimal | NCCN did not further delineate between degrees of emetic potential | |
Cisplatin (Platinol) | High | High | High | Some only consider emetogenic potential high when dose 70 mg/m2 or more |
Cladribine (Leustatin) | Minimal | Minimal | Minimal | |
Clofarabine (Clolar) | Moderate | Moderate | Moderate | |
Crizotinib (Xalkori) (oral) | High/Moderate | Moderate | Moderate | |
Cyclophosphamide (Cytoxan) | High: greater than 1500 mg/m2 or when given with certain anthracyclines Moderate: up to and including 1500 mg/m2 |
High: 1500 mg/m2 or more, or when given with anthracyclines Moderate: less than 1500 mg/m2 |
High: > 1500 mg/m2 or when combined with anthracyclines (in breast cancer patients)
Moderate: < 1500 mg/m2 |
|
Cyclophosphamide (Cytoxan) (oral) | High/Moderate: 100 mg/m2/day or more Low/Minimal: less than 100 mg/m2/day |
Moderate | Moderate | NCCN did not further delineate between degrees of emetic potential |
Cytarabine (Ara-C) | Moderate: >200 mg/m2 Low: 100 to 200 mg/m2 Minimal: less than 100 mg/m2 |
Moderate: >1000 mg/m2 Low: ≤1000 mg/m2 |
Moderate: > 1000 mg/m2
Low: < 1000 mg/m2 |
|
Dabrafenib (Tafinlar) (oral) | Low/Minimal | Low | ||
Dacarbazine (DTIC) | High | High | High | |
Daratumumab (Darzalex) | Minimal | |||
Dactinomycin (Cosmegen) | Moderate | High | ||
Dasatinib (Sprycel) (oral) | Low/Minimal | Low | NCCN did not further delineate between degrees of emetic potential | |
Daunorubicin (Cerubidine) | Moderate | High when given with Cyclophosphamide (Cytoxan) Moderate when used alone |
High: when given with combined with cyclophosphamide (in breast cancer patients)
Moderate: when used alone |
|
Decitabine (Dacogen) | Minimal | |||
Denileukin diftitox (Ontak) | Minimal | |||
Dexrazoxane (Zinecard) | Minimal | |||
Docetaxel (Taxotere) | Low | Low | Low | |
Doxorubicin (Adriamycin) | High: 60 mg/m2 or more, or when given at any dose with Cyclophosphamide (Cytoxan) Moderate: less than 60 mg/m2 |
High when given with Cyclophosphamide (Cytoxan) Moderate when used alone |
High: when given with combined with cyclophosphamide (in breast cancer patients)
Moderate: when used alone |
|
Pegylated liposomal doxorubicin (Doxil) | Low | Low | Low | |
Epirubicin (Ellence) | High: >90 mg/m2 or when given at any dose with Cyclophosphamide (Cytoxan) Moderate: ≤90 mg/m2 |
High when given with Cyclophosphamide (Cytoxan) Moderate when used alone |
High: when combined with cyclophosphamide (in breast cancer patients)
Moderate: when used alone |
|
Eribulin (Halaven) | Low | Low | ||
Erlotinib (Tarceva) (oral) | Low/Minimal | 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 | Low | |
Etoposide (Vepesid) (oral) | High/Moderate | Low | NCCN did not further delineate between degrees of emetic potential | |
Everolimus (Afinitor) (oral) | Low/Minimal | Low | NCCN did not further delineate between degrees of emetic potential | |
Floxuridine (FUDR) | Low | |||
Fludarabine (Fludara) | Minimal | Minimal | Minimal | |
Fludarabine (Fludara) (oral) | Low/Minimal | Low | NCCN did not further delineate between degrees of emetic potential | |
Fluorouracil (5-FU) | Low | Low | Low | |
Gefitinib (Iressa) (oral) | Low/Minimal | Minimal | NCCN did not further delineate between degrees of emetic potential | |
Gemcitabine (Gemzar) | Low | Low | Low | |
Hydroxyurea (Hydrea) (oral) | Low/Minimal | Minimal | NCCN did not further delineate between degrees of emetic potential | |
Idarubicin (Idamycin) | Moderate | High when given with Cyclophosphamide (Cytoxan) Moderate when used alone |
High: when combined with cyclophosphamide (in breast cancer patients) Moderate: when used alone | |
Ifosfamide (Ifex) | High: 2000 mg/m2 or more per dose Moderate: <2 g/m2 per dose |
Moderate | Moderate | ASCO and MASCC did not subclassify based on dose |
Imatinib (Gleevec) (oral) | Low/Minimal | Moderate | Moderate | NCCN did not further delineate between degrees of emetic potential |
Interferon alfa-2a (Roferon-A) | Moderate: 10 million international units/m2 or more Low: between 5 and 10 million international units/m2 Minimal: 5 million international units/m2 or less |
NCCN did not specify interferon alfa-2a vs. 2b | ||
Interferon alfa-2b (Intron-A) | Moderate: 10 million international units/m2 or more Low: between 5 and 10 million international units/m2 Minimal: 5 million international units/m2 or less |
NCCN did not specify interferon alfa-2a vs. 2b | ||
Ipilimumab (Yervoy) | Minimal | Low | ||
Irinotecan (Camptosar) | Moderate | Moderate | Moderate | |
Ixabepilone (Ixempra) | Low | Low | Low | |
Lapatinib (Tykerb) (oral) | Low/Minimal | Low | NCCN did not further delineate between degrees of emetic potential | |
Lenalidomide (Revlimid) (oral) | Low/Minimal | Low | NCCN did not further delineate between degrees of emetic potential | |
Lenvatinib (Lenvima) (oral) | Moderate | |||
Lomustine (CCNU) (oral) | High/Moderate (single day) | single day; NCCN did not further delineate between degrees of emetic potential | ||
Lurbinectedin (Zepzelca) | Moderate | |||
Margetuximab (Margenza) | Minimal | |||
Mechlorethamine (Mustargen) | High | High | High | |
Melphalan (Alkeran) | Moderate | ASCO and MASCC recommend combination of NK1+5-HT3+DEX when melphalan is used at high dose for BMT conditioning. | ||
Melphalan (Alkeran) (oral) | Low/Minimal | Minimal | NCCN did not further delineate between degrees of emetic potential | |
Mercaptopurine (6-MP) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | ||
Methotrexate (MTX) | Moderate: 250 mg/m2 or more Low: between 50 and 250 mg/m2 Minimal: 50 mg/m2 or less |
Low | Low | ASCO and MASCC did not subclassify based on dose |
Methotrexate (MTX) (oral) | Low/Minimal | Minimal | NCCN did not further delineate between degrees of emetic potential | |
Mitomycin (Mutamycin) | Low | Low | Low | |
Mitotane (Lysodren) (oral) | High/Moderate | |||
Mitoxantrone (Novantrone) | Low | Low | Low | |
Nelarabine (Arranon) | Minimal | |||
Nilotinib (Tasigna) (oral) | Low/Minimal | Low | NCCN did not further delineate between degrees of emetic potential | |
Niraparib (Zejula) (oral) | Moderate to high | NCCN did not further delineate between degrees of emetic potential (>30%) | ||
Ofatumumab (Arzzera) | Minimal | Minimal | ||
Omacetaxine (Synribo) | Low | |||
Olaparib (Lynparza) (oral) | Moderate to high | NCCN did not further delineate between degrees of emetic potential (>30%) | ||
Oxaliplatin (Eloxatin) | Moderate | Moderate | Moderate | |
Paclitaxel (Taxol) | Low | Low | Low | |
Paclitaxel, nanoparticle albumin-bound (Abraxane) | Low | Low | ||
Panitumumab (Vectibix) | Minimal | Low | ||
Pazopanib (Votrient) (oral) | Low/Minimal | Low | 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 (Sylatron) | Minimal | NCCN did not specify interferon alfa-2a vs. 2b | ||
Pembrolizumab (Keytruda) | Minimal | |||
Pemetrexed (Alimta) | Low | Low | Low | |
Pentostatin (Nipent) | Low | |||
Pertuzumab (Perjeta) | Minimal | Low | ||
Pixantrone (Pixuvri) | Minimal | |||
Pomalidomide (Pomalyst) (oral) | Low/Minimal | Minimal | ||
Ponatinib (Iclusig) (oral) | Low/Minimal | Low | ||
Pralatrexate (Folotyn) | Low | Minimal | Minimal | |
Procarbazine (Matulane) (oral) | High/Moderate | High | High | NCCN did not further delineate between degrees of emetic potential |
Regorafenib (Stivarga) (oral) | Low/Minimal | Low | ||
Rituximab (Rituxan) | Minimal | Minimal | Minimal | |
Romidepsin (Istodax) | Low | Moderate | ||
Rucaparib (Rubraca) | Moderate to high | NCCN did not further delineate between degrees of emetic potential (>30%) | ||
Ruxolitinib (Jakafi) (oral) | Low/Minimal | Minimal | ||
Selinexor (Xpovio) (oral) | Moderate/High | Moderate/High | NCCN and ASCO did not further delineate between degrees of emetic potential | |
Sorafenib (Nexavar) (oral) | Low/Minimal | Minimal | NCCN did not further delineate between degrees of emetic potential | |
Streptozocin (Zanosar) | High | High | High | |
Sunitinib (Sutent) (oral) | Low/Minimal | Low | NCCN did not further delineate between degrees of emetic potential | |
Temozolmide (Temodar) | Moderate | Moderate | MASCC remark: No direct evidence found for temozolomide IV. Classification is based on oral temozolomide, since all sources indicate a
similar safety profile | |
Temozolmide (Temodar) (oral) | High/Moderate: >75 mg/m2/day Low/Minimal: ≤75 mg/m2/day |
Moderate | Moderate | NCCN did not further delineate between degrees of emetic potential |
Temsirolimus (Torisel) | Minimal | Low | ||
Thalidomide (Thalomid) (oral) | Low/Minimal | Low | NCCN did not further delineate between degrees of emetic potential | |
Thioguanine (Tabloid) (oral) | Low/Minimal | Minimal | NCCN did not further delineate between degrees of emetic potential | |
Thiotepa (Thioplex) | Low | Moderate | ||
Topotecan (Hycamtin) | Low | Low | Low | |
Topotecan (Hycamtin) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | ||
Trabectedin (Yondelis) | Moderate | |||
Trametinib (Mekinist) (oral) | Low/Minimal | |||
Trastuzumab (Herceptin) | Minimal | Low | Minimal | |
Trastuzumab deruxtecan (Enhertu) | High | Moderate | ||
All-trans retinoic acid (ATRA) (oral) | Low/Minimal | NCCN did not further delineate between degrees of emetic potential | ||
Umbralisib (Ukoniq) (oral) | Low/Minimal | |||
Valrubicin (Valstar) | Minimal | |||
Vandetanib (Caprelsa) (oral) | Low/Minimal | Low | NCCN did not further delineate between degrees of emetic potential | |
Vemurafenib (Zelboraf) (oral) | Low/Minimal | |||
Vinblastine (Velban) | Minimal | Minimal | Minimal | |
Vincristine (Oncovin) | Minimal | Minimal | Minimal | |
Vincristine liposomal (Marqibo) | Minimal | |||
Vinflunine (Javlor) | Low | |||
Vinorelbine (Navelbine) | Minimal | Minimal | Minimal | |
Vinorelbine (Navelbine) (oral) | Moderate | |||
Vismodegib (Erivedge) (oral) | High/Moderate | Minimal | ||
Vorinostat (Zolinza) (oral) | Low/Minimal | Low | NCCN did not further delineate between degrees of emetic potential | |
Ziv-aflibercept (Zaltrap) | Low | Low |
Highly emetogenic IV chemotherapy (HEC)
Day 1 CINV prophylaxis | Day 2-4 CINV prophylaxis | |
ASCO 2017 | NK1 + 5-HT3 + DEX + OLN | DEX + OLN
(if APR on day 1, then + APR days 2-3) |
MASCC 2019 | NK1 + 5-HT3 + DEX +/- OLN | DEX +/- OLN
(if APR on day 1, then + APR days 2-3) |
NCCN 2022 | - NK1 + 5-HT3 + DEX + OLN | DEX + OLN
(if po APR on day 1, then + APR days 2-3) |
- NK1 + 5-HT3 + DEX | DEX
(if po APR on day 1, then + APR days 2-3) | |
- OLN + Palonosetron + DEX | OLN |
Neurokinin-1 (NK1) antagonist-containing regimen (except netupitant)
Neurokinin 1 (NK1) antagonist
- Aprepitant (Emend) 125 mg PO once on day 1, then 80 mg PO once per day on days 2 & 3
- Aprepitant injectable emulsion (Cinvanti) 130 mg IV once on day 1
- Fosaprepitant (Emend for Injection) 150 mg IV once on day 1
- Rolapitant (Varubi) 180 mg PO once on day 1
Note: All of the above NK1 antagonists are equally effective in IV and PO formulations at recommended doses [4]
Serotonin (5-HT3) antagonist
- Dolasetron (Anzemet) 100 mg PO once on day 1
- Granisetron (choose one of the options below):
- 2 mg PO once on day 1
- 0.01 mg/kg (maximum dose 1 mg) IV once on day 1
- transdermal patch as 3.1 mg/24H patch (containing 34.3 mg granisetron total dose) placed ~24 to 48 hours before the first dose of chemotherapy. May use patch up to 7 days.
- Ondansetron (Zofran) (choose one of the options below):
- 8 to 16 mg IV[5] once on day 1
- Palonosetron (Aloxi) 0.25 mg IV once on day 1
- Tropisetron (Navoban) 5 mg IV or PO day 1
Note: When given at biologically equivalent doses, all of the above 5-HT3 antagonists are equally efficacious and appear to be interchangeable[6]
Note: Ramosetron is another available 5-HT3, but not approved by FDA
Dexamethasone (DEX)
Steroids contraindicated for use with interleukin-2 and interferon.
- If Aprepitant (Emend) used:
- Dexamethasone (Decadron) 12 mg IV or PO once on day 1, then 8 mg PO once per day on days 2 to 4
- If Fosaprepitant (Emend for Injection) used:
- Dexamethasone (Decadron) 12 mg IV or PO once on day 1, then 8 mg PO once per day on days 2 to 4
- If Rolapitant (Varubi) used:
- Dexamethasone (Decadron) 12 mg IV or PO once on day 1, then 8 mg PO twice per day on days 2 to 4
Dexamethasone use beyond day 1 might be revised based on the 2018 meta analysis results[7]
Netupitant-containing regimen
- Netupitant and palonosetron (Akynzeo) 300/0.5 mg PO once on day 1 as a fixed oral formulation
- Dexamethasone (Decadron) 12 mg PO or IV once on day 1, then 8 mg PO or IV once per day on days 2 to 4
Olanzapine (OLN) containing regimen
- Olanzapine (Zyprexa) 10 mg PO once per day on days 1 to 4
- Aprepitant (Emend) 125 mg PO once on day 1, then 80 mg PO once per day on days 2 & 3, OR Fosaprepitant (Emend for Injection) 150 mg IV once on day 1
- Palonosetron (Aloxi) 0.25 mg IV once on day 1, OR Granisetron 1mg IV or 2mg PO, OR Ondansetron 8 mg PO or IV
- Dexamethasone (Decadron) 12 mg PO on day 1, and 8 mg PO on days 2, 3, and 4
Reference:
Moderately emetogenic IV chemotherapy (MEC)
Day 1 CINV prophylaxis | Day 2-4 CINV prophylaxis | |
ASCO 2017 | 5-HT3 + DEX | DEX maybe offered for: oxaliplatin, or anthracycline, or cyclophosphamide |
MASCC 2016 | 5-HT3 + DEX | DEX can be considered for: oxaliplatin, or anthracycline, or cyclophosphamide |
NCCN 2022 | - 5-HT3 + DEX | DEX or 5-HT3 |
- NK1 + 5-HT3 + DEX
(for selected patients with additional risk factors or previous Rx failure) |
Aprepitant PO daily days 2 and 3 if aprepitant POused on day 1
+/- DEX | |
- OLN + Palonosetron + DEX | OLN |
Serotonin (5-HT3) antagonist
- Dolasetron (Anzemet) 100 mg PO once on day 1
- Granisetron (choose one of the options below):
- 2 mg PO once on day 1
- 0.01 mg/kg (maximum dose 1 mg) IV once on day 1
- transdermal patch as 3.1 mg/24H patch (containing 34.3 mg granisetron total dose) placed ~24 to 48 hours before the first dose of chemotherapy. May use patch up to 7 days.
- Ondansetron (Zofran) (choose one of the options below):
- 8 to 16 mg IV[5] once on day 1
- Palonosetron (Aloxi) 0.25 mg IV once on day 1
- Tropisetron (Navoban) 5 mg IV or PO day 1
Dexamethasone (DEX)
Steroids contraindicated for use with interleukin-2 and interferon.
- If Aprepitant (Emend) used:
- Dexamethasone (Decadron) 12 mg IV or PO once on day 1, then 8 mg PO once per day on days 2 to 4
- If Fosaprepitant (Emend for Injection) used:
- Dexamethasone (Decadron) 12 mg IV or PO once on day 1, then 8 mg PO once per day on days 2 to 4
- If Rolapitant (Varubi) used:
- Dexamethasone (Decadron) 12 mg IV or PO once on day 1, then 8 mg PO twice per day on days 2 to 4
Dexamethasone use beyond day 1 might be revised based on the 2018 meta analysis results[7]
Netupitant-containing regimen
- Netupitant and palonosetron (Akynzeo) 300/0.5 mg PO once on day 1 as a fixed oral formulation
- Dexamethasone (Decadron) 12 mg PO or IV once on day 1, then 8 mg PO or IV once per day on days 2 to 4
Olanzapine (OLN) containing regimen
Note: a 4-drug regimen based on Navari et al. 2016[9]
- Olanzapine (Zyprexa) 10 mg PO once per day on days 1 to 4
- Aprepitant (Emend) 125 mg PO once on day 1, then 80 mg PO once per day on days 2 & 3, OR Fosaprepitant (Emend for Injection) 150 mg IV once on day 1
- Palonosetron (Aloxi) 0.25 mg IV once on day 1, OR Granisetron 1mg IV or 2mg PO, OR Ondansetron 8 mg PO or IV
- Dexamethasone (Decadron) 12 mg PO on day 1, and 8 mg PO on days 2, 3, and 4
Carboplatin based chemotherapy
Guideline and emetic risk | Day 1 CINV prophylaxis | Day 2-4 CINV prophylaxis |
ASCO 2017 (MEC)
AUC 4 or more |
NK1 + 5-HT3 + DEX | NONE
(if APR on day 1, then +APR days 2-3) |
MASCC 2019 (MEC)
(doesn’t specify AUC) |
NK1 + 5-HT3 + DEX | NONE
(if APR on day 1, then +APR days 2-3) |
NCCN 2019
AUC 4 or more (HEC) AUC less than 4 (MEC) |
NK1 + 5-HT3 + DEX | DEX |
5-HT3 + DEX |
Recommendation to add NK1 is largely based on 2 phase III studies[10][11]. One of them was conducted in female patients with GYN malignancy only. [10] 5-HT3 used in those trials was either granisetron or ondansetron.
Bone marrow transplant (BMT) conditioning regimens
Note: Day 0 is the day of BMT, days with "-" in front are days prior to transplant, days with "+" afterwards are days after transplant
Allogeneic BMT conditioning regimens
Conditioning regimen | CINV prophylaxis |
---|---|
FMT (fludarabine, melphalan, thiotepa) | - NK1 on day -7
- 5-HT3 on days -7 to -1 |
Flu/Mel (fludarabine, melphalan) | - NK1 on day -2
- 5-HT3 on days -6 to -1 - DEX on days -6 to -1 |
Flu/Cy/TBI (fludarabine, cyclophosphamide, total body irradiation) | |
Cy/TBI (cyclophosphamide, total body irradiation) | - NK1 on day -6
- 5-HT3 on days -6 to -1 - DEX on days -6 to -4 |
Bu/Flu (bufulfan, fludarabine) | |
Bu/Cy (busulfan, cyclophosphamide) |
Autologous BMT conditioning regimens
Conditioning regimen | CINV prophylaxis |
---|---|
High dose melphalan[12] | - NK1 on days -3 to 0
- 5-HT3 on days -3 to 0 - DEX on days -3 to -1 |
BEAM (busulfan, etoposide, cytarabine, melphalan) | |
TBC (thiotepa, busulfan, cyclophosphamide) |
Highly to moderately emetogenic PO chemotherapy
These are NCCN recommendations only. ASCO did not provide separate antiemetic recommendations for PO vs. IV chemotherapy.
Start before chemotherapy and continue once per day:
Serotonin (5-HT3) antagonist
- Granisetron (choose one of the options below):
- 2 mg PO once per day
- 1 mg PO twice per day
- Ondansetron (Zofran) 16 to 24 mg PO once per day
Optional
- Lorazepam (Ativan) 0.5 to 2 mg PO/IV/sublingual Q4-6H prn nausea on days 1 to 4
- H2 blocker or proton pump inhibitor
Low emetic risk IV chemotherapy
Day 1 | Day 2-4 | |
ASCO 2017 | Single dose 5-HT3 or DEX 8mg | No routine prophylaxis |
MASCC 2016 | 5-HT3 or DEX or Dopamine RA | No routine prophylaxis |
NCCN 2022 | DEX or Metoclopramide or Prochlorperazine or
5-HT3 other than Palonosetron |
No routine prophylaxis |
Repeat once per day for chemotherapy regimens that last more than one day.
- Dexamethasone (Decadron)
- NCCN: 12 mg IV or PO on the days of chemotherapy
- ASCO: 8 mg IV or PO on the days of chemotherapy
- Metoclopramide (Reglan) 10-40 mg IV or PO x1, then Q4-6H prn nausea
- Prochlorperazine (Compazine) 10 mg IV or PO x1, then Q4-6H prn nausea
Minimal emetic risk chemotherapy
- No routine prophylaxis recommended by all 3 guideline groups. Assess patient prior to cycle 2 and add single agent prophylactic antiemetic if patient had emesis with cycle 1.
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 once per day:
- Metoclopramide (Reglan) 10-40 mg IV or PO x1, then Q4-6H prn nausea
- Prochlorperazine (Compazine) 10 mg IV or PO x1, then Q4-6H prn nausea
- Haloperidol (Haldol) 0.5 to 2 mg IV or PO Q4-6H prn nausea (monitor for dystonic reactions)
Optional
- Lorazepam (Ativan) 0.5 to 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 once per day
- 1 mg PO twice per day
- Ondansetron (Zofran) 16 to 24 mg PO once per day
Breakthrough CINV treatment
General Principles
-Use antiemetic from another class than the prophylactic regimen
-Agents which are successful in treating a patient’s breakthrough CINV should be given routinely for a period of time rather than on an as needed basis.
-5-HT3 and NK1 RA are generally not effective or approved for treatment of breakthrough nausea/vomiting (assuming they were used as part of prophylaxis)
Olanzapine
- Olanzapine (Zyprexa) 10 mg PO daily on days 1-3 if CINV develop in the first 24 hours after HEC [13]. Use 5 mg if 10 mg is not well tolerated.[14]
Metoclopromide
- Metoclopramide (Reglan) 10 mg PO (IV) every 8 hours on days 1-3 if CINV develop in the first 24 hours after HEC [13].
Benzodiazepine
- Lorazepam (Ativan) 0.5 to 2 mg PO (IV) Q4-6H prn nausea
Cannabinoid
- Dronabinol (Marinol) 5-10 mg PO Q3-6H prn nausea
- Nabilone (Cesamet) 1-2 mg PO twice per day prn nausea
Other agents
- Haloperidol (Haldol) 0.5 to 2 mg IV or PO Q4-6H prn nausea (monitor for dystonic reactions)
- Scopolamine (Scopoderm) 1 patch Q72H prn nausea
- Prochlorperazine (Compazine) (choose one of the options below):
- 25 mg suppository PR every 12 hours prn nausea
- 10 mg IV or PO Q4-6H prn nausea
- Promethazine (Phenergan) 12.5-25 mg IV or PO every 6 hours for 1-3 days
- Dexamethasone (Decadron) 8 mg PO (IV) every 6-8 hours
Serotonin 5-HT3 antagonists
Are generally ineffective for breakthrough CINV (assuming they were used as part of prophylactic regimen).
- Ondansetron (Zofran) 8 to 16 mg PO once per day prn nausea
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 (Xanax) 0.5 to 2 mg PO three times per day starting the night before treatment
- Lorazepam (Ativan) 0.5 to 1 mg PO beginning the night before treatment and then repeat the next 1-2 hours before anticancer therapy begins
Reference
- ↑ NCCN antiemesis guidelines
- ↑ ASCO antiemesis guidelineshttps://ascopubs.org/doi/abs/10.1200/JCO.20.01296
- ↑ MASCC antiemetic guidlines https://www.mascc.org/antiemetic-guidelines
- ↑ Grunberg S, Chua D, Maru A, Dinis J, DeVandry S, Boice JA, Hardwick JS, Beckford E, Taylor A, Carides A, Roila F, Herrstedt J. Single-dose fosaprepitant for the prevention of chemotherapy-induced nausea and vomiting associated with cisplatin therapy: randomized, double-blind study protocol--EASE. J Clin Oncol. 2011 Apr 10;29(11):1495-501. Epub 2011 Mar 7. link to original article PubMed
- ↑ 5.0 5.1 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.
- ↑ Karin Jordan et al. "Comparative activity of antiemetic drugs" link to original article
- ↑ 7.0 7.1 Ronald CHow et Al. "Efficacy and safety of 1-day versus 3-day dexamethasone for the prophylaxis of chemotherapy-induced nausea and vomiting: a systematic review and meta-analysis of randomized controlled trials" http://jhmhp.amegroups.com/article/view/4296
- ↑ Navari RM, Qin R, Ruddy KJ, Liu H, Powell SF, Bajaj M, Dietrich L, Biggs D, Lafky JM, Loprinzi CL. Olanzapine for the Prevention of Chemotherapy-Induced Nausea and Vomiting. N Engl J Med. 2016 Jul 14;375(2):134-42. link to original article link to PMC article PubMed
- ↑ Navari RM, Qin R, Ruddy KJ, Liu H, Powell SF, Bajaj M, Dietrich L, Biggs D, Lafky JM, Loprinzi CL. Olanzapine for the Prevention of Chemotherapy-Induced Nausea and Vomiting. N Engl J Med. 2016 Jul 14;375(2):134-42. link to original article PubMed
- ↑ 10.0 10.1 Yahata H, Kobayashi H, Sonoda K, et al: Effi- cacy of aprepitant for the prevention of chemotherapy- induced nausea and vomiting with a moderately emetogenic chemotherapy regimen: A multicenter, placebo-controlled, double-blind, randomized study in patients with gynecologic cancer receiving pac- litaxel and carboplatin. Int J Clin Oncol 21:491-497, 2016 https://pubmed.ncbi.nlm.nih.gov/26662632
- ↑ Hesketh PJ, Schnadig ID, Schwartzberg LS, et al: Efficacy of the neurokinin-1 receptor antagonist rolapitant in preventing nausea and vomiting in pa- tients receiving carboplatin-based chemotherapy. Cancer 122:2418-2425, 2016https://pubmed.ncbi.nlm.nih.gov/27176138
- ↑ . Aprepitant, granisetron, and dexamethasone for prevention of chemotherapy-induced nausea and vomiting after high-dose melphalan in autologous transplantation for multiple myeloma: results of a randomized, placebo-controlled phase III trial. J Clin Oncol. 2014;32:3413-20. PubMed ID 25225424.
- ↑ 13.0 13.1 R. M. Navari, C. K. Nagy, and S. E. Gray, “The use of olanzapine versus metoclopramide for the treatment of breakthrough chemotherapy-induced nausea and vomiting in patients receiving highly emetogenic chemotherapy,” Supportive Care in Cancer, vol. 21, no. 6, pp. 1655–1663, 2013
- ↑ S. Chanthawong, S. Subongkot, and A. Sookprasert, “Effectiveness of olanzapine for the treatment of breakthrough chemotherapy induced nausea and vomiting,” Journal of the Medical Association of Thailand, vol. 97, pp. 349–355, 2014