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 are 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

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 ASCO emetogenic potential Comment
Ado-trastuzumab emtansine (Kadcyla) 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))
Aldesleukin (Proleukin) Moderate: >12 to 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
Axitinib (Inlyta) (oral) Low/Minimal
Azacitidine (Vidaza) Moderate Moderate
Bendamustine 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
Bosutinib (Bosulif) (oral) Low/Minimal
Brentuximab vedotin (Adcetris) Low
Busulfan (Myleran) High/Moderate: ≥4 mg/day
Low/Minimal: <4 mg/day
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
Cabozantinib (Cometriq) (oral) Low/Minimal
Capecitabine (Xeloda) (oral) Low/Minimal NCCN did not further delineate between degrees of emetic potential
Carboplatin (Paraplatin) Moderate Moderate
Carfilzomib (Kyprolis) Low
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 High Some only consider emetogenic potential high when receiving ≥70 mg/m2
Cladribine (Leustatin) Minimal Minimal
Clofarabine (Clolar) Moderate Moderate
Crizotinib (Xalkori) (oral) High/Moderate
Cyclophosphamide (Cytoxan) High: >1500 mg/m2 or when given with certain anthracyclines
Moderate: ≤1500 mg/m2
High: ≥1500 mg/m2 or when given with anthracyclines
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 to 200 mg/m2
Minimal: <100 mg/m2
Moderate: >1000 mg/m2
Low: ≤1000 mg/m2
Dabrafenib (Tafinlar) (oral) Low/Minimal
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 High when given with Cyclophosphamide (Cytoxan)
Moderate when used alone
Decitabine (Dacogen) Minimal
Denileukin diftitox (Ontak) Minimal
Dexrazoxane (Zinecard) Minimal
Docetaxel (Taxotere) Low Low
Doxorubicin (Adriamycin) High: ≥60 mg/m2 or when given at any dose with Cyclophosphamide (Cytoxan)
Moderate: <60 mg/m2
High when given with Cyclophosphamide (Cytoxan)
Moderate when used alone
Pegylated liposomal doxorubicin (Doxil) 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
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
Floxuridine (FUDR) Low
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 High when given with Cyclophosphamide (Cytoxan)
Moderate when used alone
Ifosfamide (Ifex) High: ≥2 g/m2 per dose
Moderate: <2 g/m2 per dose
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) 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
Mitotane (Lysodren) (oral) High/Moderate
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
Omacetaxine (Synribo) Low
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
Pertuzumab (Perjeta) Minimal
Pomalidomide (Pomalyst) (oral) Low/Minimal
Ponatinib (Iclusig) (oral) Low/Minimal
Pralatrexate (Folotyn) Low Minimal
Procarbazine (Matulane) (oral) High/Moderate NCCN did not further delineate between degrees of emetic potential
Regorafenib (Stivarga) (oral) Low/Minimal
Rituximab (Rituxan) Minimal Minimal
Romidepsin (Istodax) Low
Ruxolitinib (Jakafi) (oral) Low/Minimal
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
Trametinib (Mekinist) (oral) Low/Minimal
Trastuzumab (Herceptin) Minimal Low
All-trans retinoic acid (ATRA) (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
Vemurafenib (Zelboraf) (oral) Low/Minimal
Vinblastine (Velban) Minimal Minimal
Vincristine (Oncovin) Minimal Minimal
Vincristine liposomal (Marqibo) Minimal
Vinorelbine (Navelbine) Minimal Minimal
Vismodegib (Erivedge) (oral) High/Moderate
Vorinostat (Zolinza) (oral) Low/Minimal NCCN did not further delineate between degrees of emetic potential
Ziv-aflibercept (Zaltrap) Low

Antiemetics for highly emetogenic IV chemotherapy

Neurokinin-1 (NK1) antagonist-containing regimen (except netupitant)

Select ONE option from each class:

Neurokinin 1 antagonist

Serotonin (5-HT3) antagonist

Steroid

Steroids contraindicated for use with interleukin-2 and interferon.

Netupitant-containing regimen

Olanzapine-contain regimen

Note: a 4-drug regimen based on Navari et al. 2016[6] is likely to be recommended in the next release of the NCCN Guidelines.

Optional

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 (Aloxi). Palonosetron (Aloxi) is preferred by the NCCN.

  • Dolasetron (Anzemet) 100 mg PO day 1
  • Granisetron (Kytril) (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 (Kytril) 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):
    • 16 to 24 mg PO day 1
    • 8 to 16 mg IV day 1[5] IV day 1
  • Palonosetron (Aloxi) (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.

Optional

Day 2 and 3

ASCO only recommends Dexamethasone (Decadron), 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 (Anzemet) 100 mg PO daily
  • Granisetron (Kytril) (choose one of the options below):
    • 1 to 2 mg PO once per day on days 2 & 3
    • 1 mg PO BID on days 2 & 3
    • 0.01 mg/kg (max 1mg) IV on days 2 & 3
    • continued use of 3.1 mg/24H transdermal patch
  • Ondansetron (Zofran) (choose one of the options below):
    • 8 mg PO BID on days 2 & 3
    • 16 mg PO once per day on days 2 & 3
    • 8 to 16 mg IV [5] days 2 to 3

Steroid

Steroids contraindicated for use with interleukin-2 and interferon.

Neurokinin 1 antagonist +/- steroid if NK-1 used on day 1

Optional

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 once per day:

Serotonin (5-HT3) antagonist

Optional

Antiemetics for low emetic risk IV chemotherapy

Repeat once per day for chemotherapy regimens that last more than one day. ASCO only recommends Dexamethasone (Decadron), whereas NCCN allows you to choose any one medication to use: either Dexamethasone (Decadron), metoclopramide, or prochlorperazine.

Optional

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 once per day:

Optional

If continued nausea/vomiting

Use serotonin (5-HT3) antagonist:

Breakthrough antinausea treatment

Use a medication from a different drug class from the current regimen as a prn medication.

Benzodiazepine

Cannabinoid

Miscellaneous

Phenothiazine

Serotonin 5-HT3 antagonist

Steroid

Steroids contraindicated for use with interleukin-2 and interferon.

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 TID starting the night before treatment
  • Lorazepam (Ativan) 0.5 to 2 mg PO the night before and the morning of treatment

Reference

  1. NCCN antiemesis guidelines version 2.2016
  2. Antiemetics: American Society of Clinical Oncology Clinical Practice Guideline Update (2011)
  3. ASCO 2011 antiemetics guideline PDF
  4. ASCO 2011 antiemetics table
  5. 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.
  6. 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