20110223-821807b9  

Highly and moderately emetogenic antineoplastic agents have the potential to induce both acute (≤24 hours) and delayed (>24 hours) nausea and vomiting after chemotherapy. The guideline recommendations include prophylaxis for both types of nausea and vomiting where appropriate.

Table. Emetic Risk of Intravenous Antineoplastic Agents

Emetic Risk

Agent

High

Carmustine
Cisplatin
Cyclophosphamide ≥1,500 mg/m2 
Dacarbazine
Dactinomycin
Mechlorethamine
Streptozotocin

Moderate

Azacitidine
Alemtuzumab
Bendamustine
Carboplatin
Clofarabine
Cyclophosphamide <1,500 mg/m2 
Cytarabine >1,000 mg/m2 
Daunorubicin*
Doxorubicin*
Epirubicin*
Idarubicin*
Ifosfamide
Irinotecan
Oxaliplatin

Low

Fluorouracil
Bortezomib
Cabazitaxel
Catumaxomab
Cytarabine ≤1,000 mg/m2 
Docetaxel
Doxorubicin HCL liposome injection
Etoposide
Gemcitabine
Ixabepilone
Methotrexate
Mitomycin
Mitoxantrone
Paclitaxel
Panitumumab
Pemetrexed
Temsirolimus
Topotecan
Trastuzumab

Minimal

2-Chlorodeoxyadenosine
Bevacizumab
Bleomycin
Busulfan
Cetuximab
Fludarabine
Pralatrexate
Rituximab
Vinblastine
Vincristine
Vinorelbine

Data adapted from Gralla RJ, Roila F, Tonato M, et al: MASCC/ESMO antiemetic guideline 2010.

 [Link to MASCC/ESMO antiemetic guidelines online] 

This list of agents is not exhaustive

*These anthracyclines, when combined with cyclophosphamide, are now designated as high emetic risk.

Clinical Question 1

What is the optimal treatment to prevent nausea and vomiting from highly emetogenic antineoplastic agents?

Recommendation 1. The three-drug combination of a neurokinin 1 (NK1) receptor antagonist (days 1 through 3 for aprepitant; day 1 only for fosaprepitant), a 5-hydroxytryptamine-3 (5-HT3) receptor antagonist (day 1 only), and dexamethasone (days 1 through 3 or 1 to 4) is recommended for patients receiving highly emetogenic chemotherapy. This recommendation remains unchanged since the 2006 update but has been reworded for clarification. The Update Committee also recommended reclassification of the combined anthracycline and cyclophosphamide (AC) regimen as highly emetogenic.

Clinical Question 2

What is the optimal treatment to prevent nausea and vomiting from moderately emetogenic antineoplastic agents?

Recommendation 2. The two-drug combination of palonosetron (day 1 only) and dexamethasone (days 1 through 3) is recommended for patients receiving moderately emetogenic chemotherapy. If palonosetron is not available, clinicians may substitute a first generation 5-HT3 receptor antagonist, preferably granisetron or ondansetron.

Limited evidence also supports adding aprepitant to the combination. Should clinicians opt to add aprepitant for patients receiving moderate-risk chemotherapy, any one of the 5-HT3 receptor antagonists is appropriate.

Clinical Question 3

What is the optimal treatment to prevent nausea and vomiting from low emetogenic antineoplastic agents?

Recommendation 3. A single 8-mg dose of dexamethasone before chemotherapy is suggested. No change from 2006.

Clinical Question 4

What is the optimal treatment to prevent nausea and vomiting from minimally emetogenic antineoplastic agents?

Recommendation 4. No antiemetic should be administered routinely before or after chemotherapy. No change from the original guideline.

Clinical Question 5

What is the optimal treatment to prevent nausea and vomiting from combination chemotherapy?

Recommendation 5. Patients should be administered antiemetics appropriate for the component chemotherapeutic (antineoplastic) agent of greatest emetic risk. No change from the original guideline. Anthracycline-cyclophosphamide combinations are now classified as highly emetogenic.

Clinical Question 6

What is the role of adjunctive drugs for nausea and vomiting induced by cancer treatments?

Recommendation 6. Lorazepam and diphenhydramine are useful adjuncts to antiemetic drugs but are not recommended as single agent antiemetics. No change from 2006.

Clinical Question 7

What is the role of complementary and alternative medicine therapies to prevent or control nausea and vomiting induced by chemotherapy?

Recommendation 7. No published randomized controlled trial data meeting the inclusion criteria are currently available to support a recommendation about such therapies.

Special Populations

Clinical Question 8

What is the optimal treatment to prevent nausea and vomiting associated with cancer therapy for pediatric patients?

Recommendation 8. The combination of a 5-HT3 receptor antagonist plus a corticosteroid is suggested before chemotherapy in children receiving chemotherapy of high or moderate emetic risk. Because of the variation of pharmacokinetic parameters in children, weight-based doses of 5-HT3 receptor antagonists higher than those used in adults may be required for antiemetic protection. No change from 2006.

Clinical Question 9

What is the optimal treatment to prevent nausea and vomiting in patients who are undergoing high-dose chemotherapy with stem-cell or bone marrow transplantation?

Recommendation 9. A 5-HT3 receptor antagonist combined with dexamethasone is recommended. Aprepitant should be considered, although evidence to support its use is limited.

Clinical Question 10

What is the optimal treatment to prevent nausea and vomiting for patients receiving multiday chemotherapy?

Recommendation 10. It is suggested that antiemetics appropriate for the emetogenic risk class of the chemotherapy be administered for each day of the chemotherapy and for 2 days after, if appropriate. No change from the original guideline. The Update Committee suggests, on the basis of limited data, that patients receiving 5-day cisplatin regimens be treated with a 5-HT3 receptor antagonist in combination with dexamethasone and aprepitant.

Clinical Question 11

What is the optimal antiemetic regimen for patients who experience nausea and vomiting secondary to cancer therapy despite optimal prophylaxis?

Recommendation 11. Language from the 2006 guideline was reformatted for clarity. Clinicians should (1) re-evaluate emetic risk, disease status, concurrent illnesses, and medications; (2) ascertain that the best regimen is being administered for the emetic risk; (3) consider adding lorazepam or alprazolam to the regimen; and (4) consider adding olanzapine to the regimen or substituting high-dose intravenous metoclopramide for the 5-HT3 receptor antagonist or adding a dopamine antagonist to the regimen.

Clinical Question 12

What treatment options are available for patients who experience anticipatory nausea and vomiting?

[See full Guideline for details]
[Link to free full-text Guideline summary at NCG | Free full-text Guideline PDF from J Clin Oncol]

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