Clinical Practice Guidelines   







Skip to end of metadata
Go to start of metadata

 This is an original JCO publication from 2015. Please visit the JCO website to access the full article.


Use of Antiemetics


 

 Authors

Paul J. Hesketh, Kari Bohlke, Gary H. Lyman, Ethan Basch, Maurice Chesney, Rebecca Anne Clark-Snow, Michael A. Danso, Karin Jordan, Mark R. Somerfield, and Mark G. Kris

BOTTOM LINE

Antiemetics: American Society of Clinical Oncology Focused Guideline Update

Intervention

Antiemetics for patients receiving cancer therapy.

Target Audience

Medical oncologists, radiation oncologists, oncology nurses, patients, caregivers.

Key Recommendations

  • Updated recommendation: All patients who receive highly emetogenic chemotherapy regimens (including anthracycline plus cyclophosphamide) should be offered a three-drug combination of a neurokinin 1 receptor antagonist, a 5- hydroxytryptamine-3 (5-HT3) receptor antagonist, and dexamethasone. The oral combination of netupitant and palonosetron (NEPA) plus dexamethasone is an additional treatment option in this setting.
  • The preferred 5-HT3 receptor antagonist for patients who receive moderately emetogenic chemotherapy regimens is palonosetron; antiemetic treatment includes that agent combined with a corticosteroid.
  • Antiemetic treatment for patients who receive combination chemotherapy should be determined according to the agent with the greatest degree of emetic risk. 
  • Both dexamethasone and a 5-HT3 receptor antagonist are recommended for patients receiving high-dose chemotherapy.
  • Pediatric patients receiving either highly or moderately emetogenic chemotherapy should be treated with a 5-HT3 receptor antagonist and corticosteroids; higher weight-based dosing may be required.
  • For those treated with highly emetogenic radiation therapy, a 5-HT3 receptor antagonist before each fraction and a 5-day course of dexamethasone are recommended.
  • A 5-HT3 receptor antagonist before each fraction is also recommended before moderately emetogenic radiation therapy; a 5-day course of dexamethasone is optional.
  • For patients who receive combination chemotherapy and radiotherapy, antiemetic therapy is dictated by the emetogenicity of chemotherapy, unless the emetic risk of radiation therapy is higher.

Methods

An update committee reviewed the results of two phase III randomized trials and one randomized dose-ranging study of NEPA.

Additional Resources

Additional information is available at www.asco.org/guidelines/antiemetics and www.asco.org/guidelineswiki. Patient information is available at www.cancer.net.

ASCO believes that cancer clinical trials are vital to inform medical decisions and improve cancer care and that all patients should have the opportunity to participate.

SUMMARY OF RECOMMENDATIONS

Clinical QuestionRecommendation
2015 Update

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

Should NEPA be incorporated into existing recommendations?

All patients who receive highly emetogenic chemotherapy regimens (including anthracyclinecyclophosphamide) should be offered a three-drug combination of an NK1 receptor antagonist, a 5-HT3 receptor antagonist, and dexamethasone. The oral combination of netupitant and palonosetron (NEPA) plus dexamethasone is an additional treatment option in this setting.
2011 Recommendations*
What is the optimal treatment to prevent nausea and vomiting from moderately emetogenic antineoplastic agents?The preferred 5-HT3 receptor antagonist for patients who receive moderately emetogenic chemotherapy regimens is palonosetron; antiemetic treatment includes that agent combined with a corticosteroid.
What is the optimal treatment to prevent nausea and vomiting from low emetogenic antineoplastic agents?A single 8-mg dose of dexamethasone before chemotherapy is suggested.
What is the optimal treatment to prevent nausea and vomiting from minimally emetogenic antineoplastic agents?No antiemetic should be administered routinely before or after chemotherapy.
What is the optimal treatment to prevent nausea and vomiting from combination chemotherapy?Patients should be administered antimetics appropriate for the component chemotherapeutic (antineoplastic) agent of greatest emetic risk.
What is the role of adjunctive drugs for nausea and vomiting induced by cancer treatments?Lorazepam and diphenhydramine are useful adjuncts to antiemetic drugs but are not recommended as single-agent antiemetics.
What is the optimal treatment to prevent nausea and vomiting associated with cancer therapy for pediatric patients?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. Due to variation of pharmacokinetic parameters in children, higher weight-based doses of 5-HT3 receptor antagonists than those used in adults may be required for antiemetic protection.
What is the optimal treatment to prevent nausea and vomiting in patients who are undergoing high-dose chemotherapy with stem cell or bone marrow transplant?A 5-HT3 receptor antagonist combined with dexamethasone is recommended.
What is the optimal treatment to prevent nausea and vomiting for patients receiving multi-day chemotherapy?It is suggested that antiemetics appropriate for the emetogenic risk class of the chemotherapy be administered for each day of the chemotherapy and for two days after, if appropriate.
The Update Committee suggests, based on limited data, that patients receiving five-day cisplatin regimens be treated with a 5-HT3 receptor antagonist in combination with dexamethasone and aprepitant.
What is the optimal antiemetic regimen for patients who experience nausea and vomiting secondary to cancer therapy despite optimal prophylaxis?

Language from the 2006 guideline was re-formatted 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.

What treatment options are available for patients who experience anticipatory nausea and vomiting?Use of the most active antiemetic regimens appropriate for the chemotherapy being administered to prevent acute or delayed emesis is suggested. Such regimens should be used with initial chemotherapy, rather than assessing the patient’s emetic response with less effective treatment. If anticipatory emesis occurs, behavioral therapy with systematic desensitization is effective and suggested.
What is the optimal prophylaxis for nausea and vomiting caused by high emetic risk radiation therapy?For those treated with highly emetogenic radiation therapy, a 5-HT3 receptor antagonist before each fraction and a 5-day course of dexamethasone are recommended.
What is the optimal prophylaxis for nausea and vomiting caused by moderate emetic risk radiation therapy?A 5-HT3 receptor antagonist before each fraction is also recommended before moderately emetogenic radiation; a 5-day course of dexamethasone is optional.
What is the optimal treatment to manage nausea and vomiting associated with low emetic risk radiation therapy?The Update Committee recommends a 5-HT3 receptor antagonist alone as either prophylaxis or rescue. For patients who experience RINV while receiving rescue therapy only, prophylactic treatment should continue until radiotherapy is complete.
What is the optimal treatment to manage nausea and vomiting associated with minimal emetic risk radiation therapy?Patients should receive rescue therapy with either a dopamine receptor antagonist or a 5-HT3 receptor antagonist. Prophylactic antiemetics should continue throughout radiation treatment if a patient experiences RINV while receiving rescue therapy.
What is the optimal treatment to manage nausea and vomiting during concurrent radiation and chemotherapy?Patients should receive antiemetic prophylaxis according to the emetogenicity of chemotherapy, unless the emetic risk with the planned radiotherapy is higher.

*2011 recommendations are pending a full update to the guideline.

 

   

 

 

ASCO Guideline Disclaimer: The clinical practice guidelines and other guidance published herein are provided by the American Society of Clinical Oncology, Inc. (“ASCO”) to assist practitioners in clinical decision making. The information therein should not be relied upon as being complete or accurate, nor should it be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. With the rapid development of scientific knowledge, new evidence may emerge between the time information is developed and when it is published or read. The information is not continually updated and may not reflect the most recent evidence. The information addresses only the topics specifically identified therein and is not applicable to other interventions, diseases, or stages of diseases. This information does not mandate any particular course of medical care. Further, the information is not intended to substitute for the independent professional judgment of the treating physician, as the information does not account for individual variation among patients. Recommendations reflect high, moderate or low confidence that the recommendation reflects the net effect of a given course of action.  The use of words like “must,” “must not,” “should,” and “should not” indicate that a course of action is recommended or not recommended for either most or many patients, but there is latitude for the treating physician to select other courses of action in individual cases. In all cases, the selected course of action should be considered by the treating physician in the context of treating the individual patient. Use of the information is voluntary.  ASCO provides this information on an “as is” basis, and makes no warranty, express or implied, regarding the information. ASCO specifically disclaims any warranties of merchantability or fitness for a particular use or purpose. ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this information or for any errors or omissions.


You must have an account to comment or submit evidence. Contact the Guidelines Site Administrator for assistance.

 

  • No labels