Chemotherapy-Induced Nausea and Vomiting Prophylaxis

CHEMOTHERAPY-INDUCED NAUSEA AND VOMITING PROPHYLAXIS

The recommended approach for the prevention and management of chemotherapy-induced nausea and vomiting (CINV) varies by the emetic risk of the treatment regimen. Adherence to antiemetic guidelines has resulted in improved control of nausea and vomiting, and improved adherence to chemotherapy regimen. The ASCO guideline provides updated recommendations for the prevention and management of nausea and vomiting due to antineoplastic agents for cancer.

ANTIEMETIC REGIMENS
Emetic risk category1,2 Drug regimen
High emetic risk NK1 receptor antagonist + 5-HT3 receptor antagonist + dexamethasone + olanzapine
Moderate emetic risk3 5-HT3 receptor antagonist + dexamethasone
Low emetic risk 5-HT3 receptor antagonist OR dexamethasone
Minimal emetic risk No routine antiemetic prophylaxis
Breakthrough / Refractory Add to standard antiemetic regimen: olanzapine or drug of a different class or benzodiazepine or dopamine receptor antagonist or cannabinoids
ANTIEMETIC DOSING
Drug Day 14 Day 2 Day 3 Day 4
HIGH RISK
NK1 receptor antagonist3
Aprepitant OR 125mg PO 80mg PO 80mg PO  
FosaprepitantOR 150mg IV      
Rolapitant OR 180mg PO      
Netupitant-palonosetron5 300mg/0.5mg PO      
5-HT3 receptor antagonist5
Granisetron OR 2mg PO OR 1mg or 0.01mg/kg IV OR 1 patch OR 10mg SC      
Ondansetron OR 8mg PO twice daily OR 24mg soluble films OR 8mg or 0.15mg/kg IV      
Palonosetron OR 0.50mg PO OR 0.25mg IV      
Dolasetron 100mg PO      
Corticosteroid
Dexamethasone6 12mg PO or IV7 8mg PO or IV7,8,9 8mg PO or IV7,8,9 8mg PO or IV7,8,9
Atypical Antipsychotic
Olanzapine 10mg PO 10mg PO8 10mg PO8 10mg PO8
Moderate risk3
5-HT3 receptor antagonist
Granisetron OR 2mg PO OR 1mg or 0.01mg/kg IV OR 1 patch OR 10mg SC      
Ondansetron OR 8mg PO twice daily OR 8mg soluble film twice daily OR 8mg or 0.15mg/kg IV      
Palonosetron OR 0.50mg PO OR 0.25mg IV      
Dolasetron 100mg PO      
Corticosteroid
Dexamethasone3 8mg PO or IV 8mg PO or IV10 8mg PO or IV10  
LOW RISK
5-HT3 receptor antagonist
Granisetron OR 2mg PO OR 1mg or 0.01mg/kg IV OR 1 patch OR 10mg SC      
Ondansetron OR 8mg PO twice daily OR 8mg soluble film twice daily OR 8mg or 0.15mg/kg IV      
Palonosetron OR 0.50mg PO OR 0.25mg IV      
Dolasetron 100mg PO      
Corticosteroid
Dexamethasone 8mg PO or IV      
NOTES

Key: 5HT3 = 5-hydroxytryptamine-3 (serotonin); AUC = area under the curve; CINV = chemotherapy induced nausea and vomiting; IV = intravenous; NK1 = neurokinin 1; PO = oral; SC = subcutaneous

1  For emetic risk category of chemotherapeutic agents, see “Emetogenic Potential of Antineoplastic Agent” chart.

2  Adults treated with antineoplastic combinations should receive the antiemetic regimen appropriate for the component antineoplastic agent of greatest emetic risk.

3  For adults treated with carboplatin AUC ≥4mg/mL (emetic risk is at the higher end of the moderate-emetic risk category), add NK1 receptor antagonist for a 3-drug regimen. Dexamethasone dosing is Day 1 only: 20mg with rolapitant, and 12mg with aprepitant, fosaprepitant, or netupitant-palonosetron.

4  Give antiemetic regimen on the day of chemotherapy (single-day) before the dose of the antineoplastic agent. For multi-day chemotherapy, first determine the emetic risk of the agent(s) included in the regimen. Patients should receive the agent of the highest therapeutic index daily during chemotherapy and for 2 days thereafter. Granisetron transdermal patch or granisetron ext-rel inj, which deliver therapy over multiple days rather than a daily 5-HT3 receptor antagonist, can be given.

5  If netupitant-palonosetron is used, no additional 5-HT3 receptor antagonist is needed.

6  Dexamethasone dosing is for patients receiving the recommended 4-drug regimen for high-emetic risk. If NK1 receptor antagonist was omitted, the dexamethasone dose should be adjusted to 20mg on Day 1 and 16mg on Days 2–4.

7  If rolapitant is used, give with dexamethasone 20mg PO or IV on Day 1, and 8mg PO or IV twice daily on Days 2–4.

8  For cisplatin and other high-emetic-risk single agents, dexamethasone and olanzapine should be continued on Days 2–4. For anthracycline + cyclophosphamide regimens, only continue olanzapine on Days 2–4.

9  If fosaprepitant is used, give with dexamethasone 8mg PO or IV on Day 2, and 8mg PO or IV twice daily on Days 3–4.

10 For moderate-emetic risk agents that are known to cause delayed nausea & vomiting (eg, cyclophosphamide, doxorubicin, oxaliplatin), may continue dexamethasone on Days 2–3.

REFERENCES
Hesketh PJ, Kris MG, Basch E, et al. Antiemetics: American Society of Clinical Oncology Clinical Practice Guideline Update. Journal of Clinical Oncology. 2017;35(28):3240-3261. doi:10.1200/jco.2017.74.4789.

Created 4/2020