Guidelines for Use of Antiemetics
2006 Guidelines for Use of Antiemetics from
American Society of Clinical Oncology
Table 1. Summary of Recommendations for Antiemetics in Oncology: Antiemetic Regimens
Specific Emetic Risk Categories | Current Recommendations |
High
(> 90%) emetic risk |
- The three-drug combination of a 5-HT3 serotonin receptor antagonist,
dexamethasone, and aprepitant is recommended before chemotherapy.
- In all patients receiving cisplatin
and all other agents of high emetic risk, the two-drug combination of dexamethasone and aprepitant
is recommended.
- The Update Committee no longer recommends the combination of a 5-HT3 serotonin
receptor antagonist and dexamethasone on days 2 and 3.
|
Moderate
(> 30% to 90%) emetic risk |
- The three-drug combination of a 5-HT3 receptor serotonin
antagonist, dexamethasone, and aprepitant is recommended for patients receiving AC.
- For patients
receiving chemotherapy of moderate emetic risk other than AC, we recommend the two-drug
combination of a 5-HT3 receptor serotonin antagonist and dexamethasone.
- In patients receiving AC,
aprepitant as a single agent is recommended on days 2 and 3. For all other chemotherapies of
moderate
emetic risk, single-agent dexamethasone or a 5-HT3 serotonin receptor antagonist is suggested for
the
prevention of emesis on days 2 and 3.
|
Low
(10% to 30%) emetic risk |
- Dexamethasone 8 mg is suggested. No routine preventive
use of
antiemetics for delayed emesis is suggested.
|
Minimal
(< 10%) emetic risk |
- No change from the original guideline.
- No antiemetic should be administered
routinely before or after chemotherapy.
|
Combination chemotherapy |
- No change from the original guideline.
- Patients should be administered
antiemetics appropriate for the chemotherapeutic agent of greatest emetic risk.
|
Multiple consecutive days of chemotherapy |
- No change from the original guideline.
- It is suggested that
antiemetics appropriate for the risk class of the chemotherapy, as outlined above, be administered
for
each day of the chemotherapy and for 2 days after, if appropriate.
|
Antiemetic agents: lower therapeutic index |
- For persons receiving chemotherapy of high emetic risk,
there
is no group of patients for whom agents of lower therapeutic index are appropriate first-choice
antiemetics.
- These agents should be reserved for patients intolerant of or refractory to 5-HT3 serotonin
receptor antagonists, NK1 receptor antagonists, and dexamethasone.
|
Antiemetic agents: adjunctive drugs |
- Lorazepam and diphenhydramine are useful adjuncts to
antiemetic
drugs, but are not recommended as single agents.
|
Antiemetic agents: combinations of antiemetics |
- It is recommended that 5-HT3 serotonin receptor
antagonists be administered with dexamethasone and aprepitant in patients receiving chemotherapy of
high emetic risk and in patients receiving AC.
- A 5-HT3 serotonin receptor antagonist combined with
dexamethasone should be used in patients receiving agents of moderate emetic risk other than AC.
|
5-HT3: 5-hydroxytryptamine-3
AC: anthracycline and cyclophosphamide
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Table 2. Summary of Recommendations for Antiemetics in Oncology: Radiation-Induced Emesis
Recommendation Category | Current Recommendations |
High risk: total-body irradiation |
- No change from original guideline.
- The Update Committee suggests giving a 5-HT3
serotonin receptor antagonist with or without a corticosteroid before each fraction
and for at least 24 hours after.
|
Moderate emetic risk: upper abdomen (intermediate
risk) hemibody irradiation, upper abdomen,
abdominal-pelvic, mantle, craniospinal irradiation,
and cranial radiosurgery |
- The Update Committee recommends a 5-HT3 serotonin
receptor antagonist before
each fraction.
|
Low emetic risk: lower thorax, cranium (radiosurgery),
and craniospinal |
- No change from original guideline.
- The Update Committee recommends a 5-HT3
serotonin receptor antagonist before each fraction.
|
Minimal emetic risk: radiation of breast, head and
neck, cranium, and extremities |
- No change from original guideline.
- The Update Committee suggests that treatment
be administered on an as-needed basis only.
- Dopamine or serotonin receptor
antagonists are advised.
- Antiemetics should be continued prophylactically for each
remaining radiation treatment day.
|
5-HT3: 5-hydroxytryptamine-3
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Table 3. Dose and Schedule of Antiemetics to Prevent Emesis Induced by Antineoplastic Therapy of Moderate Emetic Risk
Antiemetics for Intravenous Antineoplastic Therapy of Moderate Emetic Risk |
Single Dose Administered Before Chemotherapy |
Single Dose Administered Daily |
|
5-HT3 serotonin receptor antagonists
|
Dolasetron |
Oral: 100 mg |
|
IV: 100 mg or 1.8 mg/kg |
|
Granisetron |
Oral: 2 mg |
|
IV: 1 mg or 0.01 mg/kg |
|
Ondansetron |
Oral: 16 mg (8 mg twice daily) |
|
IV: 8 mg or 0.15 mg/kg |
|
Palonosetron |
IV: 0.25 mg |
|
Tropisetron |
Oral: 5 mg |
|
IV: 5 mg |
|
Dexamethasone |
Oral: 12 mg (with aprepitant) |
Oral: 8 mg days 2, 3 |
IV: 8 mg/kg |
|
Aprepitant * |
Oral: 125 mg |
Oral: 80 mg days 2, 3 |
5-HT3: 5-hydroxytryptamine-3
IV: intravenous
* For patients receiving a combination of an anthracycline and cyclophosmaide
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References |
- American Society of Clinical Oncology; Kris MG, Hesketh PJ, Somerfield MR, Feyer P, Clark-Snow R, Koeller JM, Morrow GR, Chinnery LW, Chesney MJ, Gralla RJ, Grunberg SM. American Society of Clinical Oncology guideline for antiemetics in oncology: update 2006. J Clin Oncol. 2006 Jun 20;24(18):2932-47. Epub 2006 May 22. [PubMed Citation]
- Gralla RJ, Osoba D, Kris MG, Kirkbride P, Hesketh PJ, Chinnery LW, Clark-Snow R, Gill DP, Groshen S, Grunberg S, Koeller JM, Morrow GR, Perez EA, Silber JH, Pfister DG. Recommendations for the use of antiemetics: evidence-based, clinical practice guidelines. American Society of Clinical Oncology. J Clin Oncol. 1999 Sep;17(9):2971-94. No abstract available. Erratum in: J Clin Oncol 1999 Dec;17(12):3860. J Clin Oncol 2000 Aug;18(16):3064. [PubMed Citation]
- Hesketh PJ. Chemotherapy-induced nausea and vomiting. N Engl J Med. 2008 Jun 5;358(23):2482-94. [PubMed Citation]
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