Chemotherapy-Induced Nausea and Vomiting Management

Antiemetic Regimens

The American Society of Clinical Oncology recommends a three-drug regimen for highly emetogenic chemotherapy, consisting of a 5-HT3 antagonist, dexamethasone, and aprepitant, administered 30 minutes before chemotherapy 1.
For highly emetogenic chemotherapy, the National Comprehensive Cancer Network suggests a regimen of ondansetron 8 mg IV, dexamethasone 12 mg IV, and aprepitant 125 mg PO on day 1, followed by aprepitant 80 mg PO on days 2-3 1, 2, 3.
The European Society for Medical Oncology recommends palonosetron 0.25 mg IV plus dexamethasone 12 mg IV on day 1 for moderately emetogenic chemotherapy, with optional continuation of dexamethasone 8 mg PO daily on days 2-3 4.

When aprepitant is combined with dexamethasone, the dexamethasone dose should be reduced by 50% due to CYP3A4 inhibition by aprepitant, as recommended by the Annals of Oncology 5, 6.
Aprepitant affects the metabolism of chemotherapy agents metabolized via CYP3A4, such as docetaxel and paclitaxel, and other medications like warfarin, according to the Journal of Clinical Oncology 6.

For breakthrough nausea despite adequate prophylaxis, the National Comprehensive Cancer Network suggests adding medications from different drug classes, such as combining ondansetron with metoclopramide 10-40 mg IV and/or dexamethasone if not already prescribed 3, 7.
First-line breakthrough agents include metoclopramide 10-40 mg PO/IV every 4-6 hours, prochlorperazine 10 mg PO/IV every 4-6 hours, and ondansetron 16 mg PO or 8 mg IV daily, as recommended by the Journal of the National Comprehensive Cancer Network 3, 7.

For delayed emesis following highly emetogenic chemotherapy, the American Society of Clinical Oncology recommends continuing aprepitant 80 mg PO and dexamethasone 8 mg PO twice daily on days 2-4 after chemotherapy 1, 4.
For moderately emetogenic chemotherapy with significant delayed emesis risk, dexamethasone 8 mg PO daily on days 2-3 is recommended by the European Society for Medical Oncology 4.

Pre-hydration with normal saline is recommended to maintain adequate urine output for nephrotoxic agents, such as cisplatin, according to the Journal of the National Comprehensive Cancer Network 3.
Monitoring of renal function and electrolytes is also recommended, as well as post-chemotherapy hydration as clinically indicated 3, 8.

Oral and IV formulations of 5-HT3 antagonists are equally effective for prophylaxis, according to the Annals of Oncology 2, 9.
If a patient has active nausea/vomiting, antiemetics should be administered intravenously, as recommended by the Annals of Oncology 2, 9.

Lorazepam 0.5-2 mg PO/IV every 4-6 hours is useful for anticipatory nausea and as an adjunct to antiemetics, but not recommended as single-agent therapy, according to the Journal of the National Comprehensive Cancer Network 3, 1, 7.
H2 blockers or proton pump inhibitors may be added for patients with epigastric discomfort, as suggested by the Journal of the National Comprehensive Cancer Network 3.

The National Comprehensive Cancer Network recommends metoclopramide for low emetogenic risk chemotherapy prophylaxis at a dose of 10-40 mg PO or IV every 4-6 hours 10
The National Comprehensive Cancer Network suggests metoclopramide as a breakthrough treatment at a dose of 10-40 mg PO or IV every 4-6 hours when first-line antiemetics fail 10

For low emetogenic risk chemotherapy, the National Comprehensive Cancer Network recommends a dose of 10-40 mg PO or IV every 4 or every 6 hours, starting before chemotherapy and repeating daily for fractionated doses 10
The National Comprehensive Cancer Network recommends considering the addition of an H2 blocker or proton pump inhibitor to metoclopramide for low emetogenic risk chemotherapy 10

The National Comprehensive Cancer Network advises monitoring for dystonic reactions and using diphenhydramine 25-50 mg PO or IV every 4-6 hours for extrapyramidal symptoms 10
The National Comprehensive Cancer Network notes a black box warning for metoclopramide, including the risk of tardive dyskinesia, hyperglycemia, type II diabetes, and increased mortality in elderly dementia patients 10

The Annals of Oncology suggests administering metoclopramide intravenously if active nausea/vomiting is present 11