Chemotherapy-Induced Emesis

Phases of Chemotherapy-Induced Emesis

The National Comprehensive Cancer Network recommends that acute emesis typically occurs within the first 24 hours after chemotherapy administration, with a peak intensity after 5-6 hours, and is influenced by factors such as female sex, age under 50, and alcohol consumption 1, 2
The intensity of acute emesis reaches its peak typically after 5-6 hours, and risk factors include female sex, age under 50, and history of motion sickness 2, 3
The American College of Physicians and other medical organizations agree that delayed emesis develops more than 24 hours after chemotherapy administration, often after treatment with Cisplatin, Carboplatin, Cyclophosphamide, and/or Doxorubicin, and can last up to 6-7 days 2, 4
The National Comprehensive Cancer Network states that delayed emesis is more common than acute emesis, often more severe, and tends to be more resistant to therapy, with a peak intensity 48-72 hours after Cisplatin administration 1, 4

Younger female patients receiving chemotherapy for breast cancer are more prone to nausea than other patient groups, according to the National Comprehensive Cancer Network 2, 5

The frequency of chemotherapy-induced emesis depends primarily on the emetogenic potential of the specific chemotherapeutic agents, which are classified into four levels of risk: high, moderate, low, and minimal, as defined by the National Comprehensive Cancer Network 1, 4, 5
High emetogenic risk is defined as 90% or more of patients experiencing acute emesis, moderate risk as 30-90%, low risk, and minimal risk, with corresponding percentages of patients experiencing emesis 5

Various neurotransmitters are involved in emesis, including serotonin (5-HT3), dopamine, acetylcholine, corticosteroids, histamine, cannabinoids, opioids, and neurokinin-1 (NK-1), as stated by the National Comprehensive Cancer Network 3, 6

Oxaliplatin is classified as a moderate-emetic-risk (MER) agent by major guideline organizations, including the American Society of Clinical Oncology (ASCO) and the Multinational Association of Supportive Care in Cancer (MASCC), with a 30-90% risk of causing nausea and vomiting without prophylactic antiemetics 7, 8
The ASCO 2017 guidelines specifically identify oxaliplatin as a moderate-emetic-risk agent known to cause delayed nausea and vomiting 7

For oxaliplatin monotherapy or standard FOLFOX regimens, the American Society of Clinical Oncology recommends using a two-drug combination: a 5-HT₃ receptor antagonist on day 1 and dexamethasone on day 1 7
Because oxaliplatin causes delayed nausea and vomiting, the American Society of Clinical Oncology suggests considering extending dexamethasone to days 2-3 7

Patient-specific factors that increase emetogenic risk include previous chemotherapy-induced nausea and vomiting, according to the European Society for Medical Oncology 9
For patients with multiple risk factors receiving oxaliplatin, the European Society for Medical Oncology recommends strongly considering escalating to a three-drug regimen, adding an NK₁ receptor antagonist to the 5-HT₃ antagonist and dexamethasone 10, 9

The European Society for Medical Oncology advises against withholding more effective antiemetics for "rescue" use, as antiemetics are most effective when used prophylactically 11
The American Society of Clinical Oncology recommends not assuming single-day dexamethasone is sufficient, as oxaliplatin specifically causes delayed emesis, warranting consideration of days 2-3 dexamethasone 7
The American Society of Clinical Oncology suggests screening for nausea and vomiting at every outpatient visit to identify inadequate control early 12