Radiation-Induced Nausea and Vomiting Management

Introduction to Guidelines

The American Society of Clinical Oncology (ASCO) and Multinational Association of Supportive Care in Cancer (MASCC) guidelines from 2024 and 2022 explicitly recommend against the use of cannabinoids for the prevention of radiation-induced nausea and vomiting 1

For radiation-induced nausea and vomiting, 5-HT3 antagonists (such as Ondansetron, Granisetron) are the therapy of choice, with the addition of Dexamethason 4 mg during fractions 1-5 for high-risk patients (>90%, e.g., total body irradiation) 2, 3
For moderate-risk patients (60-90%, e.g., upper abdominal irradiation), a 5-HT3 antagonist should be used before each fraction, with optional Dexamethason 4 mg during fractions 1-5 2, 4
For low-risk patients (30-60%), a 5-HT3 antagonist can be used either prophylactically or as needed 2

If nausea occurs despite 5-HT3 antagonists, other causes such as constipation, electrolyte disturbances, hypercalcemia, and CNS metastases should be excluded 2
An antiemetic from a different class should be added (not replaced), such as Metoclopramide 10-20 mg orally three times a day (preferred dopamine antagonist) 1, 2, 4
Alternatively, Prochlorperazine 5-10 mg orally or intravenously, or Haloperidol 0.5-1 mg every 6-8 hours can be used 2
Dexamethason 4 mg can be added if not already used 2
Lorazepam can be used in addition for breakthrough nausea 4

Dronabinol should not be used as first-line therapy for radiation-induced nausea and vomiting, as it is not approved by the FDA for this indication and lacks evidence for its effectiveness 1
In extremely rare cases where all standard therapies have failed, Dronabinol may be considered as a last resort, off-label, and without evidence basis for radiation-induced nausea and vomiting 1

The MASCC guideline from 2022 explicitly advises against the use of cannabinoids for the prevention of radiation-induced nausea and vomiting 1
Most studies on cannabinoids were conducted in the 1970s and 1980s and investigated chemotherapy-induced, not radiation-induced, nausea and vomiting 1
There is limited evidence for the effectiveness of cannabinoids in radiation-induced nausea and vomiting 1
The FDA approval for Dronabinol is limited to chemotherapy-induced nausea and vomiting in patients who have failed conventional antiemetics, not radiation-induced nausea and vomiting 1
Important side effects of Dronabinol include dysphoria, euphoria, sedation, dizziness, and confusion (occurring in 18% of patients) 1
Psychiatric side effects are particularly important to consider in patients with a psychiatric history 1