Chemotherapy-Induced Nausea and Vomiting Management

Introduction to Anti-Emetic Regimens

• The National Comprehensive Cancer Network recommends a combination of a 5-HT3 antagonist, an NK1 antagonist, and dexamethasone for chemotherapy-induced nausea and vomiting (CINV) prevention, with the specific combination determined by the emetogenic risk of the chemotherapy 1, 2, 3, 4

High Emetogenic Risk Chemotherapy

• For high emetogenic risk chemotherapy, the American College of Clinical Oncology recommends triple therapy with aprepitant 125 mg PO on day 1, palonosetron 0.25 mg IV on day 1, and dexamethasone 12 mg PO/IV on days 1-4 1, 5, 6
• Alternative 5-HT3 antagonists to palonosetron include ondansetron, granisetron, or dolasetron, with dosages of 16-24 mg PO or 8-12 mg IV for ondansetron, 2 mg PO or 0.01 mg/kg IV for granisetron, and 100 mg PO/IV for dolasetron 5, 6

Moderate Emetogenic Risk Chemotherapy

• For moderate emetogenic risk chemotherapy, the National Comprehensive Cancer Network recommends palonosetron 0.25 mg IV on day 1, dexamethasone 12 mg PO/IV on day 1, and aprepitant 125 mg PO on day 1 for select higher-risk agents 2, 3, 4, 5
• On days 2-3, options include aprepitant 80 mg PO daily, dexamethasone 12 mg PO/IV daily, or a 5-HT3 antagonist (not palonosetron) 2, 3, 4, 5

Low and Minimal Emetogenic Risk Chemotherapy

• For low emetogenic risk chemotherapy, options include dexamethasone 12 mg PO/IV daily, metoclopramide 10-40 mg PO/IV every 4-6 hours, or prochlorperazine 10 mg PO/IV every 4-6 hours 5, 8
• For minimal emetogenic risk chemotherapy, no routine prophylaxis is required 5, 8

Breakthrough and Rescue Treatment

• The National Comprehensive Cancer Network recommends adding an agent from a different drug class for breakthrough nausea and vomiting, with options including prochlorperazine, metoclopramide, ondansetron, granisetron, haloperidol, olanzapine, dexamethasone, and cannabinoids 1, 3, 5, 8
• Around-the-clock scheduled dosing is preferred over PRN dosing for prevention of established emesis 1, 3, 4

Important Safety Considerations

• Dolasetron IV formulation has been withdrawn due to cardiac safety concerns, and only the oral formulation is available 7
• Monitor for dystonic reactions with metoclopramide and prochlorperazine, and treat with diphenhydramine 25-50 mg PO/IV every 4-6 hours 3, 8

Delayed Emesis Prevention

• For high emetogenic chemotherapy, continue prophylaxis for 2-4 days after chemotherapy completion with dexamethasone and aprepitant 1, 2, 3