Chemotherapy-Induced Nausea and Vomiting Management

Introduction to Antiemetic Regimens

The National Comprehensive Cancer Network (NCCN) and American Society of Clinical Oncology (ASCO) guidelines recommend a three-drug combination of an NK1 receptor antagonist, a 5-HT3 receptor antagonist (preferably palonosetron), and dexamethasone for highly emetogenic chemotherapy, with optional addition of lorazepam and an H2 blocker or proton pump inhibitor 1, 2, 3, 4

Palonosetron 0.25 mg IV is the preferred 5-HT3 receptor antagonist due to its superior efficacy in preventing both acute and delayed nausea and vomiting, with a longer half-life than first-generation 5-HT3 antagonists 4, 2
Alternative 5-HT3 receptor antagonists include ondansetron 16-24 mg PO or 8-12 mg IV (maximum 32 mg) and granisetron 2 mg PO or 1 mg PO BID or 0.01 mg/kg (maximum 1 mg) IV 1, 2, 4, 5
Aprepitant 125 mg PO is an option for NK1 receptor antagonist, as an alternative to Fosaprepitant 150 mg IV 1, 2, 4
Dexamethasone 12 mg PO or IV is the recommended corticosteroid, with a duration of at least 4 days for high emetogenic chemotherapy 1, 2, 4

The recommended dosages are:

Medication	Dosage
Palonosetron	0.25 mg IV on day 1 only
Ondansetron	8-16 mg IV or 16-24 mg PO on day 1
Granisetron	1-2 mg PO or 0.01 mg/kg (maximum 1 mg) IV on day 1
Aprepitant	125 mg PO on day 1, then 80 mg PO on days 2-3
Fosaprepitant	150 mg IV on day 1 only
Dexamethasone	12 mg PO or IV, with a duration of at least 4 days

Lorazepam 0.5-2 mg PO or IV or sublingual every 4-6 hours PRN can be added to help manage anticipatory symptoms, and 1 mg PO at bedtime the night before chemotherapy and 1 mg the morning of chemotherapy for anticipatory nausea and vomiting 1, 4, 6
H2 blocker or proton pump inhibitor can be added as an optional adjunct 1, 4
For breakthrough nausea or vomiting, add an agent from a different drug class, such as olanzapine 5-10 mg PO daily, metoclopramide 10-40 mg PO or IV every 4-6 hours, prochlorperazine 10 mg PO or IV every 4-6 hours, or haloperidol 1-2 mg PO or IV every 4-6 hours 1, 5

Inadequate duration of prophylaxis, relying on PRN dosing, overlooking delayed emesis, and ignoring patient-specific risk factors are common mistakes in antiemetic therapy 1
For elderly patients, consider starting with lower doses of all agents and titrate slowly due to increased risk of side effects, as suggested by the National Comprehensive Cancer Network 7
5-HT3 antagonists are typically given only on day 1, while dexamethasone and NK1 antagonists may continue for 2-4 days, according to the National Comprehensive Cancer Network 4