Chemotherapy-Induced Nausea and Vomiting Management

Introduction

Chemotherapy-induced nausea and vomiting (CINV) is a common side effect of cancer treatment, requiring effective management to improve patient outcomes, as reported by the National Comprehensive Cancer Network and the American Society of Clinical Oncology 1, 2, 3, 4

The European Society for Medical Oncology recommends dexamethasone as the medication of choice for preventing acute emesis in patients receiving chemotherapy with cisplatin (high emetogenic potential): 20 mg IV single dose on day 1, and for cyclophosphamide/anthracycline: 8 mg IV single dose on day 1 2
Alternative medications to dexamethasone include prednisolone: 100-150 mg oral once daily, and methylprednisolone: 100 mg oral once daily 2
A triple therapy regimen consisting of a 5-HT3 antagonist, dexamethasone, and an NK1 antagonist, such as aprepitant 125 mg PO day 1, then 80 mg PO days 2-3, is recommended for patients receiving highly emetogenic chemotherapy, with a strength of evidence level I 5, 2, 6
For patients receiving moderately emetogenic chemotherapy, a dual therapy regimen consisting of a 5-HT3 antagonist and dexamethasone may be sufficient 5, 6

The National Comprehensive Cancer Network and the American College of Physicians recommend the use of 5-HT3 antagonists, such as ondansetron 16-24 mg PO or 8-12 mg IV, granisetron 2 mg PO or 1 mg PO bid or 0.01 mg/kg IV, and palonosetron 0.25 mg IV, for the prevention of acute emesis in patients receiving chemotherapy, with the goal of preventing nausea/vomiting rather than treating it once it occurs 5, 1, 2, 3, 4

Recommended doses for oral antiemetics include:

Medication	Dose
Ondansetron	16-24 mg PO once daily [2]
Granisetron	2 mg PO once daily [2]
Tropisetron	5 mg PO once daily [2]
Dolasetron	100 mg PO once daily [2]
Metoclopramide	20-30 mg PO 3-4 times daily [2]
Prochlorperazine	10-20 mg PO 3-4 times daily [2]
Domperidone	20 mg PO 3-4 times daily [2]
Metopimazine	15-30 mg PO 3-4 times daily [2]
Dexamethasone	20 mg PO once daily [2]
Prednisolone	100-150 mg PO once daily [2]
Methylprednisolone	100 mg PO once daily [2]
Aprepitant	125 mg PO on day 1, followed by 80 mg PO on days 2 and 3 after chemotherapy [2]
Lorazepam	1-2 mg PO 1-4 times daily [2]

Dexamethasone is administered twice daily for delayed emesis (24-120 hours after chemotherapy) 2
When combined with aprepitant, the dose of corticosteroids should be reduced by 50% due to drug interactions, with a strength of evidence level I 2
Oral and IV antiemetic formulations have equivalent efficacy, and the choice between them should be based on the patient's ability to take oral medications 5

If inadequate control of nausea/vomiting: add dopamine antagonists to serotonin antagonists and corticosteroids 2
For anticipatory nausea/vomiting: consider lorazepam or behavioral techniques 2
For breakthrough symptoms, adding an agent from a different class, such as prochlorperazine 10 mg PO/IV every 4-6 hours, metoclopramide 10-40 mg PO/IV every 4-6 hours, or olanzapine 2.5-5 mg PO twice daily, is recommended 5
It is essential to rule out other causes of nausea and vomiting in cancer patients, including radiotherapy, infection, electrolyte disturbances, constipation, gastrointestinal obstruction, brain metastases, and medication side effects, such as opioids and antibiotics 2, 3, 4

For patients receiving immunotherapy (particularly ipilimumab), caution may be needed with dexamethasone as systematic corticosteroids may attenuate immunotherapy benefits 7
For upper abdominal radiation, ondansetron or granisetron with or without dexamethasone is recommended, along with lorazepam 0.5-2 mg PO/IV and alprazolam 0.25-0.5 mg PO three times daily 8
For radiation-induced nausea and vomiting, a 5-HT3 antagonist with or without dexamethasone can be used, based on the radiation field 9
The European Society for Medical Oncology (ESMO) and the American Society of Clinical Oncology recommend a standard triple regimen (5-HT3 antagonist + dexamethasone + NK1 antagonist) for the prevention of CINV, with strong evidence support (Level I, Grade A) 1, 3, 10