Management of Vomiting Associated with Rituximab Infusion

Antiemetic Options for Rituximab-Associated Vomiting

The European Society for Medical Oncology recommends ondansetron as the antiemetic agent for reducing vomiting associated with rituximab infusion, while domperidone is not specifically supported by guidelines for this indication 1, 2
The National Comprehensive Cancer Network recommends adding dexamethasone to ondansetron to significantly enhance antiemetic efficacy 1, 2
The recommended dosing for ondansetron is 8 mg administered over 15 minutes prior to rituximab infusion, and dexamethasone dosing is 8-20 mg single dose before rituximab infusion 3, 4, 5
Dopamine antagonists, such as domperidone, are generally considered less effective than 5-HT3 antagonists for chemotherapy-induced vomiting, but can be used as an alternative or adjunct therapy 1, 5

The American Society of Clinical Oncology recommends administering ondansetron 8 mg IV 30 minutes before rituximab infusion, and adding dexamethasone 8-20 mg IV for primary prevention 3, 5
For breakthrough vomiting, the European Society for Medical Oncology recommends adding a medication from a different class, such as a dopamine antagonist like metoclopramide 1
For anticipatory nausea/vomiting, the National Comprehensive Cancer Network recommends considering lorazepam 1-2 mg for added anxiolytic effect 1, 5

The European Society for Medical Oncology notes that high-dose ondansetron (32 mg IV) has been associated with QT interval prolongation, but lower doses used for rituximab-associated vomiting appear safer 1
For refractory cases, the American Society of Clinical Oncology recommends considering adding a medication from a different class or switching to a different 5-HT3 antagonist 1