Chemotherapy-Induced Nausea and Vomiting Management

Introduction to Antiemetic Regimens

The National Comprehensive Cancer Network recommends a combination of 5-HT3 receptor antagonists, dexamethasone, and aprepitant for chemotherapy-induced nausea and vomiting, with the specific regimen tailored to the emetogenic potential of the chemotherapy 1, 2

For high emetogenic risk chemotherapy, the National Comprehensive Cancer Network recommends starting before chemotherapy with a three-drug combination: aprepitant 125 mg PO day 1, followed by 80 mg PO days 2-3, dexamethasone 12 mg PO or IV days 1-4, and a 5-HT3 antagonist (preferably palonosetron 0.25 mg IV day 1) 2
For moderate emetogenic risk chemotherapy, the National Comprehensive Cancer Network recommends starting before chemotherapy with aprepitant 125 mg PO day 1, followed by 80 mg PO days 2-3 (in select patients), dexamethasone 12 mg PO or IV day 1, and a 5-HT3 antagonist (options include ondansetron, granisetron, dolasetron, or palonosetron) 2
For low emetogenic risk chemotherapy, a single antiemetic agent is often sufficient as prophylaxis, and no routine prophylaxis is needed after day 1 1

The American Society of Clinical Oncology recommends 5-HT3 receptor antagonists as first-line treatment for moderately and highly emetogenic chemotherapy, with options including ondansetron 16-24 mg PO or 8-12 mg IV day 1, granisetron 1-2 mg PO or 1 mg PO twice daily or 0.01 mg/kg IV, dolasetron 100 mg PO or 1.8 mg/kg IV, and palonosetron 0.25 mg IV (preferred for high emetogenic risk) 1, 2
Dexamethasone is the preferred corticosteroid, with dosing recommendations including 20 mg IV single dose before chemotherapy for cisplatin-induced emesis, 8 mg IV single dose for cyclophosphamide/anthracycline-based chemotherapy, and twice daily for delayed emesis 1
Aprepitant 125 mg PO day 1, followed by 80 mg PO days 2-3, is recommended for high emetogenic risk chemotherapy, with fosaprepitant 115 mg IV as a substitute for aprepitant on day 1 1, 2

For acute CINV (within 24 hours), the National Comprehensive Cancer Network recommends triple therapy with 5-HT3 antagonist + dexamethasone + aprepitant for high emetogenic risk chemotherapy 2
For delayed CINV (persisting 1-5 days after therapy), continue aprepitant on days 2-3 if used on day 1, and consider adding metoclopramide to dexamethasone 2
For refractory nausea and vomiting, add dopamine antagonists (e.g., metoclopramide) to 5-HT3 antagonists and corticosteroids, and consider switching to a different 5-HT3 antagonist 1, 3
For anticipatory nausea and vomiting, lorazepam 0.5-2 mg PO or IV or sublingual, and behavioral techniques may be helpful 1, 2, 3

Oral and IV antiemetic formulations have equivalent efficacy, and oral doses are recommended when possible 1, 2
5-HT3 antagonists of the same class are of comparable efficacy, but high-dose ondansetron (32 mg IV) has been associated with QT interval prolongation 1, 4
When administering aprepitant with corticosteroids, reduce corticosteroid dose to 50% due to CYP3A4 interaction 1

The American College of Emergency Physicians recommends 5-HT3 antagonists, such as ondansetron 8 mg IV, granisetron 1 mg IV, dolasetron 100 mg IV, or tropisetron 5 mg IV, as first-line therapy for severe nausea, with comparable efficacy 5
All 5-HT3 antagonists demonstrate comparable efficacy, so selection can be based on availability and cost 5

Dexamethasone IV enhances antiemetic efficacy when combined with 5-HT3 antagonists, with recommended doses including 20 mg IV single dose for cisplatin-induced emesis, 8 mg IV single dose for cyclophosphamide/anthracycline-based chemotherapy 5

IV administration is recommended over oral routes when a patient is actively experiencing nausea and vomiting, with IV ondansetron producing larger improvements in nausea scores 5
Antiemetics should be given prophylactically 30-60 minutes before chemotherapy when possible, with a dosing strategy that includes scheduled around-the-clock administration for persistent nausea 5
Combination therapy with full doses of corticosteroids, 5-HT3 antagonists, and dopamine antagonists IV can be used for refractory nausea 5