Summary of Recommendations

Document Overview

Design and created by Guideline Central in participation with the European Society for Medical Oncology and Multinational Association of Supportive Care in Cancer.

Prevention of Chemotherapy- and Radiotherapy-Induced Nausea and Vomiting

Multinational Association of Supportive Care in Cancer

European Society for Medical Oncology

Publication Date: Jan 11, 2024

Page Last Updated: Feb 9, 2026

Prevention of acute nausea and vomiting following carboplatin-based MEC

A three-drug regimen including single doses of a 5-HT3-RA, dexamethasone and an NK1-RA (aprepitant, fosaprepitant, fosnetupitant, netupitant or rolapitant), given before ChT is recommended for patients receiving carboplatin AUC ≥5.
- Netupitant/fosnetupitant is administered with palonosetron as part of the fixed-dose combination agent NEPA.
There are no data justifying the use of an NK1-RA for carboplatin AUC <5 [I, A].

Prevention of delayed nausea and vomiting following carboplatin-based MEC

No steroid (or other antiemetic) should be routinely administered after day 1 carboplatin administration [II, B].
- If aprepitant 125 mg is used on day 1, then aprepitant 80 mg × 1 should be administered on days 2 and 3.
- One day of steroids has demonstrated non-inferiority compared with 3 days of steroids.

Prevention of acute nausea and vomiting following oxaliplatin-based MEC

A two-drug regimen, including single doses of a 5-HT3-RA and DEX, given before ChT, is recommended for patients receiving oxaliplatin.
- Palonosetron is the preferred 5-HT3-RA in this population.
The addition of an NK1-RA (aprepitant, fosaprepitant, netupitant, fosnetupitant or rolapitant) is suggested for oxaliplatin ChT-induced nausea and vomiting (CINV) prophylaxis in women aged ≤50 years old [III, B].
- Netupitant/fosnetupitant is administered with palonosetron as part of the fixed-dose combination agent NEPA.
There is no evidence that an NK1-RA should be routinely used first line in women >50 years old [III, B].

Prevention of delayed nausea and vomiting following oxaliplatin-based MEC

No steroid (or other antiemetic) should be routinely administered after day 1 oxaliplatin administration [II, B].
- If aprepitant 125 mg is used on day 1, then aprepitant 80 mg × 1 should be administered on days 2 and 3.
- One day of steroids has demonstrated non-inferiority compared with 3 days of steroids.

Prevention of acute nausea and vomiting following other MEC (non-carboplatin, non-oxaliplatin)

A two-drug regimen including single doses of a 5-HT3-RA and DEX, given before ChT, is recommended for patients receiving other MEC [II, C].
- The emetic potential of sacituzumab–govitecan and trastuzumab–deruxtecan appears to be at the high end of the moderate category, most closely resembling that of carboplatin AUC ≥5. While prospective studies are needed, it is suggested to prevent emesis as for carboplatin AUC ≥5.

Prevention of delayed nausea and vomiting following other MEC (non-carboplatin, non-oxaliplatin)

No steroid (or other antiemetic) should be routinely administered after day 1 MEC administration [II, B].
One day of steroids has demonstrated non-inferiority compared with 3 days of steroids.

Olanzapine in ChT of moderate emetic risk prevention

No evidence exists for the use of olanzapine as first-line prophylaxis [II, C].

High Emetic Risk ChT

Prevention of acute nausea and vomiting following non-AC ChT of high emetic risk

A four-drug regimen including single doses of a 5-HT3-RA, dexamethasone, an NK1-RA (aprepitant, fosaprepitant, netupitant, fosnetupitant or rolapitant) and olanzapine given before ChT is recommended [I, A].
- Netupitant/fosnetupitant is administered with palonosetron as part of the fixed-dose combination agent NEPA.

Prevention of delayed nausea and vomiting following non-AC ChT of high emetic risk

In patients receiving non-AC high emetic risk ChT treated with a combination of a 5-HT3-RA, DEX, an NK1-RA and olanzapine to prevent acute nausea and vomiting, dexamethasone–olanzapine on days 2-4 is suggested to prevent delayed nausea and vomiting [II, B].
- A few studies have investigated a 1-day dexamethasone regimen as an option in cisplatin with one study demonstrating comparable efficacy between a 1-day and multi-day dexamethasone schedules.
- If aprepitant 125 mg is used on day 1, then aprepitant 80 mg × 1 should be administered on days 2 and 3.

Prevention of acute nausea and vomiting following AC-based ChT of high emetic risk

In women treated with AC-based ChT, a four-drug regimen including single doses of a 5-HT3-RA, dexamethasone, an NK1-RA (aprepitant, fosaprepitant, netupitant, fosnetupitant or rolapitant) and olanzapine given before ChT is recommended [I, A].
- This recommendation is based on extensive data in women treated with adjuvant AC for breast cancer.
- Netupitant/fosnetupitant is administered with palonosetron as part of the fixed-dose combination agent NEPA.

Prevention of delayed nausea and vomiting following AC-based ChT of high emetic risk

In women treated with a combination of a 5-HT3-RA, dexamethasone, an NK1-RA and olanzapine to prevent acute nausea and vomiting, olanzapine on days 2-4 is suggested to prevent delayed nausea and vomiting [II, B].
- This recommendation is based on extensive data in women treated with adjuvant AC for breast cancer.
- If aprepitant 125 mg is used on day 1, then aprepitant 80 mg × 1 should be administered on days 2 and 3.

Dose and schedule of olanzapine in the prevention of acute and delayed nausea and vomiting following ChT of high emetic risk

The best investigated dose is 10 mg. 5 mg is superior to placebo, but it is unknown if it is as effective as 10 mg, because no robust studies have compared the 5 mg and 10 mg doses. The only schedule investigated is once daily for 4 days (see sub-bullet about sedation) [II, B].
- If sedation is a concern, a starting daily dose of 5 mg and/or administration at bedtime is an option.

Prevention of acute and delayed nausea and vomiting induced by Moderately Emetogenic Chemotherapy

Prevention of acute nausea and vomiting following carboplatin-based MEC

A three-drug regimen including single doses of a 5-HT3-RA, dexamethasone and an NK1-RA (aprepitant, fosaprepitant, fosnetupitant, netupitant or rolapitant), given before ChT is recommended for patients receiving carboplatin AUC ≥5.
- Netupitant/fosnetupitant is administered with palonosetron as part of the fixed-dose combination agent NEPA.
There are no data justifying the use of an NK1-RA for carboplatin AUC <5 [I, A].

Prevention of delayed nausea and vomiting following carboplatin-based MEC

No steroid (or other antiemetic) should be routinely administered after day 1 carboplatin administration [II, B].
- If aprepitant 125 mg is used on day 1, then aprepitant 80 mg × 1 should be administered on days 2 and 3.
- One day of steroids has demonstrated non-inferiority compared with 3 days of steroids.

Prevention of acute nausea and vomiting following oxaliplatin-based MEC

A two-drug regimen, including single doses of a 5-HT3-RA and DEX, given before ChT, is recommended for patients receiving oxaliplatin.
- Palonosetron is the preferred 5-HT3-RA in this population.
The addition of an NK1-RA (aprepitant, fosaprepitant, netupitant, fosnetupitant or rolapitant) is suggested for oxaliplatin ChT-induced nausea and vomiting (CINV) prophylaxis in women aged ≤50 years old [III, B].
- Netupitant/fosnetupitant is administered with palonosetron as part of the fixed-dose combination agent NEPA.
There is no evidence that an NK1-RA should be routinely used first line in women >50 years old [III, B].

Prevention of delayed nausea and vomiting following oxaliplatin-based MEC

No steroid (or other antiemetic) should be routinely administered after day 1 oxaliplatin administration [II, B].
- If aprepitant 125 mg is used on day 1, then aprepitant 80 mg × 1 should be administered on days 2 and 3.
- One day of steroids has demonstrated non-inferiority compared with 3 days of steroids.

Prevention of acute nausea and vomiting following other MEC (non-carboplatin, non-oxaliplatin)

A two-drug regimen including single doses of a 5-HT3-RA and DEX, given before ChT, is recommended for patients receiving other MEC [II, C].
- The emetic potential of sacituzumab–govitecan and trastuzumab–deruxtecan appears to be at the high end of the moderate category, most closely resembling that of carboplatin AUC ≥5. While prospective studies are needed, it is suggested to prevent emesis as for carboplatin AUC ≥5.

Prevention of delayed nausea and vomiting following other MEC (non-carboplatin, non-oxaliplatin)

No steroid (or other antiemetic) should be routinely administered after day 1 MEC administration [II, B].
- One day of steroids has demonstrated non-inferiority compared with 3 days of steroids.

Olanzapine in ChT of moderate emetic risk prevention

No evidence exists for the use of olanzapine as first-line prophylaxis [II, C].

Grading of Recommendations, Assessment, Development, and Evaluation (GRADE)-Based Recommendations

Implications for:	Strong Recommendation (S)	Conditional Recommendation (C)
Patients	Most individuals in this situation would want the recommended course of action, and only a small proportion would not.	The majority of individuals in this situation would want the suggested course of action, but many would not.
Clinicians	Most individuals should receive the intervention. Adherence to this recommendation according to the guideline could be used as a quality criterion or performance indicator. Formal decision aids are not likely to be needed to help individuals make decisions consistent with their values and preferences.	Recognize that different choices will be appropriate for individual patients and that you must help each patient arrive at a management decision consistent with his or her values and preferences. Decision aids may be useful in helping individuals to make decisions consistent with their values and preferences.
Policy	The recommendation can be adopted as policy in most situations.	Policymaking will require substantial debate and involvement of various stakeholders.

Certainty in the Evidence
High	H	Low	L
Moderate	M	Very Low	VL

Source: Grading of Recommendations Assessment, Development and Evaluation Working Group (Schunemann HJ et al. Am J Respir Crit Care Med. 2006;174:605-14. Guyatt GH et al. BMJ 2008;336:924-6).

Document Overview

Document Title: Prevention of Chemotherapy- and Radiotherapy-Induced Nausea and Vomiting

Authoring Societies

Multinational Association of Supportive Care in Cancer

European Society for Medical Oncology

Document Publication Date: Jan 11, 2024

Page Last Reviewed/Updated: Feb 9, 2026

Document Type: Guideline

Country of Publication: European

Full Text Freely Available: Yes

Full Text Guideline: www.esmoopen.com/article/S2059-7029(23)01436-9/fulltext

Source Citation: Herrstedt J, Clark-Snow R, Ruhlmann CH, Molassiotis A, Olver I, Rapoport BL, Aapro M, Dennis K, Hesketh PJ, Navari RM, Schwartzberg L, Affronti ML, Garcia-Del-Barrio MA, Chan A, Celio L, Chow R, Fleury M, Gralla RJ, Giusti R, Jahn F, Iihara H, Maranzano E, Radhakrishnan V, Saito M, Sayegh P, Bosnjak S, Zhang L, Lee J, Ostwal V, Smit T, Zilic A, Jordan K, Scotté F; participants of the MASCC/ESMO Consensus Conference 2022. Electronic address: clinicalguidelines@esmo.org. 2023 MASCC and ESMO guideline update for the prevention of chemotherapy- and radiotherapy-induced nausea and vomiting. ESMO Open. 2024 Feb;9(2):102195. doi: 10.1016/j.esmoop.2023.102195. Epub 2024 Jan 11. PMID: 38458657; PMCID: PMC10937211.

Document Scope, Criteria, and Use Cases

Document Objectives: This article is an update of the 2015 guidelines on antiemetics for the prevention of nausea and vomiting in patients with cancer to optimise the utility of available antiemetic prophylaxis.

Scope: Prevention, Treatment

Diseases/Conditions (MeSH)

D011878 - Radiotherapy

D017024 - Chemotherapy, Adjuvant

D009325 - Nausea

D014839 - Vomiting

Keywords: Chemotherapy-induced nausea and vomiting

Target Patient Population: Patients undergoing chemotherapy or radiotherapy

Target Provider Population: Medical oncologists, radiation oncologists, primary care physicians, palliative care specialists, oncology nurses

Health Care Settings: Ambulatory, Hospital

Intended Users: Nurse, Nurse Practitioner, Physician, Physician Assistant

Prevention of Chemotherapy- and Radiotherapy-Induced Nausea and Vomiting

Summary of Recommendations

Prevention of acute nausea and vomiting following carboplatin-based MEC

High Emetic Risk ChT

Prevention of acute and delayed nausea and vomiting induced by Moderately Emetogenic Chemotherapy

Low and minimal emetic risk ChT

High-dose ChT, multi-day ChT or those with breakthrough nausea and vomiting

Integrative and non-pharmacological therapies

Grading of Recommendations, Assessment, Development, and Evaluation (GRADE)-Based Recommendations

Document Overview

Document Scope, Criteria, and Use Cases