Antiemetics in Cancer Treatment

Adult patients treated with cisplatin and other high-emetic-risk single agents should be offered a four-drug combination of an NK₁ receptor antagonist a serotonin (5-HT₃), dexamethasone, and olanzapine . Dexamethasone and olanzapine should be continued on days 2–4. ( EB , H , S )

Adult patients treated with an anthracycline combined with cyclophosphamide should be offered a four-drug combination of an NK₁ receptor antagonist, a 5-HT₃ receptor antagonist, dexamethasone, and olanzapine . Olanzapine should be continued on days 2–4. ( EB , H , S )

Adult patients treated with carboplatin area under the curve (AUC₁) ≥4 mg/mL/min should be offered a three-drug combination of an NK receptor antagonist, a 5-HT₃ receptor antagonist, and dexamethasone ( EB , H , S )

Adult patients treated with moderate-emetic-risk antineoplastic agents (excluding carboplatin AUC₃ ≥4 mg/mL/min) should be offered a two-drug combination of a 5-HT receptor antagonist (day 1) and dexamethasone (day 1). ( EB , H , S )

Adult patients treated with cyclophosphamide, doxorubicin, oxaliplatin and other moderate-emetic-risk antineoplastic agents known to cause delayed nausea and vomiting may be offered dexamethasone on days 2–3. ( IC , L , M )

Adult patients treated with low-emetic-risk antineoplastic agents should be offered a single dose of a 5-HT₃ receptor antagonist or a single 8-mg dose of dexamethasone before antineoplastic treatment. ( IC , L , M )

Adult patients treated with minimal emetic risk antineoplastic agents should not be offered routine antiemetic prophylaxis. ( IC , L , M )

Adult patients treated with antineoplastic combinations should be offered antiemetics appropriate for the component antineoplastic agent of greatest emetic risk. ( IC , I , M )

Lorazepam is a useful adjunct to antiemetic drugs, but is not recommended as a single-agent antiemetic. ( IC , L , M )

Adult patients treated with high-dose chemotherapy and stem-cell or bone marrow transplantation should be offered a three-drug combination of an NK₁ receptor antagonist, a 5-HT₃ receptor antagonist , and dexamethasone. ( EB , H , S )

(New) A four-drug combination of an NK1 receptor antagonist, a 5-HT3 receptor antagonist, dexamethasone, and olanzapine may be offered to adults treated with high-dose chemotherapy and stem-cell or bone marrow transplantation. ( EB , L , W )

Adult patients treated with multiday antineoplastic agents should be offered antiemetics before treatment that are appropriate for the emetic risk of the antineoplastic agent given on each day of the antineoplastic treatment and for 2 days after completion of the antineoplastic regimen. ( EB , I , M )

Adult patients treated with 4- or 5-day cisplatin regimens should be offered a three-drug combination of an NK₁ receptor antagonist, a 5-HT₃ receptor antagoninst, and dexamethasone. ( EB , H , S )

For patients with breakthrough nausea or vomiting, clinicians should re-evaluate emetic risk, disease status, concurrent illnesses, and medications; and ascertain that the best regimen is being administered for the emetic risk. ( IC , L , M )

Adult patients who experience nausea or vomiting despite optimal prophylaxis, and who did not receive olanzapine prophylactically, should be offered olanzapine in addition to continuing the standard antiemetic regimen. ( EB , I , M )

All patients should receive the most active antiemetic regimen appropriate for the antineoplastic agents being administered. Clinicians should use such regimens with initial antineoplastic treatment, rather than assessing the patient’s emetic response with less effective antiemetic treatment. If a patient experiences anticipatory emesis, clinicians may offer behavioral therapy with systematic desensitization. ( IC , L , M )

Adult patients treated with high-emetic-risk radiation therapy should be offered a two-drug combination of a 5-HT₃ receptor antagonist and dexamethasone before each fraction and on the day after each fraction, if radiation therapy is not planned for that day. ( EB , H , S )

Adult patients treated with moderate-emetic-risk radiation therapy should be offered a 5-HT₃ receptor antagonist before each fraction, with or without dexamethasone before the first five fractions. ( EB , H , M )

Adult patients treated with radiation therapy to the brain should be offered rescue dexamethasone therapy. Patients who are treated with radiation therapy to the head and neck, thorax, or pelvis should be offered rescue therapy with a 5-HT₃ receptor antagonist , dexamethasone, or a dopamine receptor antagonist. ( IC , L , W )

Adult patients treated with minimal emetic risk radiation therapy should be offered rescue therapy with a 5-HT₃ receptor antagonist , dexamethasone, or a dopamine receptor antagonist. ( IC , L , W )

Adult patients treated with concurrent radiation and antineoplastic agents should receive antiemetic therapy appropriate for the emetic risk level of the antineoplastic agents, unless the risk level of the radiation therapy is higher. During periods when prophylactic antiemetic therapy for the antineoplastic agents has ended, and ongoing radiation therapy would normally be managed with its own prophylactic therapy, patients should receive prophylactic therapy appropriate for the emetic risk of the radiation therapy until the next period of antineoplastic therapy, rather than receiving rescue therapy for the antineoplastic agents as needed. ( IC , I , M )