# Radiation Oncology/Supportive care/Nausea

* Front Page: Radiation Oncology | RTOG Trials | Randomized Trials
Supportive Care for Nausea and Vomiting

## Ematogenicity Potential

* ASCO 2020 PMID 28759346 --Antiemetics: American Society of Clinical Oncology Clinical Practice Guideline Update (Hesketh PJ, J Clin Oncol. 2017 Oct 1;35(28):3240-3261. doi: 10.1200/JCO.2017.74.4789. Epub 2017 Jul 31.)
** Classification of chemotherapy regimens
** Classification of radiation therapy regimens:
*** High Risk: Total Body Irradiation => Odansetron / Granisetron + Dexamethasone
*** Moderate Risk: Upper abdomen, Craniospinal => Odansetron / Granisetron / Topisetron + Dexamethasone
*** Low Risk: Brain, H&N, Thorax, Pelvis => Odansetron/Granisetron PRN, Dexamethasone PRN, Prochlorperazine / Metoclopramide PRN
* ASCO; 1997 PMID 8996130 -- "Proposal for classifying the acute emetogenicity of cancer chemotherapy." (Hesketh PJ, J Clin Oncol. 1997 Jan;15(1):103-9.)
** Review of clinical trials. Chemotherapy agents divided into 5 levels
| Class | Ematogenicity | Drugs |
| I | <10% | Bleomycin, Busulfan, Chlorambucil (oral), Fludarabine, Hydroxyurea, MTX <50 mg/m2, Mustard gas, Thioguanine (oral), Vinblastine, Vincristine, Vinorelbine |
| II | 10-30% | Docetaxel, Etoposide, 5-FU <1000 mg/m2, Gemcitabine, MTX 5-250 mg/m2, Mitomycin, Paclitaxel |
| III | 30-60% | Cyclophosphamide <750 mg/m2, Cyclophosphamide (oral), Daxorubicin <60 mg/m2, Epirubicin <90 mg/m2, Idarubicin, Ifosfamide, MTX 250-1000 mg/m2, Mitoxantrone <15 mg/m2 |
| IV | 60-90% | Carboplatin, Carmustine <250 mg/m2, Cisplatin <50 mg/m2, Cyclophosphamide 750-1500 mg/m2, Cytarabine > 1000 mg/m2, Daxorubicin >60 mg/m2, MTX >1000 mg/m2, Procarbazine (oral) |
| V | >90% | Carmustine >250 mg/m2, Cisplatin >50 mg/m2, Cyclophosphamide >1500 mg/m2, Dacarbazine, Mechlorethamie, Streptozocin |

## 5-HT3 antagonists

* Ondansetron (Zofran)
* Granisetron (Kytril)
* Dolasetron (Anzemet)
* Palonosetron (Aloxi) - IV, 0.25 mg
* Umea; 1996 (Sweden) PMID 8879372 -- "A randomised placebo controlled study with ondansetron in patients undergoing fractionated radiotherapy." (Franzen L, Ann Oncol. 1996 Aug;7(6):587-92.)
** Randomized. 111 patients, abdominal RT, at least 10 fractions. Used [EORTC C30] questionnaire
** Outcome: complete control of emesis ondansetron 67% vs. placebo 45% (SS). Number of emetic episodes on worst day 1.4 vs. 3.1 (SS), also fewer days with emesis for ondansetron. Benefit during week 1-3, not after
** Conclusion: Prophylactic ondansetron effective in preventing N/V in abdominal RT

## NK-1 antagonists

* Aprepitant (Emend) - PO
* Aprepitant Protocol 052
** 2003 PMID 14559886 -- "The oral neurokinin-1 antagonist aprepitant for the prevention of chemotherapy-induced nausea and vomiting: a multinational, randomized, double-blind, placebo-controlled trial in patients receiving high-dose cisplatin--the Aprepitant Protocol 052 Study Group." (Hesketh PJ, J Clin Oncol. 2003 Nov 15;21(22):4112-9. Epub 2003 Oct 14.)
** Randomized. 530 patients, receiving cisplatin >=70 mg/m2 for first time. Arm 1) standard therapy (ondansetron + dexamethasone) vs. Arm 2) aprepitant + standard therapy. N/V episodes recorded in diary. CR defined as no emesis on days 1-5
*** Outcome: CR standard 52% vs. aprepitant + standard 73% (SS)
*** Conclusion: Addition of aprepitant provided superior protection against chemotherapy-induced nausea and vomiting