Antiemesis

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Adapted from the NCCNNCCN antiemesis guidelines, ASCOASCO antiemesis guidelineshttps://ascopubs.org/doi/abs/10.1200/JCO.20.01296
 and MASCC/ESMOMASCC antiemetic guidlines https://www.mascc.org/antiemetic-guidelines
=Guidelines=
Given the rapid change in evidence in many areas of hematology/oncology, readers are encouraged to consider any guideline published 5+ years ago to be for historical purposes, only.
==ASCO==
*2020: Hesketh et al. Antiemetics: ASCO Guideline Update EuroPMC
**2017: Hesketh et al. Antiemetics: American Society of Clinical Oncology Clinical Practice Guideline Update EuroPMC
**2015: Hesketh et al. Antiemetics: American Society of Clinical Oncology Focused Guideline Update EuroPMC
**2011: Basch et al. Antiemetics: American Society of Clinical Oncology clinical practice guideline update EuroPMC
**2006: Kris et al. American Society of Clinical Oncology guideline for antiemetics in oncology: update 2006 EuroPMC
==ESMO==
*2009: Herrstedt & Roila. Chemotherapy-induced nausea and vomiting: ESMO clinical recommendations for prophylaxis EuroPMC
**2008: Herrstedt & Roila. Chemotherapy-induced nausea and vomiting: ESMO clinical recommendations for prophylaxis EuroPMC
**2007: Herrstedt. Chemotherapy-induced nausea and vomiting: ESMO clinical recommendations for prophylaxis EuroPMC
**2005: Herrstedt et al. ESMO Minimum Clinical Recommendations for prophylaxis of chemotherapy-induced nausea and vomiting (NV) EuroPMC
**2001: ESMO Recommendations for prophylaxis of chemotherapy-induced nausea and vomiting (NV) EuroPMC
==MASCC/ESMO==
*2023: Herrstedt et al. 2023 MASCC and ESMO guideline update for the prevention of chemotherapy- and radiotherapy-induced nausea and vomiting EuroPMC
*2016: Herrstedt et al. 2016 Updated MASCC/ESMO Consensus Recommendations: Prevention of Nausea and Vomiting Following High Emetic Risk Chemotherapy EuroPMC
*2016: Einhorn et al. 2016 updated MASCC/ESMO consensus recommendations: prevention of nausea and vomiting following multiple-day chemotherapy, high-dose chemotherapy, and breakthrough nausea and vomiting EuroPMC
*2016: Roila et al. 2016 updated MASCC/ESMO consensus recommendations: Prevention of nausea and vomiting following moderately emetogenic chemotherapy EuroPMC
*2016: Olver et al. 2016 Updated MASCC/ESMO Consensus Recommendations: Controlling nausea and vomiting with chemotherapy of low or minimal emetic potential EuroPMC
**2010: Olver et al. Guidelines for the control of nausea and vomiting with chemotherapy of low or minimal emetic potential EuroPMC
*2016: Dupuis et al. 2016 updated MASCC/ESMO consensus recommendations: Prevention of acute chemotherapy-induced nausea and vomiting in children EuroPMC
==NCCN==
*NCCN Guidelines - Antiemesis
**2012: Ettinger et al. Antiemesis. EuroPMC
**2009: Ettinger et al. Antiemesis. Clinical Practice Guidelines in Oncology. EuroPMC
**2007: Ettinger et al. Antiemesis. EuroPMC
**2004: Ettinger et al. Antiemesis clinical practice guidelines in oncology. EuroPMC
==Children's Oncology Group (COG)==
*2024: COG Guidelines on Chemotherapy-induced Nausea and Vomiting in Pediatric Cancer Patients
=Emetic risk of chemotherapy, immunotherapy, TKIs and other agents=
Hint: You can sort the table by clicking on the boxes containing arrows at the top of each column.
All drugs are IV route unless otherwise specified.
NCCN, ASCO and MASCC categories of emetic risk in the absence of prophylaxis:
*High: >90% frequency of emesis (HEC)
*Moderate: 30-90% frequency of emesis (MEC)
*Low: 10-30% frequency of emesis
*Minimal: less than 10% frequency of emesis
ASCO guidelines say that in cases of combination chemotherapy regimens, patients should be given antiemetics that are recommended for the individual medication with the highest emetic risk. The exception is with anthracycline and Cyclophosphamide (Cytoxan) combinations as described below.
Drug 	NCCN emetogenic potential (2021) 	ASCO emetogenic potential
(2020) 	MASCC/ESMO emetogenic potential (2019) 	Comment
Trastuzumab emtansine (Kadcyla) 	Low 	Low 	Low 	
Anthracycline (see differences between NCCN & ASCO) & Cyclophosphamide (Cytoxan) combination chemotherapy	High (Doxorubicin (Adriamycin) or Epirubicin (Ellence) with Cyclophosphamide (Cytoxan)) 	High (Daunorubicin (Cerubidine), Doxorubicin (Adriamycin), Epirubicin (Ellence), or Idarubicin (Idamycin) with Cyclophosphamide (Cytoxan))	High 	MASCC comment - in patients with breast cancer
Aldesleukin (Proleukin) 	Moderate: >12 to 15 million international units/m2Low: ≤12 million international units/m2 	 	 	
Alemtuzumab (Campath) 	Minimal 	Moderate 	Moderate 	
Altretamine (Hexalen) or Hexamethylmelamine (oral) 	Moderate/High 	Moderate/High 	 	NCCN and ASCO did not further delineate between degrees of emetic potential
Amifostine (Ethyol) 	Moderate: >300 mg/m2Low: ≤300 mg/m2 	 	 	
Arsenic trioxide (Trisenox) 	Low 	Moderate 	 	
Asparaginase (Elspar) 	Minimal 	 	 	
Atezolizumab (Tecentriq) 	Minimal 	Minimal 	 	
Axitinib (Inlyta) (oral) 	Minimal/Low 	Minimal/Low 	Low 	
Azacitidine (Vidaza) 	Moderate 	Moderate 	Moderate 	
Bendamustine 	Moderate 	Moderate 	Moderate 	
Belinostat (Beleodaq) 	 	 	Low 	
Bevacizumab (Avastin) 	Minimal 	Minimal 	Minimal 	
Bexarotene (Targretin) (oral) 	Low/Minimal 	 	 	NCCN did not further delineate between degrees of emetic potential
Bleomycin (Blenoxane) 	Minimal 	Minimal 	Minimal 	
Blinatumomab (Blincyto) 	 	Low 	Low 	
Bortezomib (Velcade) 	Minimal 	Low 	Low 	
Bosutinib (Bosulif) (oral) 	Low/Minimal 	Moderate 	Moderate 	
Brentuximab vedotin (Adcetris) 	Low 	 	Low 	
Busulfan (Myleran) 	High/Moderate: at least 4 mg/day Low/Minimal: less than 4 mg/day 	Minimal 	Minimal 	
Busulfan (Myleran) (oral) 	High/Moderate: at least 4 mg/dayLow/Minimal: less than 4 mg/day 	 	 	NCCN did not further delineate between degrees of emetic potential
Cabazitaxel (Jevtana) 	Low 	Low 	Low 	
Cabozantinib (Cometriq) (oral) 	Low/Minimal 	Moderate 	 	
Capecitabine (Xeloda) (oral) 	Low/Minimal 	 	Low 	NCCN did not further delineate between degrees of emetic potential
Carboplatin (Paraplatin) 	High: AUC 4 or more
Moderate: AUC less than 4 	Moderate (but recommended triplet combination of NK1, 5-HT3, and Dex if AUC 4 or more) 	Moderate (but recommended triplet combination of NK1, 5-HT3, and dexamethasone) 	MASCC/ESMO did not subclassify based on dose
Carfilzomib (Kyprolis) 	Low 	 	Low 	
Carmustine (BCNU) 	High: >250 mg/m2Moderate: ≤250 mg/m2 	High 	High 	ASCO and MASCC/ESMO did not subclassify based on dose
Catumaxomab (Removab) 	 	Low 	Low 	
Cetuximab (Erbitux) 	Minimal 	Minimal 	Low 	
Ceritinib (Zykadia) 	 	Moderate 	 	
Chlorambucil (Leukeran) (oral) 	Low/Minimal 	 	Minimal 	NCCN did not further delineate between degrees of emetic potential
Cisplatin (Platinol) 	High 	High 	High 	Some only consider emetogenic potential high when dose 70 mg/m2 or more
Cladribine (Leustatin) 	Minimal 	Minimal 	Minimal 	
Clofarabine (Clolar) 	Moderate 	Moderate 	Moderate 	
Crizotinib (Xalkori) (oral) 	High/Moderate 	Moderate 	Moderate 	
Cyclophosphamide (Cytoxan) 	High: greater than 1500 mg/m2 or when given with certain anthracyclinesModerate: up to and including 1500 mg/m2 	High: 1500 mg/m2 or more, or when given with anthracyclinesModerate: less than 1500 mg/m2 	High: > 1500 mg/m2 or when combined with anthracyclines (in breast cancer patients)
Moderate: < 1500 mg/m2	
Cyclophosphamide (Cytoxan) (oral) 	High/Moderate: 100 mg/m2/day or moreLow/Minimal: less than 100 mg/m2/day 	Moderate 	Moderate 	NCCN did not further delineate between degrees of emetic potential
Cytarabine (Ara-C) 	Moderate: >200 mg/m2Low: 100 to 200 mg/m2Minimal: less than 100 mg/m2 	Moderate: >1000 mg/m2Low: ≤1000 mg/m2 	Moderate: > 1000 mg/m2
Low: < 1000 mg/m2 	
Dabrafenib (Tafinlar) (oral) 	Low/Minimal 	 	Low 	
Dacarbazine (DTIC) 	High 	High 	High 	
Daratumumab (Darzalex) 	 	Minimal 	 	
Dactinomycin (Cosmegen) 	Moderate 	High 	 	
Dasatinib (Sprycel) (oral) 	Low/Minimal 	 	Low 	NCCN did not further delineate between degrees of emetic potential
Daunorubicin (Cerubidine) 	Moderate 	High when given with Cyclophosphamide (Cytoxan)Moderate when used alone 	High: when given with combined with cyclophosphamide (in breast cancer patients)
Moderate: when used alone	
Decitabine (Dacogen) 	Minimal 	 	 	
Denileukin diftitox (Ontak) 	Minimal 	 	 	
Dexrazoxane (Zinecard) 	Minimal 	 	 	
Docetaxel (Taxotere) 	Low 	Low 	Low 	
Doxorubicin (Adriamycin) 	High: 60 mg/m2 or more, or when given at any dose with Cyclophosphamide (Cytoxan)Moderate: less than 60 mg/m2 	High when given with Cyclophosphamide (Cytoxan)Moderate when used alone 	High: when given with combined with cyclophosphamide (in breast cancer patients)
Moderate: when used alone	
Pegylated liposomal doxorubicin (Doxil) 	Low 	Low 	Low 	
Epirubicin (Ellence) 	High: >90 mg/m2 or when given at any dose with Cyclophosphamide (Cytoxan)Moderate: ≤90 mg/m2 	High when given with Cyclophosphamide (Cytoxan)Moderate when used alone 	High: when combined with cyclophosphamide (in breast cancer patients)
Moderate: when used alone	
Eribulin (Halaven) 	Low 	 	Low 	
Erlotinib (Tarceva) (oral) 	Low/Minimal 	 	Minimal 	NCCN did not further delineate between degrees of emetic potential
Estramustine (Emcyt) (oral) 	High/Moderate 	 	 	NCCN did not further delineate between degrees of emetic potential
Etoposide (Vepesid) 	Low 	Low 	Low 	
Etoposide (Vepesid) (oral) 	High/Moderate 	 	Low 	NCCN did not further delineate between degrees of emetic potential
Everolimus (Afinitor) (oral) 	Low/Minimal 	 	Low 	NCCN did not further delineate between degrees of emetic potential
Floxuridine (FUDR) 	Low 	 	 	
Fludarabine (Fludara) 	Minimal 	Minimal 	Minimal 	
Fludarabine (Fludara) (oral) 	Low/Minimal 	 	Low 	NCCN did not further delineate between degrees of emetic potential
Fluorouracil (5-FU) 	Low 	Low 	Low 	
Gefitinib (Iressa) (oral) 	Low/Minimal 	 	Minimal 	NCCN did not further delineate between degrees of emetic potential
Gemcitabine (Gemzar) 	Low 	Low 	Low 	
Hydroxyurea (Hydrea) (oral) 	Low/Minimal 	 	Minimal 	NCCN did not further delineate between degrees of emetic potential
Idarubicin (Idamycin) 	Moderate 	High when given with Cyclophosphamide (Cytoxan)Moderate when used alone 	High: when combined with cyclophosphamide (in breast cancer patients) Moderate: when used alone	
Ifosfamide (Ifex) 	High: 2000 mg/m2 or more per dose Moderate: <2 g/m2 per dose 	Moderate 	Moderate 	ASCO and MASCC did not subclassify based on dose
Imatinib (Gleevec) (oral) 	Low/Minimal 	Moderate 	Moderate 	NCCN did not further delineate between degrees of emetic potential
Interferon alfa-2a (Roferon-A) 	Moderate: 10 million international units/m2 or moreLow: between 5 and 10 million international units/m2Minimal: 5 million international units/m2 or less	 	 	NCCN did not specify interferon alfa-2a vs. 2b
Interferon alfa-2b (Intron-A) 	Moderate: 10 million international units/m2 or moreLow: between 5 and 10 million international units/m2Minimal: 5 million international units/m2 or less	 	 	NCCN did not specify interferon alfa-2a vs. 2b
Ipilimumab (Yervoy) 	Minimal 	 	Low 	
Irinotecan (Camptosar) 	Moderate 	Moderate 	Moderate 	
Ixabepilone (Ixempra) 	Low 	Low 	Low 	
Lapatinib (Tykerb) (oral) 	Low/Minimal 	 	Low 	NCCN did not further delineate between degrees of emetic potential
Lenalidomide (Revlimid) (oral) 	Low/Minimal 	 	Low 	NCCN did not further delineate between degrees of emetic potential
Lenvatinib (Lenvima) (oral) 	 	Moderate 	 	
Lomustine (CCNU) (oral) 	High/Moderate (single day) 	 	 	single day; NCCN did not further delineate between degrees of emetic potential
Lurbinectedin (Zepzelca) 	Moderate 	 	 	
Margetuximab (Margenza) 	Minimal 	 	 	
Mechlorethamine (Mustargen) 	High 	High 	High 	
Melphalan (Alkeran) 	Moderate 	 	 	ASCO and MASCC recommend combination of NK1+5-HT3+DEX when melphalan is used at high dose for BMT conditioning.
Melphalan (Alkeran) (oral) 	Low/Minimal 	 	Minimal 	NCCN did not further delineate between degrees of emetic potential
Mercaptopurine (6-MP) (oral) 	Low/Minimal 	 	 	NCCN did not further delineate between degrees of emetic potential
Methotrexate (MTX) 	Moderate: 250 mg/m2 or moreLow: between 50 and 250 mg/m2Minimal: 50 mg/m2 or less 	Low 	Low 	ASCO and MASCC did not subclassify based on dose
Methotrexate (MTX) (oral) 	Low/Minimal 	 	Minimal 	NCCN did not further delineate between degrees of emetic potential
Mitomycin (Mutamycin) 	Low 	Low 	Low 	
Mitotane (Lysodren) (oral) 	High/Moderate 	 	 	
Mitoxantrone (Novantrone) 	Low 	Low 	Low 	
Nelarabine (Arranon) 	Minimal 	 	 	
Nilotinib (Tasigna) (oral) 	Low/Minimal 	 	Low 	NCCN did not further delineate between degrees of emetic potential
Niraparib (Zejula) (oral) 	Moderate to high 	 	 	NCCN did not further delineate between degrees of emetic potential (>30%)
Ofatumumab (Arzzera) 	Minimal 	 	Minimal 	
Omacetaxine (Synribo) 	Low 	 	 	
Olaparib (Lynparza) (oral) 	Moderate to high 	 	 	NCCN did not further delineate between degrees of emetic potential (>30%)
Oxaliplatin (Eloxatin) 	Moderate 	Moderate 	Moderate 	
Paclitaxel (Taxol) 	Low 	Low 	Low 	
Paclitaxel, nanoparticle albumin-bound (Abraxane) 	Low 	 	Low 	
Panitumumab (Vectibix) 	Minimal 	 	Low 	
Pazopanib (Votrient) (oral) 	Low/Minimal 	 	Low 	NCCN did not further delineate between degrees of emetic potential
Peg-asparginase (Oncaspar) 	Minimal 	 	 	
Peginterferon alfa-2a (Pegasys) 	Minimal 	 	 	NCCN did not specify interferon alfa-2a vs. 2b
Peginterferon alfa-2b (Sylatron) 	Minimal 	 	 	NCCN did not specify interferon alfa-2a vs. 2b
Pembrolizumab (Keytruda) 	 	 	Minimal 	
Pemetrexed (Alimta) 	Low 	Low 	Low 	
Pentostatin (Nipent) 	Low 	 	 	
Pertuzumab (Perjeta) 	Minimal 	 	Low 	
Pixantrone (Pixuvri) 	 	 	Minimal 	
Pomalidomide (Pomalyst) (oral) 	Low/Minimal 	 	Minimal 	
Ponatinib (Iclusig) (oral) 	Low/Minimal 	 	Low 	
Pralatrexate (Folotyn) 	Low 	Minimal 	Minimal 	
Procarbazine (Matulane) (oral) 	High/Moderate 	High 	High 	NCCN did not further delineate between degrees of emetic potential
Regorafenib (Stivarga) (oral) 	Low/Minimal 	 	Low 	
Rituximab (Rituxan) 	Minimal 	Minimal 	Minimal 	
Romidepsin (Istodax) 	Low 	 	Moderate 	
Rucaparib (Rubraca) 	Moderate to high 	 	 	NCCN did not further delineate between degrees of emetic potential (>30%)
Ruxolitinib (Jakafi) (oral) 	Low/Minimal 	 	Minimal 	
Selinexor (Xpovio) (oral) 	Moderate/High 	Moderate/High 	 	NCCN and ASCO did not further delineate between degrees of emetic potential
Sorafenib (Nexavar) (oral) 	Low/Minimal 	 	Minimal 	NCCN did not further delineate between degrees of emetic potential
Streptozocin (Zanosar) 	High 	High 	High 	
Sunitinib (Sutent) (oral) 	Low/Minimal 	 	Low 	NCCN did not further delineate between degrees of emetic potential
Temozolmide (Temodar) 	Moderate 	 	Moderate 	MASCC remark: No direct evidence found for temozolomide IV. Classification is based on oral temozolomide, since all sources indicate a
similar safety profile
Temozolmide (Temodar) (oral) 	High/Moderate: >75 mg/m2/dayLow/Minimal: ≤75 mg/m2/day 	Moderate 	Moderate 	NCCN did not further delineate between degrees of emetic potential
Temsirolimus (Torisel) 	Minimal 	Low 	 	
Thalidomide (Thalomid) (oral) 	Low/Minimal 	 	Low 	NCCN did not further delineate between degrees of emetic potential
Thioguanine (Tabloid) (oral) 	Low/Minimal 	 	Minimal 	NCCN did not further delineate between degrees of emetic potential
Thiotepa (Thioplex) 	Low 	 	Moderate 	
Topotecan (Hycamtin) 	Low 	Low 	Low 	
Topotecan (Hycamtin) (oral) 	Low/Minimal 	 	 	NCCN did not further delineate between degrees of emetic potential
Trabectedin (Yondelis) 	 	 	Moderate 	
Trametinib (Mekinist) (oral) 	Low/Minimal 	 	 	
Trastuzumab (Herceptin) 	Minimal 	Low 	Minimal 	
Trastuzumab deruxtecan (Enhertu) 	High 	Moderate 	 	
All-trans retinoic acid (ATRA) (oral) 	Low/Minimal 	 	 	NCCN did not further delineate between degrees of emetic potential
Umbralisib (Ukoniq) (oral) 	Low/Minimal 	 	 	
Valrubicin (Valstar) 	Minimal 	 	 	
Vandetanib (Caprelsa) (oral) 	Low/Minimal 	 	Low 	NCCN did not further delineate between degrees of emetic potential
Vemurafenib (Zelboraf) (oral) 	Low/Minimal 	 	 	
Vinblastine (Velban) 	Minimal 	Minimal 	Minimal 	
Vincristine (Oncovin) 	Minimal 	Minimal 	Minimal 	
Vincristine liposomal (Marqibo) 	Minimal 	 	 	
Vinflunine (Javlor) 	 	 	Low 	
Vinorelbine (Navelbine) 	Minimal 	Minimal 	Minimal 	
Vinorelbine (Navelbine) (oral) 	 	Moderate 	 	
Vismodegib (Erivedge) (oral) 	High/Moderate 	 	Minimal 	
Vorinostat (Zolinza) (oral) 	Low/Minimal 	 	Low 	NCCN did not further delineate between degrees of emetic potential
Ziv-aflibercept (Zaltrap) 	Low 	 	Low 	
=Highly emetogenic IV chemotherapy (HEC)=
 	Day 1 CINV prophylaxis 	Day 2-4 CINV prophylaxis
ASCO 2017 	NK1 + 5-HT3 + DEX + OLN 	DEX + OLN
(if APR on day 1, then + APR days 2-3)
MASCC 2019 	NK1 + 5-HT3 + DEX +/- OLN	DEX +/- OLN
(if APR on day 1, then + APR days 2-3)
NCCN 2022 	 	
NCCN 2022 	DEX + OLN
(if po APR on day 1, then + APR days 2-3)	
NCCN 2022 	DEX
(if po APR on day 1, then + APR days 2-3)	
- OLN + Palonosetron + DEX	OLN 	
==Neurokinin-1 (NK1) antagonist-containing regimen (except netupitant)==
===Neurokinin 1 (NK1) antagonist===
*Aprepitant (Emend) 125 mg PO once on day 1, then 80 mg PO once per day on days 2 & 3
*Aprepitant injectable emulsion (Cinvanti) 130 mg IV once on day 1
*Fosaprepitant (Emend for Injection) 150 mg IV once on day 1
*Rolapitant (Varubi) 180 mg PO once on day 1
Note: All of the above NK1 antagonists are equally effective in IV and PO formulations at recommended doses Grunberg S, Chua D, Maru A, Dinis J, DeVandry S, Boice JA, Hardwick JS, Beckford E, Taylor A, Carides A, Roila F, Herrstedt J. Single-dose fosaprepitant for the prevention of chemotherapy-induced nausea and vomiting associated with cisplatin therapy: randomized, double-blind study protocol--EASE. J Clin Oncol. 2011 Apr 10;29(11):1495-501. Epub 2011 Mar 7. link to original article EuroPMC
===Serotonin (5-HT3) antagonist===
*Dolasetron (Anzemet) 100 mg PO once on day 1
*Granisetron (choose one of the options below):
**2 mg PO once on day 1
**0.01 mg/kg (maximum dose 1 mg) IV once on day 1
**transdermal patch as 3.1 mg/24H patch (containing 34.3 mg granisetron total dose) placed ~24 to 48 hours before the first dose of chemotherapy. May use patch up to 7 days.
*Ondansetron (Zofran) (choose one of the options below):
**8 to 16 mg IVAs of 6/28/2012, the once daily dose of ondansetron (Zofran) 32 mg is no longer recommended due to dose-dependent QTc prolongation. The Ondansetron (Zofran) package insert recommends only a maximum of 16 mg per dose, which can be given as often as every 4 hours x up to 3 doses, as detailed in the 6/29/2012 FDA Drug Safety Communication. once on day 1
*Palonosetron (Aloxi) 0.25 mg IV once on day 1
*Tropisetron (Navoban) 5 mg IV or PO day 1
Note: When given at biologically equivalent doses, all of the above 5-HT3 antagonists are equally efficacious and appear to be interchangeableKarin Jordan et al. "Comparative activity of antiemetic drugs"
link to original article
Note: Ramosetron is another available 5-HT3, but not approved by FDA
===Dexamethasone (DEX)===
Steroids contraindicated for use with interleukin-2 and interferon.
*If Aprepitant (Emend) used:
**Dexamethasone (Decadron) 12 mg IV or PO once on day 1, then 8 mg PO once per day on days 2 to 4
*If Fosaprepitant (Emend for Injection) used:
**Dexamethasone (Decadron) 12 mg IV or PO once on day 1, then 8 mg PO once per day on days 2 to 4
*If Rolapitant (Varubi) used:
**Dexamethasone (Decadron) 12 mg IV or PO once on day 1, then 8 mg PO twice per day on days 2 to 4
Dexamethasone use beyond day 1 might be revised based on the 2018 meta analysis resultsRonald CHow et Al. "Efficacy and safety of 1-day versus 3-day dexamethasone for the prophylaxis of chemotherapy-induced nausea and vomiting: a systematic review and meta-analysis of randomized controlled trials"
https://jhmhp.amegroups.com/article/view/4296
==Netupitant-containing regimen==
*Netupitant and palonosetron (Akynzeo) 300/0.5 mg PO once on day 1 as a fixed oral formulation
*Dexamethasone (Decadron) 12 mg PO or IV once on day 1, then 8 mg PO or IV once per day on days 2 to 4
==Olanzapine (OLN) containing regimen==
*Olanzapine (Zyprexa) 10 mg PO once per day on days 1 to 4
*Aprepitant (Emend) 125 mg PO once on day 1, then 80 mg PO once per day on days 2 & 3, OR Fosaprepitant (Emend for Injection) 150 mg IV once on day 1
*Palonosetron (Aloxi) 0.25 mg IV once on day 1, OR Granisetron 1mg IV or 2mg PO, OR Ondansetron 8 mg PO or IV
*Dexamethasone (Decadron) 12 mg PO on day 1, and 8 mg PO on days 2, 3, and 4
Reference: 
#Navari et al. 2016Navari RM, Qin R, Ruddy KJ, Liu H, Powell SF, Bajaj M, Dietrich L, Biggs D, Lafky JM, Loprinzi CL. Olanzapine for the Prevention of Chemotherapy-Induced Nausea and Vomiting. N Engl J Med. 2016 Jul 14;375(2):134-42. link to original article link to PMC article EuroPMC
=Moderately emetogenic IV chemotherapy (MEC)=
 	Day 1 CINV prophylaxis	Day 2-4 CINV prophylaxis
ASCO 2017 	5-HT3 + DEX 	DEX maybe offered for: oxaliplatin, or anthracycline, or cyclophosphamide
MASCC 2016 	5-HT3 + DEX 	DEX can be considered for: oxaliplatin, or anthracycline, or cyclophosphamide
NCCN 2022 	 	
NCCN 2022 	DEX or 5-HT3 	
NCCN 2022 	Aprepitant PO daily days 2 and 3 if aprepitant POused on day 1
+/- DEX	
- OLN + Palonosetron + DEX	OLN 	
===Serotonin (5-HT3) antagonist===
*Dolasetron (Anzemet) 100 mg PO once on day 1
*Granisetron (choose one of the options below):
**2 mg PO once on day 1
**0.01 mg/kg (maximum dose 1 mg) IV once on day 1
**transdermal patch as 3.1 mg/24H patch (containing 34.3 mg granisetron total dose) placed ~24 to 48 hours before the first dose of chemotherapy. May use patch up to 7 days.
*Ondansetron (Zofran) (choose one of the options below):
**8 to 16 mg IVAs of 6/28/2012, the once daily dose of ondansetron (Zofran) 32 mg is no longer recommended due to dose-dependent QTc prolongation. The Ondansetron (Zofran) package insert recommends only a maximum of 16 mg per dose, which can be given as often as every 4 hours x up to 3 doses, as detailed in the 6/29/2012 FDA Drug Safety Communication. once on day 1
*Palonosetron (Aloxi) 0.25 mg IV once on day 1
*Tropisetron (Navoban) 5 mg IV or PO day 1
===Dexamethasone (DEX)===
Steroids contraindicated for use with interleukin-2 and interferon.
*If Aprepitant (Emend) used:
**Dexamethasone (Decadron) 12 mg IV or PO once on day 1, then 8 mg PO once per day on days 2 to 4
*If Fosaprepitant (Emend for Injection) used:
**Dexamethasone (Decadron) 12 mg IV or PO once on day 1, then 8 mg PO once per day on days 2 to 4
*If Rolapitant (Varubi) used:
**Dexamethasone (Decadron) 12 mg IV or PO once on day 1, then 8 mg PO twice per day on days 2 to 4
Dexamethasone use beyond day 1 might be revised based on the 2018 meta analysis results
==Netupitant-containing regimen==
*Netupitant and palonosetron (Akynzeo) 300/0.5 mg PO once on day 1 as a fixed oral formulation
*Dexamethasone (Decadron) 12 mg PO or IV once on day 1, then 8 mg PO or IV once per day on days 2 to 4
==Olanzapine (OLN) containing regimen==
Note: a 4-drug regimen based on Navari et al. 2016Navari RM, Qin R, Ruddy KJ, Liu H, Powell SF, Bajaj M, Dietrich L, Biggs D, Lafky JM, Loprinzi CL. Olanzapine for the Prevention of Chemotherapy-Induced Nausea and Vomiting. N Engl J Med. 2016 Jul 14;375(2):134-42. link to original article EuroPMC
*Olanzapine (Zyprexa) 10 mg PO once per day on days 1 to 4
*Aprepitant (Emend) 125 mg PO once on day 1, then 80 mg PO once per day on days 2 & 3, OR Fosaprepitant (Emend for Injection) 150 mg IV once on day 1
*Palonosetron (Aloxi) 0.25 mg IV once on day 1, OR Granisetron 1mg IV or 2mg PO, OR Ondansetron 8 mg PO or IV
*Dexamethasone (Decadron) 12 mg PO on day 1, and 8 mg PO on days 2, 3, and 4
=Carboplatin based chemotherapy=
Guideline and emetic risk	Day 1 CINV prophylaxis	Day 2-4 CINV prophylaxis
ASCO 2017 (MEC)
AUC 4 or more	NK1 + 5-HT3 + DEX 	NONE
(if APR on day 1, then +APR days 2-3)
MASCC 2019 (MEC)
(doesn’t specify AUC)	NK1 + 5-HT3 + DEX 	NONE
(if APR on day 1, then +APR days 2-3)
NCCN 2019
AUC 4 or more (HEC)
AUC less than 4 (MEC)	NK1 + 5-HT3 + DEX 	DEX
NCCN 2019
AUC 4 or more (HEC)
AUC less than 4 (MEC)	5-HT3 + DEX 	
Recommendation to add NK1 is largely based on 2 phase III studiesYahata H, Kobayashi H, Sonoda K, et al: Effi- cacy of aprepitant for the prevention of chemotherapy- induced nausea and vomiting with a moderately emetogenic chemotherapy regimen: A multicenter, placebo-controlled, double-blind, randomized study in patients with gynecologic cancer receiving pac- litaxel and carboplatin. Int J Clin Oncol 21:491-497, 2016
https://europepmc.org/article/MED/26662632
Hesketh PJ, Schnadig ID, Schwartzberg LS, et al: Efficacy of the neurokinin-1 receptor antagonist rolapitant in preventing nausea and vomiting in pa- tients receiving carboplatin-based chemotherapy. Cancer 122:2418-2425, 2016https://europepmc.org/article/MED/27176138. One of them was conducted in female patients with GYN malignancy only. 5-HT3 used in those trials was either granisetron or ondansetron. 
=Bone marrow transplant (BMT) conditioning regimens=
Note: Day 0 is the day of BMT, days with "-" in front are days prior to transplant, days with "+" afterwards are days after transplant
=Allogeneic BMT conditioning regimens=
Conditioning regimen 	CINV prophylaxis
FMT (fludarabine, melphalan, thiotepa) 	- NK1 on day -7
- 5-HT3 on days -7 to -1
Flu/Mel (fludarabine, melphalan) 	- NK1 on day -2
- 5-HT3 on days -6 to -1
- DEX on days -6 to -1
Flu/Cy/TBI (fludarabine, cyclophosphamide, total body irradiation)	
Cy/TBI (cyclophosphamide, total body irradiation) 	- NK1 on day -6
- 5-HT3 on days -6 to -1
- DEX on days -6 to -4
Bu/Flu (bufulfan, fludarabine) 	
Bu/Cy (busulfan, cyclophosphamide) 	
==Autologous BMT conditioning regimens==
Conditioning regimen 	CINV prophylaxis
High dose melphalan 	- NK1 on days -3 to 0
- 5-HT3 on days -3 to 0
- DEX on days -3 to -1
BEAM (busulfan, etoposide, cytarabine, melphalan)	
TBC (thiotepa, busulfan, cyclophosphamide) 	
=Highly to moderately emetogenic PO chemotherapy=
These are NCCN recommendations only. ASCO did not provide separate antiemetic recommendations for PO vs. IV chemotherapy.
Start before chemotherapy and continue once per day:
==Serotonin (5-HT3) antagonist==
*Granisetron (choose one of the options below):
**2 mg PO once per day
**1 mg PO twice per day
*Ondansetron (Zofran) 16 to 24 mg PO once per day
==Optional==
*Lorazepam (Ativan) 0.5 to 2 mg PO/IV/sublingual Q4-6H prn nausea on days 1 to 4
*H2 blocker or proton pump inhibitor
=Low emetic risk IV chemotherapy=
 	Day 1 	Day 2-4
ASCO 2017 	Single dose 5-HT3 or DEX 8mg	No routine prophylaxis
MASCC 2016	5-HT3 or DEX or Dopamine RA 	No routine prophylaxis
NCCN 2022 	DEX or Metoclopramide or Prochlorperazine or
5-HT3 other than Palonosetron	No routine prophylaxis
Repeat once per day for chemotherapy regimens that last more than one day.
*Dexamethasone (Decadron)
**NCCN: 12 mg IV or PO on the days of chemotherapy
**ASCO: 8 mg IV or PO on the days of chemotherapy
*Metoclopramide (Reglan) 10-40 mg IV or PO x1, then Q4-6H prn nausea
*Prochlorperazine (Compazine) 10 mg IV or PO x1, then Q4-6H prn nausea
=Minimal emetic risk chemotherapy=
*No routine prophylaxis recommended by all 3 guideline groups. Assess patient prior to cycle 2 and add single agent prophylactic antiemetic if patient had emesis with cycle 1.
=Low to minimal emetic risk PO chemotherapy=
*use antiemetics prn first
==If nausea/vomiting==
Choose one of the medications below to start before chemotherapy and continue once per day:
*Metoclopramide (Reglan) 10-40 mg IV or PO x1, then Q4-6H prn nausea
*Prochlorperazine (Compazine) 10 mg IV or PO x1, then Q4-6H prn nausea
*Haloperidol (Haldol) 0.5 to 2 mg IV or PO Q4-6H prn nausea (monitor for dystonic reactions)
==Optional==
*Lorazepam (Ativan) 0.5 to 2 mg PO/IV/sublingual Q4-6H prn nausea days 1-4
*H2 blocker or proton pump inhibitor
==If continued nausea/vomiting==
Use serotonin (5-HT3) antagonist:
*Granisetron (choose one of the options below):
**2 mg PO once per day
**1 mg PO twice per day
*Ondansetron (Zofran) 16 to 24 mg PO once per day
=Breakthrough CINV treatment=
General Principles
-Use antiemetic from another class than the prophylactic regimen
-Agents which are successful in treating a patient’s breakthrough CINV should be given routinely for a period of time rather than on an as needed basis. 
-5-HT3 and NK1 RA are generally not effective or approved for treatment of breakthrough nausea/vomiting (assuming they were used as part of prophylaxis)
==Olanzapine==
*Olanzapine (Zyprexa) 10 mg PO daily on days 1-3 if CINV develop in the first 24 hours after HEC R. M. Navari, C. K. Nagy, and S. E. Gray, “The use of olanzapine versus metoclopramide for the treatment of breakthrough chemotherapy-induced nausea and vomiting in patients receiving highly emetogenic chemotherapy,” Supportive Care in Cancer, vol. 21, no. 6, pp. 1655–1663, 2013. Use 5 mg if 10 mg is not well tolerated.S. Chanthawong, S. Subongkot, and A. Sookprasert, “Effectiveness of olanzapine for the treatment of breakthrough chemotherapy induced nausea and vomiting,” Journal of the Medical Association of Thailand, vol. 97, pp. 349–355, 2014
==Metoclopromide==
*Metoclopramide (Reglan) 10 mg PO (IV) every 8 hours on days 1-3 if CINV develop in the first 24 hours after HEC .
==Benzodiazepine==
*Lorazepam (Ativan) 0.5 to 2 mg PO (IV) Q4-6H prn nausea
==Cannabinoid==
*Dronabinol (Marinol) 5-10 mg PO Q3-6H prn nausea
*Nabilone (Cesamet) 1-2 mg PO twice per day prn nausea
==Other agents==
*Haloperidol (Haldol) 0.5 to 2 mg IV or PO Q4-6H prn nausea (monitor for dystonic reactions)
*Scopolamine (Scopoderm) 1 patch Q72H prn nausea
*Prochlorperazine (Compazine) (choose one of the options below):
**25 mg suppository PR every 12 hours prn nausea
**10 mg IV or PO Q4-6H prn nausea
*Promethazine (Phenergan) 12.5-25 mg IV or PO every 6 hours for 1-3 days
*Dexamethasone (Decadron) 8 mg PO (IV) every 6-8 hours
==Serotonin 5-HT3 antagonists==
Are generally ineffective for breakthrough CINV (assuming they were used as part of prophylactic regimen). 
*Ondansetron (Zofran) 8 to 16 mg PO once per day prn nausea
=Anticipatory nausea/vomiting=
*Prevent anticipation by optimizing antiemetic therapy for every cycle of chemotherapy
*Behavioral therapy
**Relaxation/systemic desensitization
**Hypnosis/guided imagery
**Music therapy
*Acupuncture/acupressure
*Alprazolam (Xanax) 0.5 to 2 mg PO three times per day starting the night before treatment
*Lorazepam (Ativan) 0.5 to 1 mg PO beginning the night before treatment and then repeat the next 1-2 hours before anticancer therapy begins
=Reference=
Category:Supportive oncology
Category:Emesis prevention