ASCO Updates Guidelines for Antiemetic Therapy in Adult, Pediatric Patients Receiving Chemotherapy

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The updated ASCO guidelines include the addition of olanzapine in emetic regimens for adults.
The updated ASCO guidelines include the addition of olanzapine in emetic regimens for adults.

The effectiveness of antiemetic therapy for chemotherapy-induced nausea and vomiting (CINV) have increased greatly. Adhering to the regimens, especially when dealing with the emetic risk associated with specific chemotherapy regimens, leads to better outcomes and control. An expert panel convened by the American Society of Clinical Oncology (ASCO) updated its guidelines for antiemetic therapy for oncology.

A significant update to the guidelines is the inclusion of olanzapine, an atypical antipsychotic, in the antiemetic regimens for adult patients. The following are the key recommendations from the guidelines.

For Adult Patients Receiving

High-emetic-risk antineoplastic agents:

  • Strong recommendation: Patients receiving cisplatin and other high-emetic-risk monotherapy should be offered a combination of 4 drugs comprised of neurokinin 1 (NK1) receptor antagonist, a serotonin (5-HT3) receptor antagonist, olanzapine, and dexamethasone. Olanzapine and dexamethasone should be continued for days 2 to 4.
  • Strong recommendation: Patients receiving anthracycline plus cyclophosphamide should be offered a combination of 4 drugs comprised of neurokinin 1 (NK1) receptor antagonist, a serotonin (5-HT3) receptor antagonist, olanzapine, and dexamethasone. Olanzapine should be continued for days 2 to 4.

Moderate-emetic-risk antineoplastic agents:

  • Strong recommendation: Patients receiving carboplatin area under the curve (AUC) ≥4 mg/mL should be offered a combination of 3 drugs comprised of an NK1 receptor antagonist, a 5-HT3 receptor antagonist, and dexamethasone.
  • Strong recommendation: Patients receiving moderate-emetic-risk agents excluding carboplatin AUC ≥4 mg/mL should be offered a combination of 2 drugs on comprised of a 5-HT3 receptor antagonist and dexamethasone on day 1.
  • Moderate recommendation: Patients receiving cyclophosphamide, doxorubicin, oxaliplatin, and other moderate-emetic-risk agents associated with late-onset nausea and vomiting may be offered dexamethasone on days 2 to 3.

Low-emetic-risk antineoplastic agents:

  • Moderate recommendation: Patients should be offered single dose 5-HT3 receptor antagonist or single dose dexamethasone 8 mg prior to therapy

Adjunctive agents:

  • Moderate recommendation: Lorazepam may be useful as an adjunct to antiemetic therapy but not as monotherapy for nausea and vomiting.

Cannabinoids:

  • New: Evidence for the use of medical marijuana remains insufficient to recommend its use to control and manage chemotherapy induced nausea and vomiting. Only the US Food and Drug Administration (FDA)-approved cannabinoids — dronabinol and nabilone — remain recommended as antiemetic agents

High-dose chemotherapy with stem cell or bone marrow transplantation:

  • Moderate recommendation: Patients should be offered a combination of 3 drugs comprised of an NK1 receptor antagonist, a 5-HT3 receptor antagonist, and dexamethasone.

Multiday antineoplastic therapy

  • Strong recommendation: Patients who receive 4- to 5-day cisplatin regimens should be offered a combination of 3 drugs comprised of an NK1 receptor antagonist, a 5-HT3 receptor antagonist, and dexamethasone.

Breakthrough nausea and vomiting:

  • Moderate recommendation: Patients who received optimal prophylaxis who did not receive olanzapine, should be offered olanzapine in addition to continuing the antiemetic regimen
  • Moderate recommendation: Patients who received optimal prophylaxis and olanzapine may be offered an adjunct agent in another class, including NK1 receptor antagonists, lorazepam or alprazolam, a dopamine receptor antagonist, or cannabinoids, in addition to continuing the antiemetic regimen

High-emetic-risk radiation therapy

  • Strong recommendation: Patients should be offered a combination of 2 drugs comprised of a 5-HT3 receptor antagonist and dexamethasone before each fraction and the day after each fraction if radiation is not scheduled for that day

Low-emetic-risk radiation therapy

  • Weak recommendation: Patients should be offered rescue therapy with a 5-HT3 receptor antagonist, dexamethasone, or a dopamine receptor antagonist.

Concurrent radiation and antineoplastic agent therapy

  • Moderate recommendation: Patients should receive antiemetic therapy proportionate to the emetic risk of the antineoplastic administered unless the emetic risk of radiation therapy is greater. When prophylactic antiemetic therapy for antineoplastic agents is over and prophylactic therapy for radiation therapy is in progress, patients should receive antiemetic therapy proportionate to the emetic risk of radiation therapy until the next antineoplastic therapy instead of receiving rescue therapy for antineoplastic agents as needed.

For Pediatric Patients Receiving

High-emetic-risk antineoplastic agents:

  • Strong recommendation: Patients should be offered a combination of 3 drugs comprised of a 5-HT3 receptor antagonist, dexamethasone, and aprepitant.
  • New strong recommendation: Patients unable to receive aprepitant should be offered a combination of 2 drugs comprised of a 5-HT3 receptor antagonist and dexamethasone
  • New strong recommendation: Patients unable to receive dexamethasone should be offered a combination of 2 drugs comprised of palonosetron and aprepitant

Moderate-emetic-risk antineoplastic agents

  • New weak recommendation: Patients unable to receive dexamethasone should be offered a combination of 2 drugs comprised of a 5-HT3 receptor antagonist and aprepitant

Low-emetic-risk antineoplastic agents

  • New strong recommendation: Patients should be offered ondansetron or granisetron

Minimal-emetic-risk antineoplastic agents

  • New strong recommendation: Patients should not be offered routine prophylactic antiemetic therapy

The recommendations were based on a systematic review that included 41 publications. The authors conclude saying “the Expert Panel reiterated the importance of using the most effective antiemetic regimens that are appropriate for antineoplastic agents or radiotherapy being administered. Such regimens should be used with initial treatment, rather than first assessing the patient's emetic response with less-effective treatment.”

1. Hesketh PJ, Kris MG, Basch E, et al. Antiemetics: American Society of Clinical Oncology clinical practice guideline update [published online August 1, 2017]. J Clin Oncol. doi: 10.1200/JCO.2017.74.4789

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