Acute CINV Either a neurokinin-1 (NK1) antagonist-containing regimen or an olanzapine (Zyprexa, generics)-containing regimen is recommended for preventing acute CINV in patients undergoing treatment with a HEC. The NK1 antagonist-containing regimen should be a combination of a 5-HT3 receptor antagonist (preferably palonosetron), dexamethasone, and aprepitant/fosaprepitant (Emend).5 Alternatively, the 2014 National Comprehensive Cancer Network (NCCN) Guidelines also include an olanzapine-containing regimen (olanzapine, palonosetron, and dexamethasone) based on study findings from Navari and colleagues.5,28 Lorazepam (Ativan, generics) and an H2 blocker or proton pump inhibitor (PPI) may also be included with either the NK1 regimen or the olanzapine regimen.5

For prophylaxis of acute nausea and vomiting with a MEC, a 5-HT3 receptor antagonist (preferably palonosetron) plus dexamethasone is recommended.2,5,6,25 Similar to HEC, the 2014 NCCN Guidelines include an alternative olanzapine-containing regimen (olanzapine, palonosetron, and dexamethasone).5 Also similar to HEC, lorazepam and an H2 blocker or PPI may be included with either the NK1 regimen or the olanzapine regimen.5 Adjunctive use of aprepitant or fosaprepitant in this instance has been either recommended or considered optional.2,4,6,25,29

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Prophylaxis for CINV with a LEC may consist of a corticosteroid, 5-HT3 receptor antagonist, or dopamine receptor antagonist5,6,25; however, some recommendations include only dexamethasone.29 Finally, minimally emetogenic chemotherapy does not require any treatment for the possibility of acute CINV.5,6,25,29

Delayed CINV Recognition of delayed CINV may be low among health care providers due to the nature of this effect.3,30 Quality of life, however, is diminished even when only delayed CINV episodes occur.31 For HEC agents, those guidelines that distinguish acute from delayed CINV recommend a combination of dexamethasone and aprepitant for delayed CINV.25 If fosaprepitant is given on day 1, however, no additional dose of fosaprepitant is necessary.6,25 Dexamethasone or aprepitant are suggested for prophylaxis of delayed nausea and vomiting with a MEC agent.6,25 If aprepitant was used for prevention of acute CINV, it should continue to be used for delayed CINV, whereas if palonosetron was used, it is not needed again.6 LEC and minimally emetogenic chemotherapy do not require prophylactic treatment for delayed CINV.5,6,25,29

Breakthrough and anticipatory CINV Breakthrough or refractory CINV indicates a need to evaluate emetic risk, disease status, concurrent illnesses, and medications; and the antiemetic regimen should be re-examined to make sure that the most appropriate treatment is being administered for the emetic risk.29 In general, an agent from a drug class not previously used should be added to the treatment regimen.2,5 Olanzapine, lorazepam, dronabinol, nabilone (Cesamet), and oral 5-HT3 receptor antagonists are among the potential therapies.2,5 If the additional agent is effective, it should be continued to prevent additional symptoms.5 If CINV continues despite the new agent, dose adjustments or another agent should be considered.5 Regardless of whether the new agent is effective, using a higher level antiemetic therapy as primary treatment should be considered for the next chemotherapy cycle.5

The best strategy for anticipatory CINV is optimal antiemetic therapy.5,25,29 When anticipatory CINV occurs, however, it may be addressed through behavioral therapy such as relaxation, hypnosis, or systematic desensitization; acupuncture/acupressure; or alprazolam or lorazepam.2,5,25,29

Multiday chemotherapy regimens Prevention or treatment of CINV with multiday chemotherapeutic regimens is complicated by the need to address the potential for both acute and delayed CINV at each day of treatment. The possible overlap of acute and delayed CINV, the varying emetogenic potential of the individual agents, and the sequence of administration should all be taken into account.5,29 Treatment may include corticosteroids, 5-HT3 receptor antagonists, and/or NK1 antagonists.5 Some concerns are centered around repeated dosing of the antiemetics used. If dexamethasone is used, for example, side effects associated with its prolonged administration need to be taken into account. Although concerns have not been noted for repeated dosing of palonosetron, a single IV palonosetron dose of 0.25 mg may be sufficient if administered prior to the start of a short (3-day) chemotherapy regimen.5

Oral chemotherapy Oral chemotherapies are also divided into high-, moderate-, and low-to-minimal emetogenic risk categories. For high-to-moderate risk therapies, an oral 5-HT3 antagonist (dolasetron [Anzemet], granisetron [Kytril, Sancuso, generics], or ondansetron [Zofran, Zuplenz, generics]) is recommended.5 Similar to recommendations for IV chemotherapies, lorazepam and/or an H2 blocker or proton pump inhibitor may also be added. For low-to-minimal risk chemotherapies, treatment is administered as needed.5 In the event that treatment is necessary, metoclopramide, prochlorperazine, haloperidol, or an oral 5-HT3 receptor antagonist is recommended.5 Again, lorazepam and/or an H2 blocker or proton pump inhibitor may also be added.