Overview of the updated antiemetic guidelines for chemotherapy-induced nausea and vomiting
nausea and vomitingRudolph M. Navari, MD, PhDIndiana University School of Medicine–South Bend, South Bend, IN
Nausea and vomiting associated with cancer chemotherapy are experienced by 70%–80% of patients receiving
chemotherapy and can result in significant morbidity. Chemotherapy-induced nausea and vomiting (CINV) adversely
affects patient quality of life, often leading to poor compliance with the treatment regimen and serious metabolic
complications. Several classes of antiemetic drugs are available to prevent or treat CINV. Older agents include
phenothiazines, antihistamines, and corticosteroids. Serotonin (5-HT3) receptor antagonists became available
in the 1990s for use in preventing CINV. Recently, the NK1 receptor antagonist aprepitant was introduced for
use in combination therapy regimens. Despite this introduction of new and more effective antiemetic agents,
emesis remains a significant complication of chemotherapy. Updated antiemetic guidelines were published
in 2007 by the National Comprehensive Cancer Network and in 2006 by the American Society of Clinical
Oncology. Updates for clinicians who treat patients with CINV are now available and are reviewed here.
C hemotherapy-induced nausea wound dehiscence.1,11 Patients who are dehydrated,
debilitated, or malnourished, as well as those who
have an electrolyte imbalance or those who have re-
cently undergone surgery or radiation therapy, are
at greater risk of experiencing serious complications
dergoing chemotherapy experience emesis, with
Despite the recent introduction of new and
10%–44% experiencing anticipatory emesis.1,2
more effective antiemetic agents, emesis remains
CINV results in significant morbidity and neg-
a significant complication of chemotherapy. Up-
atively impacts patient quality of life.3–5 CINV
dated antiemetic guidelines were published in 2007
may cause nonadherence to chemotherapy or
by the National Comprehensive Cancer Network
dose reductions due to anticipatory nausea and
(NCCN) and in 2006 by the American Society of
Increased risk of CINV is associated with the
Manuscript received February 15, 2007; accepted March 1,
following factors: age < 50 years, female gender,
vomiting during previous chemotherapy, preg-
Funding for this publication was provided by Roche Labora-
nancy-induced nausea/vomiting, history of mo-
Correspondence to: Rudolph M. Navari, MD, PhD, Professor
tion sickness, and anxiety.9,10 CINV can result in
of Medicine, Assistant Dean, and Director, Indiana University
weakness, weight loss, electrolyte imbalance, dehy-
School of Medicine–South Bend, 100 Raclin-Carmichael Hall,
dration, or anorexia and is associated with a variety
1234 Notre Dame Avenue, South Bend, IN 46617; telephone:
of complications, including fractures, esophageal
574-631-3793; fax: 574-631-4939; e-mail: rnavari@nd.edu.
tears, decline in behavioral and mental status, and
Commun Oncol 2007;4(suppl 1):3–11 2007 Elsevier Inc. Al rights reserved.
April 2007 ■ COMMUNITY ONCOLOGY 3 Pathophysiology of nausea and vomiting Types, causes, and risk categories of CINV
derly patients (> 65 years of age) are
or requires “rescue” is called break-
4 COMMUNITY ONCOLOGY ■ April 2007
Updated antiemetic guidelines for chemotherapy-induced nausea and vomiting
TABLE 1 Emetic risk of antineoplastic agents High emetic risk Moderate emetic risk Low emetic risk Minimal emetic risk (> 90% frequency (30%–90% frequency (10%–30% frequency (< 10% frequency of of emesis)* of emesis)* of emesis)* emesis)*
* Proportion of patients who experience emesis in the absence of effective antiemetic prophylaxis† Daily use of antiemetics is not recommended based on clinical experienceAdapted, with permission from the American Society of Clinical Oncology,19 with additional information.1
Principles in the management of CINV
unless specifically stated.1,17 The 2006
forth several principles of effective an-
dition to patient-specific risk factors.
emetic risk (the risk of emesis persists
Antiemetic agents
April 2007 ■ COMMUNITY ONCOLOGY 5
Antiemetic recommendations by emetic-risk categories
Emetic-risk category ASCO guidelines NCCN guidelines
Three-drug combination of a 5-HT3 receptor
Before chemotherapy, a 5-HT3 receptor antagonist
antagonist, dexamethasone, and aprepitant
(ondansetron, granisetron, dolasetron, or palono-
setron*), dexamethasone (12 mg), and aprepitant
(125 mg) recommended, with or without lorazepam
For patients receiving cisplatin and all other
For prevention of delayed emesis, dexamethasone
agents of high emetic risk, the two-drug
(8 mg) on days 2–4 plus aprepitant (80 mg) on
combination of dexamethasone and aprepitant
days 2 and 3 recommended, with or without
recommended for prevention of delayed emesis
For patients receiving an anthracycline and
For patients receiving an anthracycline and
cyclophosphamide, the three-drug combination
cyclophosphamide and selected patients receiving
a 5-HT3 receptor antagonist, dexamethasone, and other chemotherapies of moderate emetic risk (eg,
aprepitant recommended before chemotherapy;
carboplatin, cisplatin, doxorubicin, epirubicin,
single-agent aprepitant recommended on days 2
ifosfamide, irinotecan, or methotrexate), a 5-HT3
receptor antagonist (ondansetron, granisetron,
For patients receiving other chemotherapies of
dolasetron, or palonosetron*), dexamethasone
moderate emetic risk, the two-drug combination of
(12 mg), and aprepitant (125 mg) recommended,
a 5-HT3 receptor antagonist and dexamethasone
with or without lorazepam, before chemotherapy;
recommended before chemotherapy; single-agent
for other patients, aprepitant is not recommended
dexamethasone or a 5-HT3 receptor antagonist
For prevention of delayed emesis, dexamethasone
suggested on days 2 and 3 for prevention of
(8 mg) or a 5-HT3 receptor antagonist on days 2–4
or, if used on day 1, aprepitant (80 mg) on days
2 and 3, with or without dexamethasone (8 mg)
on days 2–4, recommended, with or without
Dexamethasone (8 mg) suggested; no routine
Metoclopramide, with or without diphenhydramine;
preventive use of antiemetics for delayed emesis
dexamethasone (12 mg); or prochlorperazine
No antiemetic administered routinely before or
No routine prophylaxis; consider using antiemetics
listed under primary prophylaxis as treatment
* Order of listed antiemetics does not reflect preferenceASCO = American Society of Clinical Oncology; NCCN = National Comprehensive Cancer Network; 5-HT3 = 5-hydroxytryptamineAdapted, with permission, from the American Society of Clinical Oncology18 Reproduced and adapted with permission from the NCCN 1.2007 Antiemesis Guidelines.1 2007 National Comprehensive Cancer Network, Inc. All rights reserved.
These guidelines and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent
and complete version of the guideline, go online to www.nccn.org. Intravenous (IV)
* The FDA-approved IV dose of granisetron is 0.01 mg/kg.
Adapted, with permission, from the American Society of Clinical
6 COMMUNITY ONCOLOGY ■ April 2007
Updated antiemetic guidelines for chemotherapy-induced nausea and vomiting
Efficacy and safety of antiemetic agents in clinical trials
April 2007 ■ COMMUNITY ONCOLOGY 7 Pharmacologic management by emetogenic potential
the historic control group (0%; P <
8 COMMUNITY ONCOLOGY ■ April 2007
Updated antiemetic guidelines for chemotherapy-induced nausea and vomiting
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ABOUT THE AUTHOR
nausea and vomiting in patients with breast
with ondansetron in preventing chemother-
cancer after moderately emetogenic chemo-
Affiliation: Dr. Navari is Professor of Medicine,
Assistant Dean, and Director, Indiana Univer-
apy-induced nausea and vomiting following
therapy. J Clin Oncol 2005;23:2822–2830.
sity School of Medicine–South Bend, South
role of psychological variables in post-che-
Conflicts of interest: None disclosed.
motherapy nausea: anxiety and expectation.
April 2007 ■ COMMUNITY ONCOLOGY 11
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