Antiemetics: a clinical practice guideline update from ASCO

The American Society of Clinical Oncology (ASCO) has updated its guidelines to prevent and manage nausea and vomiting caused by antineoplastic agents or radiation therapy in cancer patients.

An expert panel conducted a systematic review that included evidence from 41 publications between November 2009 and June 2016. The panel found evidence from a phase III randomized controlled trial that showed that adding olanzapine to antiemetic prophylaxis reduces the risk of nausea among adult patients treated with high emetic-risk antineoplastic agents. Additional data also support expanded use of neurokinin 1 receptor antagonists in patients who undergo chemotherapy.

“Health care providers frequently underestimate the incidence and severity of nausea and vomiting caused by radiation therapy and chemotherapy,” the guideline authors note. “To ensure optimal symptom management, clinicians should assess symptoms throughout therapy. Patient response to antiemetic therapy may change over time, requiring reassessments and modifications to antiemetic strategies as warranted.”

A summary of the updated guidelines, which were published in the Journal of Clinical Oncology, is as follows:

Adults patients

• Adult patients treated with cisplatin and other high-emetic-risk single agents should be offered a 4-drug combination, including neurokinin 1 (NK₁) receptor antagonist, a serotonin (5-HT₃) receptor antagonist, dexamethasone, and olanzapine. Dexamethasone and olanzapine should be continued on days 2 to 4 (high quality of evidence; strong recommendation).
• Patients treated with an anthracycline combined with cyclophosphamide should be offered a 4-drug combination of an NK₁ receptor antagonist, a 5-HT₃ receptor antagonist, dexamethasone, and olanzapine. Olanzapine should be continued on days 2 to 4 (high quality of evidence; strong recommendation).
• Patients treated with carboplatin area under the curve (AUC) ≥4 mg/mL per minute should be offered a 3-drug combination of an NK₁ receptor antagonist, a 5-HT₃ receptor antagonist, and dexamethasone (high quality of evidence; strong recommendation).
• Patients treated with moderate-emetic-risk antineoplastic agents should be offered a 2-drug combination of a 5-HT₃ receptor antagonist and dexamethasone (high quality of evidence; strong recommendation).
• Patients treated with moderate-emetic-risk antineoplastic agents that are known to cause delayed nausea and vomiting may be offered dexamethasone on days 2 to 3 (low quality of evidence; moderate recommendation).
• Patients treated with low-emetic-risk antineoplastic agents should be offered a single dose of a 5-HT₃ receptor antagonist or a single 8-mg dose of dexamethasone before antineoplastic treatment (low quality of evidence; moderate recommendation).
• Patients treated with minimal-emetic-risk antineoplastic agents should not be offered routine antiemetic prophylaxis (low quality of evidence; moderate recommendation).
• Patients treated with antineoplastic combinations should be offered antiemetics that are appropriate for the component antineoplastic agent of greatest emetic risk (intermediate quality of evidence; moderate recommendation).
• Lorazepam is a useful adjunct to antiemetic drugs, but ASCO does not recommend this as a single-agent antiemetic (low quality of evidence; moderate recommendation).
• There is insufficient evidence for a recommendation regarding treatment with medical marijuana for the prevention of nausea and vomiting. Evidence is also insufficient for a recommendation regarding the use of medical marijuana in place of cannabinoids, dronabinol and nabilone.
• There is insufficient evidence for a recommendation for or against the use of ginger, acupuncture, and other alternative therapies for the prevention of nausea and vomiting in patients with cancer.
• Patients treated with high-dose chemotherapy and stem cell or bone marrow transplantation should receive 3-drug combination, including an NK₁ receptor antagonist, a 5-HT₃ receptor antagonist, and dexamethasone (high quality of evidence; strong recommendation).
• Patients treated with multi-day antineoplastic agents should be offered antiemetics before treatment and administered on each day of the antineoplastic treatment and for 2 days after the regimen is completed. (Intermediate quality of evidence; moderate recommendation).
• Patients treated with a 4-day or 5-day cisplatin regimen should be offered a 3-drug combination of an NK₁ receptor antagonist, a 5-HT₃ receptor antagonist, and dexamethasone (high quality of evidence; strong recommendation).
• In patients with breakthrough nausea or vomiting, clinicians should re-evaluate emetic risk, disease status, concurrent illnesses, and medications, and ascertain that the best regimen is being administered for the emetic risk (low quality of evidence; moderate recommendation).
• Patients who experience nausea or vomiting after optimal prophylaxis should be offered olanzapine in addition to continuing the standard antiemetic regimen (intermediate quality of evidence; moderate recommendation).
• Patients who experience nausea or vomiting despite optimal prophylaxis and who have already received olanzapine can be offered a drug of a different class in addition to the standard antiemetic regimen (low/intermediate quality of evidence; moderate recommendation).
• Patients should receive the most active antiemetic regimen that is appropriate for the antineoplastic agents being administered, and clinicians should use these regimens with the initial antineoplastic treatment, rather than assessing the patient’s emetic response with less effective antiemetic treatment (low quality of evidence; moderate recommendation).
• Patients treated with high-emetic-risk radiation therapy should be offered a 2-drug combination of a 5-HT₃ receptor antagonist and dexamethasone before each fraction and on the day after each fraction if radiation therapy is not planned for that day (high quality of evidence; strong recommendation).
• Patients treated with moderate-emetic-risk radiation therapy should be offered a 5-HT₃ receptor antagonist before each fraction, with or without dexamethasone before the first 5 fractions (high quality of evidence; moderate recommendation).
• Patients treated with radiation therapy to the brain should be offered rescue dexamethasone therapy. Radiation therapy to the head and neck, thorax, or pelvis should include rescue therapy with a 5-HT₃ receptor antagonist, dexamethasone, or a dopamine receptor antagonist (low quality of evidence; weak recommendation).
• Patients treated with minimal-emetic-risk radiation therapy should be offered rescue therapy with a 5-HT₃ receptor antagonist, dexamethasone, or a dopamine receptor antagonist (low quality of evidence; weak recommendation).
• Patients treated with concurrent radiation and antineoplastic agents should receive antiemetic therapy that is appropriate for the emetic risk level of antineoplastic agents, unless the risk level of the radiation therapy is higher (intermediate quality of evidence; moderate recommendation).

Pediatric patients

• Pediatric patients treated with high-emetic-risk antineoplastic agents should be offered a 3-drug combination of a 5-HT₃ receptor antagonist, dexamethasone, and aprepitant (intermediate quality of evidence; strong recommendation).
• Patients unable to receive aprepitant should be offered a 2-drug combination of a 5-HT₃ receptor antagonist and dexamethasone (intermediate quality of evidence; strong recommendation).
• Patients unable to receive dexamethasone should be offered a 2-drug combination of palonosetron and aprepitant (intermediate quality of evidence; strong recommendation).
• Patients treated with moderate-emetic-risk antineoplastic agents should be offered a 2-drug combination of a 5-HT₃ receptor antagonist and dexamethasone (intermediate quality of evidence; strong recommendation).
• Patients treated with moderate-emetic-risk antineoplastic agents who are unable to receive dexamethasone should be offered a 2-drug combination of a 5-HT₃ receptor antagonist and aprepitant (intermediate quality of evidence; weak recommendation).
• Patients treated with low-emetic-risk antineoplastic agents should be offered ondansetron or granisetron (low quality of evidence; strong recommendation).
• Patients treated with minimal-emetic-risk antineoplastic agents should not be offered routine antiemetic prophylaxis (low quality of evidence; strong recommendation).

Reference

Hesketh PJ, Kris MG, Basch E, et al. Antiemetics: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2017 Jul 31. doi:10.1200/JCO.2017.74.4789

From the October 01, 2017 Issue of Clinical Advisor