Antiemetics in Cancer Treatment
Publication Date: July 13, 2020
Last Updated: March 27, 2023
Treatment
Adult Patients
Note: For adult patients, the addition of a checkpoint inhibitor to chemotherapy does not change the guideline recommendation for an antiemetic regimen based on the emetogenicity of the agents administered. CPIs administered alone or in combination with another checkpoint inhibitor are minimally emetogenic and do not require the routine use of a prophylactic antiemetic.
High-Emetic-Risk Antineoplastic Agents
Adult patients treated with cisplatin and other high-emetic-risk single agents should be offered a four-drug combination of an NK1 receptor antagonist a serotonin (5-HT3), dexamethasone, and olanzapine . Dexamethasone and olanzapine should be continued on days 2–4. ( EB , H , S )
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Adult patients treated with an anthracycline combined with cyclophosphamide should be offered a four-drug combination of an NK1 receptor antagonist, a 5-HT3 receptor antagonist, dexamethasone, and olanzapine . Olanzapine should be continued on days 2–4. ( EB , H , S )
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Moderate-Emetic-Risk Antineoplastic Agents
Adult patients treated with carboplatin area under the curve (AUC1) ≥4 mg/mL/min should be offered a three-drug combination of an NK receptor antagonist, a 5-HT3 receptor antagonist, and dexamethasone ( EB , H , S )
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Adult patients treated with moderate-emetic-risk antineoplastic agents (excluding carboplatin AUC3 ≥4 mg/mL/min) should be offered a two-drug combination of a 5-HT receptor antagonist (day 1) and dexamethasone (day 1). ( EB , H , S )
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Adult patients treated with cyclophosphamide, doxorubicin, oxaliplatin and other moderate-emetic-risk antineoplastic agents known to cause delayed nausea and vomiting may be offered dexamethasone on days 2–3. ( IC , L , M )
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Low-Emetic-Risk Antineoplastic Agents
Adult 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. ( IC , L , M )
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Minimal Emetic Risk Antineoplastic Agents
Adult patients treated with minimal emetic risk antineoplastic agents should not be offered routine antiemetic prophylaxis. ( IC , L , M )
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Antineoplastic Combinations
Adult patients treated with antineoplastic combinations should be offered antiemetics appropriate for the component antineoplastic agent of greatest emetic risk. ( IC , I , M )
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Adjunctive Drugs
Lorazepam is a useful adjunct to antiemetic drugs, but is not recommended as a single-agent antiemetic. ( IC , L , M )
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Cannabinoids
Evidence remains insufficient for a recommendation regarding medical marijuana for the prevention of nausea and vomiting in patients with cancer receiving chemotherapy or radiation therapy. Evidence is also insufficient for a recommendation regarding the use of medical marijuana in place of the tested and US Food and Drug Administration-approved cannabinoids dronabinol and nabilone for the treatment of nausea and vomiting caused by chemotherapy or radiation therapy.
Complementary and Alternative Therapies
Evidence remains insufficient for a recommendation for or against the use of ginger, acupuncture/acupressure, and other complementary or alternative therapies for the prevention of nausea and vomiting in patients with cancer.
High-Dose Chemotherapy With Stem-Cell or Bone Marrow Transplantation
Adult patients treated with high-dose chemotherapy and stem-cell or bone marrow transplantation should be offered a three-drug combination of an NK1 receptor antagonist, a 5-HT3 receptor antagonist , and dexamethasone. ( EB , H , S )
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(New) A four-drug combination of an NK1 receptor antagonist, a 5-HT3 receptor antagonist, dexamethasone, and olanzapine may be offered to adults treated with high-dose chemotherapy and stem-cell or bone marrow transplantation. ( EB , L , W )
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Multiday Antineoplastic Therapy
Adult patients treated with multiday antineoplastic agents should be offered antiemetics before treatment that are appropriate for the emetic risk of the antineoplastic agent given on each day of the antineoplastic treatment and for 2 days after completion of the antineoplastic regimen. ( EB , I , M )
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Adult patients treated with 4- or 5-day cisplatin regimens should be offered a three-drug combination of an NK1 receptor antagonist, a 5-HT3 receptor antagoninst, and dexamethasone. ( EB , H , S )
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Breakthrough Nausea and Vomiting
For 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. ( IC , L , M )
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Adult patients who experience nausea or vomiting despite optimal prophylaxis, and who did not receive olanzapine prophylactically, should be offered olanzapine in addition to continuing the standard antiemetic regimen. ( EB , I , M )
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Adult patients who experience nausea or vomiting despite optimal prophylaxis, and who have already received olanzapine, may be offered a drug of a different class (eg, an NK1 receptor antagonist, lorazepam or alprazolam, a dopamine receptor antagonist, dronabinol, or nabilone) in addition to continuing the standard antiemetic regimen.
for dronabinol and nabilone ( IC , I , M )
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otherwise ( IC , L , M )
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Anticipatory Nausea and Vomiting
All patients should receive the most active antiemetic regimen appropriate for the antineoplastic agents being administered. Clinicians should use such regimens with initial antineoplastic treatment, rather than assessing the patient’s emetic response with less effective antiemetic treatment. If a patient experiences anticipatory emesis, clinicians may offer behavioral therapy with systematic desensitization. ( IC , L , M )
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High Emetic Risk Radiation Therapy
Adult patients treated with high-emetic-risk radiation therapy should be offered a two-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. ( EB , H , S )
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Moderate Emetic Risk Radiation Therapy
Adult 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 five fractions. ( EB , H , M )
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Low Emetic Risk Radiation Therapy
Adult patients treated with radiation therapy to the brain should be offered rescue dexamethasone therapy. Patients who are treated with radiation therapy to the head and neck, thorax, or pelvis should be offered rescue therapy with a 5-HT3 receptor antagonist , dexamethasone, or a dopamine receptor antagonist. ( IC , L , W )
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Minimal Emetic Risk Radiation Therapy
Adult 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. ( IC , L , W )
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Concurrent Radiation and Antineoplastic Agent Therapy
Adult patients treated with concurrent radiation and antineoplastic agents should receive antiemetic therapy appropriate for the emetic risk level of the antineoplastic agents, unless the risk level of the radiation therapy is higher. During periods when prophylactic antiemetic therapy for the antineoplastic agents has ended, and ongoing radiation therapy would normally be managed with its own prophylactic therapy, patients should receive prophylactic therapy appropriate for the emetic risk of the radiation therapy until the next period of antineoplastic therapy, rather than receiving rescue therapy for the antineoplastic agents as needed. ( IC , I , M )
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Pediatric Patients
High Emetic Risk Antineoplastic Agent
(Updated) Pediatric patients treated with high-emetic-risk antineoplastic agents should be offered a three-drug combination of a 5-HT3 receptor antagonist, dexamethasone, and aprepitant or fosaprepitant. ( EB , I , S )
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(Updated) Pediatric patients treated with high-emetic-risk antineoplastic agents who are unable to receive aprepitant or fosaprepitant should be offered a two-drug combination of a 5-HT3 receptor antagonist and dexamethasone. ( EB , I , S )
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(Updated) Pediatric patients treated with high-emetic-risk antineoplastic agents who are unable to receive dexamethasone should be offered a two-drug combination of palonosetron and aprepitant or fosaprepitant. ( EB , I , S )
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Moderate Emetic Risk Antineoplastic Agents
(Updated) Pediatric patients treated with moderate-emetic-risk antineoplastic agents who are unable to receive dexamethasone should be offered a two-drug combination of a 5-HT3 receptor antagonist and aprepitant or fosaprepitant. ( EB , I , W )
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Low Emetic Risk Antineoplastic Agents
Pediatric patients treated with low-emetic-risk antineoplastic agents should be offered ondansetron or granisetron. ( IC , L , S )
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Minimal Emetic Risk Antineoplastic Agents
Pediatric patients treated with minimal emetic risk antineoplastic agents should not be offered routine antiemetic prophylaxis. ( IC , L , S )
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Recommendation Grading
Disclaimer
The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.
Overview
Title
Antiemetics
Authoring Organization
American Society of Clinical Oncology
Publication Month/Year
July 13, 2020
Last Updated Month/Year
November 11, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Update_in_progress
Country of Publication
US
Document Objectives
To update the guideline to include new anticancer agents, antiemetics, and antiemetic regimens and to provide recommendations on the use of dexamethasone as a prophylactic antiemetic in patients receiving checkpoint inhibitors (CPIs).
Target Patient Population
Adults and children who receive antineoplastic agents and adults who undergo radiation therapy for cancer.
Target Provider Population
Medical and radiation oncologists, oncology nurses, nurse practitioners, physician assistants, oncology pharmacists
PICO Questions
Should current guideline-endorsed antiemetic regimens that include dexamethasone be modified when checkpoint inhibitors (CPIs) are incorporated in antineoplastic treatment regimens?
Inclusion Criteria
Male, Female, Adolescent, Adult, Child, Older adult
Health Care Settings
Ambulatory, Hospice, Hospital, Outpatient, Radiology services
Intended Users
Nurse, nurse practitioner, health systems pharmacist, physician, physician assistant
Scope
Treatment, Management, Prevention
Diseases/Conditions (MeSH)
D000932 - Antiemetics
Keywords
radiation therapy, Antiemetics, CINV, nausea, vomiting, Chemotherapy-induced nausea and vomiting, antineoplastic agents
Source Citation
DOI: 10.1200/JCO.20.01296 Journal of Clinical Oncology
Supplemental Methodology Resources
Methodology
Number of Source Documents
39
Literature Search Start Date
June 1, 2016
Literature Search End Date
January 24, 2020
Description of External Review Process
ASCO has a rigorous review process for guidelines. After the draft has been approved by the Expert Panel, the guideline is independently reviewed and approved by the Clinical Practice Guideline Oversight Committee (CPGC). Select members of the CPGC are asked to critically review the guideline prior to the next scheduled CPGC meeting. The CPGC members then present the results of their reviews to the full committee, discuss the review with the full committee, and the CPGC votes on whether to approve the guideline (with recusals from members who have relationships with affected companies). Approved ASCO Guidelines are then submitted to the Society’s journal for consideration of publication.
Specialties Involved
Geriatric Medicine, Hematology, Hospice And Palliative Medicine, Internal Medicine General, Oncology, Pediatrics, Pediatric Hematology Oncology, Medical Oncology, Radiation Oncology, Hematology Oncology, Pediatrics, Oncology, Oncology, Hematology
Description of Systematic Review
The Protocol specifies the purpose of the guideline product, target patient population, clinical outcomes of interest, key features of the systematic literature review, and a proposed timeline for completion. ASCO staff, the Expert Panel Co‐Chairs, and possibly other panel members selected by the Co‐Chairs (the Expert Panel Steering Committee), will typically draft the protocol for full panel review. A standard protocol worksheet is used for consistency.
Once the Co‐Chairs have approved a first draft of the Protocol, the Protocol will be shared with the full Expert Panel. At the discretion of the Guidelines Director, the CPGC leadership and/or the CPGC Methodology Subcommittee may review the Protocol to make suggestions for revision intended to clarify aspects of the plan for developing the guideline. These suggestions are sent to the Expert Panel Co‐Chairs. Work on the systematic literature review can proceed upon the sign‐off of the Protocol by the Expert Panel.
List of Questions
See full text
Description of Study Criteria
See supplement
Description of Search Strategy
Upon approval of the Protocol, a systematic review of the medical literature is conducted. ASCO staff use the information entered into the Protocol, including the clinical questions, inclusion/exclusion criteria for qualified studies, search terms/phrases, and range of study dates, to perform the systematic review. Literature searches of selected databases, including The Cochrane Library and Medline (via PubMed) are performed. Working with the Expert Panel, ASCO staff complete screening of the abstracts and full text articles to determine
eligibility for inclusion in the systematic review of the evidence.
Unpublished data from meeting abstracts are not generally used as part of normal ASCO guideline development (“Meeting Data”). However, abstract data from reputable scientific meetings and congresses may be included on a case‐by‐case basis after review by the CPGC leadership. Expert Panels should present a rationale to support integration of abstract data into a guideline. The CPGC leadership will consider the following inclusion criteria for the unpublished scientific meeting data: 1) whether the data were independently peer reviewed in connection with a reputable scientific meeting or congress; 2) the potential clinical impact of the unpublished data; 3) the methodological quality and validity of the associated study; 3) the potential harms of not including the data; and 4) the availability of other published data to inform the guideline recommendations.
Description of Study Selection
Literature search results were reviewed and deemed appropriate for full text review by two ASCO staff reviewers in consultation with the Expert Panel Co-Chairs. Data were extracted by two staff reviewers and subsequently checked for accuracy through an audit of the data by another ASCO staff member. Disagreements were resolved through discussion and consultation with the Co-Chairs if necessary. Evidence tables are provided in the manuscript and/or in Data Supplements 1.
Description of Evidence Analysis Methods
ASCO guideline recommendations are crafted, in part, using the GuideLines Into DEcision Support (GLIDES) methodology. ASCO adopted a five‐step approach to carry out quality appraisal, strength of evidence ratings and strength of recommendations ratings. The ASCO approach was primarily adapted from those developed by the AHRQ,, USPSTF, and GRADE, however with the validation of the GRADE methodology, the sole use of GRADE is being evaluated by the Clinical Practice Guidelines Committee.
Description of Evidence Grading
High: High confidence that the available evidence reflects the true magnitude and direction of the net effect (i.e., balance of benefits v harms) and that further research is very unlikely to change either the magnitude or direction of this net effect.
Intermediate: Moderate confidence that the available evidence reflects the true magnitude and direction of the net effect. Further research is unlikely to alter the direction of the net effect; however, it might alter the magnitude of the net effect.
Low: Low confidence that the available evidence reflects the true magnitude and direction of the net effect. Further research may change either the magnitude and/or direction this net effect.
Insufficient: Evidence is insufficient to discern the true magnitude and direction of the net effect. Further research may better inform the topic. The use of the consensus opinion of experts is reasonable to inform outcomes related to the topic.
Description of Recommendation Grading
ASCO uses a formal consensus methodology based on the modified Delphi technique in clinically important areas where there is limited evidence or a lack of high‐quality evidence to inform clinical guidance recommendations.
Evidence Based: There was sufficient evidence from published studies to inform a recommendation to guide clinical practice.
Formal Consensus: The available evidence was deemed insufficient to inform a recommendation to guide clinical practice. Therefore, the Expert Panel used a formal consensus process to reach this recommendation, which is considered the best current guidance for practice. The Panel may choose to provide a rating for the strength of the recommendation (i.e., "strong," "moderate," or "weak"). The results of the formal consensus process are summarized in the guideline and reported in the Data Supplement (see the Supporting Documents" field).
Informal Consensus: The available evidence was deemed insufficient to inform a recommendation to guide clinical practice. The recommendation is considered the best current guidance for practice, based on informal consensus of the Expert Panel. The Panel agreed that a formal consensus process was not necessary for reasons described in the literature review and discussion. The Panel may choose to provide a rating for the strength of the recommendation (i.e., "strong," "moderate," or "weak").
No recommendation: There is insufficient evidence, confidence, or agreement to provide a recommendation to guide clinical practice at this time. The Panel deemed the available evidence as insufficient and concluded it was unlikely that a formal consensus process would achieve the level of agreement needed for a recommendation.
Description of Funding Source
ASCO provides funding for Guideline Development.
Company/Author Disclosures
ASCO Conflict of Interest Policy complies with the CMSS Code for Interactions with Companies. ASCO requires disclosure by individuals involved in drafting, reviewing, and approving guideline recommendations.
Percentage of Authors Reporting COI
100