Chemotherapy Induced Nausea and Vomiting

By

Osama ElzaafaranyAssistant Lecturer of Clinical Oncology

Medical Research Institute – Alexandria University

Guidelines to manage :

Aim: Updated International Guidelines

CIN

CIV

Highly emetogeni

c

Moderately emetogenic

Chemotherapy-induced Nausea

Chemotherapy-induced vomiting

I.V Chemotherapy regimens & drugs

ESMO

ASCO

NCCN

CIV Management

I.V Chemo.Oral Chemo.

Breakthrough emesis

Anticipatory emesis

Emesis prevention

TimingRisk

High VS Moderate VS Low Acute VS Delayed

NCCN Guidelines2015

Emesis prevention• I.V chemo.• High risk for emesis

I.V chemo + High risk for emesis

Options

NK 1 antagonist+

5-HT3 antagonist+

Dexamethasone

D1

Day2,3,4

NK 1 antagonist+

Dexamethasone

Netupitant/Palonosetron+

Dexamethasone

Dexamethasone

Olanzapine+

Palonosetron+

Dexamethasone

Olanzapine

Emesis prevention• I.V chemo.• Moderate risk for emesis

I.V chemo + Moderate risk for emesis

Options

5-HT3 antagonist+

Dexamethasone+/-

NK 1 antagonist

D1

Day2,3

5-HT3 antagonistOR

DexamethasoneOR

NK 1 antagonist

Netupitant/Palonosetron+

Dexamethasone

-/+Dexamethasone

Olanzapine+

Palonosetron+

Dexamethasone

Olanzapine

European Society of Medical Oncology (ESMO) and the Multinational Association of Supportive

Care in Cancer (MASCC)2010

American Society of Clinical Oncology (ASCO)

2011

Summary:Combined anthracycline and cyclophosphamide (AC) regimens

were reclassified as highly emetic. AC is considered to be moderately emetic regimen in ESMO guidelines.

Patients who receive highly emetic agents should receive the three-drug combination of:

( 5-HT3 antagonist + dexamethasone + NK1 antagonist )NK1 receptor antagonist (days 1-3 for aprepitant - day 1 only for

fosaprepitant).

5- HT3 receptor antagonist (day 1 only).

Dexamethasone (days 1-3 or 1-4).

Same as

ESMO

&

NCCN

Moderately emetic regimens:Preferential use of palonosetron is recommended for

moderate emetic risk regimens, combined with dexamethasone.

The same as the ESMO guidelines for the Moderately emetic regimens

If palonosetron is not available, clinicians may substitute a first-generation 5-HT3 serotonin receptor antagonist, preferably granisetron or ondansetron.

Limited evidence also supports adding aprepitant to the combination.

For all other chemotherapies of moderate emetic risk, single agent dexamethasone or a 5-HT3 receptor antagonist is suggested for the prevention of emesis on days 2 and 3.