Downloaded 19 times
Uploaded byVarshu Goel
Antiemetics 07122017
This document provides guidelines for preventing chemotherapy-induced nausea and vomiting (CINV) in adults. It summarizes the optimal antiemetic regimens for different levels of emetic risk from antineoplastic agents as well as for breakthrough nausea. It also discusses treatment for anticipatory nausea and provides recommendations for preventing radiation-induced nausea and vomiting. The current guidelines represent an update from 2011, with some treatments strengthened or expanded, such as the addition of olanzapine for high emetic risk agents.
More Related Content
Similar to Antiemetics 07122017
Antiemetics 07122017
- 1. Dr. Varshu Goel FirstYear Post-Graduate Resident Department of Radiotherapy Maulana Azad Medical College, Delhi
- 2.
- 3.
- 4.
- 5. Mechanism of Action •Serotonin : free radicals increase serotonin production by enterochromaffin cells in GIT(vagal sensory nerve input); also act directly on CTZ • Substance P/NK1 : central acting • Dexamethasone: central action, by decreasing production of prostaglandin and serotonin • Metoclopramide: antagonist activity at D2 receptors in the chemoreceptor trigger zone and increased gastric emptying (prokinetic); and at higher doses, 5-HT3 antagonist activity centrally • Olanzapine : atypical antipsychotic agent; has ability to block many different receptors; targets dopaminergic (D1, D2, D3, D4), serotonergic (5-HT2A, 5-HT2C, 5-HT3, 5-HT6) and others 5 NCCN, 2017
- 6. Classification of CINV 6 CINVtype Clinical features Anticipatory • Feeling of nausea or vomiting prior to next chemotherapy • Conditioned response • Occurs in 25–50% of patients Acute • Occurs and resolves within 24 hours of chemotherapy • Generally peaks within 5–6 hours Delayed • Occurs 1–6 days after chemotherapy • Common with administration of cisplatin, carboplatin, cyclophosphamide, and doxorubicin Breakthrough • Occurs despite prophylactic treatment • Requires rescue therapy • Can be acute or delayed Refractory • Occurs during chemotherapy cycle after prophylaxis and/or rescue therapy has failed in earlier cycles NCCN, 2017
- 7. Nausea Vomiting 1 Lossof appetite without alteration in eating habits 1 - 2 episodes (separated by 5 minutes) in 24 hours 2 Oral intake decreased without significant weight loss, dehydration or malnutrition 3 - 5 episodes (separated by 5 minutes) in 24 hours 3 Inadequate oral caloric or fluid intake; tube feeding, TPN, or hospitalization indicated 6 episodes (separated by 5 minutes) in 24 hours; tube feeding, TPN or hospitalization indicated 4 Life-threatening consequences; urgent intervention indicated 5 Death Grades 7 CTCAE, 4.03
- 8. Emetic Risk • Theemetic risk of antineoplastic mediations was classified by using four levels based on the likelihood of emesis in the absence of antiemetic prophylaxis: • high (>90%) • moderate (30% to 90%) • low (10% to 30%) • minimal (<10%) • Patient-related risk factors • Younger age • Female gender • Susceptibility to motion sickness • No history of alcohol • Poor control with prior chemotherapy • Anxiety • Medications such as digitalis derivatives, opioids, NSAIDs, and antibiotics • Uremia • Increased intracranial pressure • Gastrointestinal abnormalities: obstruction, ascites, gastroparesis. 8 NCCN, 2017
- 9. • Emetic Riskof Single Intravenous Antineoplastic Agents in Adults 9 • High (>90%) • Moderate (30%- 90%) • Low (10%-30%) • Minimal (<10%) • Anthracycline/ cyclophosphami de combination • Carmustine • Cisplatin • Cyclophosphami de 1,500 mg/m2 • Dacarbazine • Mechlorethamin e • Streptozocin • Alemtuzumab • Bendamustine • Carboplatin • Clofarabine • Cyclophosphami de < 1,500 mg/m2 • Cytarabine > 1,000 mg/m2 • Daunorubicin • Doxorubicin • Epirubicin • Idarubicin • Ifosfamide • Irinotecan • Oxaliplatin • Romidepsin • Temozolomide • Thiotepa • Aflibercept • Belinostat • Bortezomib • Brentuximab • Cetuximab • Cytarabine 1,000 mg/m2 • Docetaxel • Etoposide • Fluorouracil • Gemcitabine • Methotrexate • Mitomycin • Nab-paclitaxel • Paclitaxel • Pemetrexed • Pegylated liposomal doxorubicin • Pertuzumab • Topotecan • Trastuzumab-emtansine • Bevacizumab • Bleomycin • Busulfan • Fludarabine • Nivolumab • Pembrolizumab • Pralatrexate • Ramucirumab • Rituximab • Trastuzumab • Vinblastine • Vincristine • Vinorelbine
- 10. • Emetic Riskof Oral Antineoplastic Agents in Adults 10 • High (>90%) • Moderate (30%- 90%) • Low (10%-30%) • Minimal (<10%) • Hexa- methylmelam ine • Procarbazine • Bosutinib • Cabozantinib • Ceritinib • Crizotinib • Cyclophosphamide • Imatinib • Lenvatinib • TAS-102 (trifluridine-tipiracil) • Temozolomide • Vinorelbine • Afatinib • Alectinib • Axatinib • Capecitabine • Etoposide • Lapatinib • Lenalidomide • Olaparib • Nilotinib • Palbociclib • Pazopanib • Ponatinib • Panobinostat • Regorafenib • Sonidegib • Sunitinib • Tegafur-uracil • Thalidomide • Vorinostat • Chlorambucil • Erlotinib • Gefitinib • Hydroxyurea • Melphalan • Methotrexate • Pomalidomide • Ruxolitinib • Sorafenib • 6-Thioguanine • Vemurafenib • Vismodegib
- 12. • Antineoplastic agent-inducednausea and vomiting in adults 12 Previous 2011 Current 2017 Optimal treatment to prevent nausea and vomiting from high emetic risk antineoplastic agents in adults who receive single-day antineoplastic agent therapy three-drug combination of a NK 1 receptor antagonist, a 5-HT3 receptor antagonist, and dexamethasone. The oral combination of netupitant and palonosetron (NEPA) plus dexamethasone is an additional treatment option in this setting. Adult patients treated with cisplatin and other high-emetic- risk single agents who receive single-day antineoplastic agent therapy should be offered a four- drug combination of : • NK1 receptor antagonist • 5-HT3 receptor antagonist • dexamethasone, and • olanzapine Dexamethasone and olanzapine should be continued on days 2 to 4 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 antagonist, and dexamethasone
- 13. • Antineoplastic agent-inducednausea and vomiting in adults 13 Previous 2011 Current 2017 High emetic risk three-drug combination of a NK 1 receptor antagonist, a 5-HT3 receptor antagonist, and dexamethasone. The oral combination of netupitant and palonosetron (NEPA) plus dexamethasone is an additional treatment option in this setting. Adult patients treated with an anthracycline combined with cyclophosphamide (AC) should be offered a four-drug combination of : • NK1 receptor antagonist • 5-HT3 receptor antagonist • dexamethasone, and • olanzapine. Olanzapine should be continued on days 2 to 4
- 14. 14 Previous Current Optimal treatment toprevent nausea and vomiting from moderate emetic risk antineoplastic agents in adults who receive single-day antineoplastic agent therapy two-drug combination of palonosetron (day 1 only) and dexamethasone (days 1-3) is recommended for patients receiving moderately emetogenic chemotherapy. If palonosetron is not available, clinicians may substitute a first generation 5-HT3 receptor antagonist, preferably granisetron or ondansetron. Limited evidence also supports adding aprepitant to the combination. Should clinicians opt to add aprepitant in patients receiving moderate risk chemotherapy, any one of the 5-HT3 receptor antagonists is appropriate. Adult patients treated with carboplatin AUC ≥ 4 mg/mL/min should be offered a three-drug combination of NK1 receptor antagonist, 5-HT3 receptor antagonist, and dexamethasone Adult patients treated with moderate emetic risk antineoplastic agents (excluding carboplatin AUC ≥ 4 mg/mL/min) should be offered a two-drug combination of a 5-HT3 receptor antagonist (day 1) and dexamethasone (day 1) 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 to 3
- 15. 15 Previous Current optimal treatment toprevent nausea and vomiting from low emetic-risk antineoplastic agents in adults who receive single-day antineoplastic agent therapy A single 8 mg dose of dexamethasone before chemotherapy is suggested. 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 Minimal emetic risk No antiemetic should be administered routinely before or after chemotherapy. Adult patients treated with minimal emetic risk antineoplastic agents should not be offered routine antiemetic prophylaxis Antineoplastic combinations Patients should be administered antiemetics appropriate for the component chemotherapeutic (antineoplastic) agent of greatest emetic risk. Adults patients treated with antineoplastic combinations should be offered antiemetics appropriate for the component antineoplastic agent of greatest emetic risk.
- 16. 16 Previous Current Adjunctive drugsLorazepam or diphenhydramine are useful adjuncts to antiemetic drugs, but are not recommended as single agent anti-emetics. Lorazepam is a useful adjunct to antiemetic drugs, but is not recommended as a single agent antiemetic. Cannabinoids Not addressed 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
- 17. 17 Previous Current Complementary therapy No publisheddata 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 transplant A 5-HT3 receptor antagonist combined with dexamethasone is suggested. Aprepitant should be considered, although evidence to support its use is limited. 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, 5-HT3 receptor antagonist, and dexamethasone
- 18. 18 Previous Current Multi-day antineoplastic therapy antiemetics appropriatefor the emetogenic risk class of the chemotherapy be administered for each day of the chemotherapy and for two days after, if appropriate. Adult patients treated with multi-day antineoplastic agents should be offered anti-emetics 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 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 antagonist, and dexamethasone
- 19. 19 Previous Current For adultswho experience nausea and vomiting secondary to antineoplastic agent therapy despite optimal prophylaxis (breakthrough) Re-evaluate emetic risk, disease status, concurrent illnesses, and medications Ascertain that the best regimen is being administered for the emetic risk Consider adding lorazepam or alprazolam to the regimen Consider adding olanzapine to the regimen or substituting high-dose intravenous metoclopramide for the 5-HT3 receptor antagonist or adding a dopamine antagonist to the regimen. Re-evaluate emetic risk, disease status, concurrent illnesses, and medications and ascertain that the best regimen is being administered for the emetic risk 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 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 (e.g., an NK1 receptor antagonist, lorazepam or alprazolam, a dopamine receptor antagonist, dronabinol, or nabilone) in addition to continuing the standard antiemetic regimen
- 20. 20 Previous Current Anticipatory nausea and vomiting Useof the most active antiemetic regimens appropriate for the chemotherapy being administered to prevent acute or delayed emesis is suggested. Such regimens should be used with initial chemotherapy, rather than assessing the patient’s emetic response with less effective treatment. If anticipatory emesis occurs, behavioral therapy with systematic desensitization is effective and suggested. 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
- 21.
- 22. 22 Previous Current High emeticrisk radiation therapy all patients should receive a 5- HT3 receptor antagonist before each fraction and for at least 24 hours after completion of radiotherapy. Patients should also receive a five day course of dexamethasone before fractions 1-5 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 Moderate emetic risk radiation therapy a 5-HT3 receptor antagonist before each fraction for the entire course of radiotherapy. Patients may be offered a short course (fractions 1-5) of dexamethasone before treatment 5-HT3 receptor antagonist before each fraction, with or without dexamethasone before the first five fractions
- 23. 23 Previous Current Low emeticrisk radiation therapy 5-HT3 receptor antagonist alone as either prophylaxis or rescue. For patients who experience RINV while receiving rescue therapy only, prophylactic treatment should continue until radiotherapy is complete Adult patients treated with radiation therapy to brain should be offered rescue dexamethasone therapy. Adult 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 minimal-emetic-risk radiation therapy rescue therapy with either a dopamine receptor antagonist or a 5-HT3 receptor antagonist. Prophylactic antiemetics should continue throughout radiation treatment if a patient experiences RINV while receiving rescue therapy. Rescue therapy with a 5-HT3 receptor antagonist, dexamethasone, or a dopamine receptor antagonist
- 24. 24 Previous Current Concurrent radiation and antineoplastic agenttherapy Patients should receive antiemetic prophylaxis according to the emetogenicity of chemotherapy, unless the emetic risk with the planned radiotherapy is higher. 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
- 25. 25 Pediatric Patients PreviousCurrent Optimal treatment to prevent nausea and vomiting from high emetic risk antineoplastic agents in pediatric patients combination of a 5-HT3 antagonist plus a corticosteroid is suggested before chemotherapy in children receiving chemotherapy of high or moderate emetic risk. Because of variation of pharmacokinetic parameters in children, higher weight- based doses of 5-HT3 antagonists than those used in adults may be required for antiemetic protection. 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 Pediatric patients treated with high emetic-risk antineoplastic agents who are unable to receive aprepitant should be offered a two-drug combination of a 5-HT3 receptor antagonist and dexamethasone 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
- 26. 26 Pediatric Patients PreviousCurrent Optimal treatment to prevent nausea and vomiting from moderate emetic risk antineoplastic agents in pediatric patients combination of a 5-HT3 antagonist plus a corticosteroid is suggested before chemotherapy in children receiving chemotherapy of high or moderate emetic risk. Because of variation of pharmacokinetic parameters in children, higher weight-based doses of 5-HT3 antagonists than those used in adults may be required for antiemetic protection. Pediatric patients treated with moderate-emetic-risk antineoplastic agents should be offered a two-drug combination of a 5-HT3 receptor antagonist and dexamethasone 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 Low emetic risk Not addressed Pediatric patients treated with low- emetic-risk antineoplastic agents should be offered ondansetron or granisetron
- 27. 27 Previous Current Minimal emeticrisk Not addressed Pediatric patients treated with minimal emetic risk antineoplastic agents should not be offered routine antiemetic prophylaxis
- 28. • Antiemetic Dosingfor Adults by Chemotherapy Risk Category 28 Emetic Risk Category Dose on Day of Chemotherapy Dose on Subsequent Days High: Cisplatin and other agents NK1 receptor antagonist (plasma half life) Aprepitant (9 - 14 hr) Fosaprepitant (9 - 14 hr) Netupitant (96 hr) - palonosetron Rolapitant (180 hr) 125 mg oral 150 mg IV 300mg netupitant/ 0.5mg palonosetron oral in single capsule (NEPA) If netupitant-palonosetron is used, no additional 5-HT3 receptor antagonist is needed 180 mg oral 80 mg oral on days 2 and 3
- 29. • Antiemetic Dosingfor Adults by Chemotherapy Risk Category 29 Emetic Risk Category Dose on Day of Chemotherapy High: Cisplatin and other agents 5-HT3 receptor antagonist Granisetron (9 hr) Ondansetron (4 hr) Palonosetron (40 hr) Dolasetron (7 hr) Tropisetron (6 hr) Ramosetron (6 hr) 2 mg oral or 1 mg or 0.01 mg/kg IV or 1 transdermal patch or 10 mg subcutaneous 8 mg oral twice daily or 8 mg oral dissolving tablet twice daily or three 8 mg oral soluble films or 8 mg or 0.15 mg/kg IV 0.50 mg oral or 0.25 mg IV 100 mg oral only 5 mg oral or 5 mg IV 0.3 mg IV
- 30. 30 Emetic Risk CategoryDose on Day of Chemotherapy Dose on Subsequent Days High: Cisplatin and other agents Dexamethasone • If aprepitant is used • If fosaprepitant is used • If netupitant- palonosetron is used • If rolapitant is used • If no NK1 receptor antagonist used Olanzapine 12 mg oral or IV 12 mg oral or IV 12 mg oral or IV 20 mg oral or IV 20 mg oral or IV 10 mg oral 8 mg oral or IV once daily on days 2-4 8 mg oral or IV on day 2; 8 mg oral or IV twice daily on days 3 and 4 8 mg oral or IV once daily on days 2-4 8 mg oral or IV twice daily on days 2-4 8 mg oral or IV twice daily on days 2-4 10 mg oral on days 2-4
- 31. • Antiemetic Dosingfor Adults by Chemotherapy Risk Category 31 Emetic Risk Category Dose on Day of Chemotherapy Dose on Subsequent Days High: Anthracycline combined with cyclophosphamide NK1 receptor antagonist 5-HT3 receptor antagonist Dexamethasone • If aprepitant is used • If fosaprepitant is used • If netupitant- palonosetron is used • If rolapitant is used Olanzapine Same as before Same as before 12 mg oral or IV 12 mg oral or IV 12 mg oral or IV 20 mg oral or IV Same as before Same as before Same as before Same as before
- 32. • Antiemetic Dosingfor Adults by Chemotherapy Risk Category 32 Emetic Risk Category Dose on Day of Chemotherapy Moderate or low risk 5-HT3 receptor antagonist Granisetron Ondansetron Palonosetron Dolasetron Tropisetron Ramosetron 2 mg oral or 1 mg or 0.01 mg/kg IV or 1 transdermal patch or 10 mg subcutaneous 8 mg oral twice daily or 8 mg oral dissolving tablet twice daily or 8 mg oral soluble film twice daily or 8mg or 0.15 mg/kg IV 0.50 mg oral or 0.25 mg IV 100 mg oral only 5 mg oral or 5 mg IV 0.3 mg IV
- 33. 33 Emetic Risk CategoryDose on Day of Chemotherapy Dose on Subsequent Days Moderate (If carboplatin area under the curve is ≥ 4 mg/mL per minute, add an NK1 receptor antagonist to the 5-HT3 receptor antagonist and dexamethasone) Dexamethasone 8 mg oral or IV (Dexamethasone dosing is day 1 only: 20 mg with rolapitant, and 12 mg with aprepitant, fosaprepitant, or netupitant- palonosetron) 8 mg oral or IV on days 2 and 3 (for moderate-emetic-risk agents with a known risk for delayed nausea and vomiting) Low Risk Dexamethasone 8 mg oral or IV
- 34. Potential Side effects •5-HT3 antagonists: QTc prolongation (not palonosetron), increased liver function tests, generally mild symptoms (headache, constipation, diarrhea) • NK-1 antagonists: weakness, dizziness, diarrhea, constipation, flatus, abdominal discomfort, reflux symptoms, hiccups, headache • Cannabinoids: mood changes; disorientation; dizziness; brief impairment of perception, coordination, and sensory functions; tachycardia; hypotension 34
- 35. Guidelines for HEC 35 AcuteCINV Delayed CINV (Day 2-4) NCCN 5-HT3 RA + Dex + NK-1 RA Or NEPA + Dex Or Olanzapine + Palonosetron + Dex Or 5-HT3 RA + Dex + Aprepitant + Olanzapine Dex Aprepitant Or Dex Or Olanzapine Or Olanzapine + Dex Aprepitant ASCO 5-HT3 RA + Dex + NK-1 RA + Olanzapine Olanzapine + Dex Aprepitant MASCC 5-HT3 RA + Dex + NK-1 RA + Olanzapine Olanzapine + Dex Aprepitant
- 36. Guidelines for MEC 36 AcuteCINV Delayed CINV (Day 2-3) NCCN 5-HT3 RA (Palonosetron or granisetron s.c. preferred) + Dex NK-1 RA Or NEPA + Dex Or Olanzapine + Palonosetron + Dex 5-HT3 RA ( if palonosetron or granisetron preferred s.c.) OR Dex Aprepitant Or Dex Or Olanzapine ASCO 5-HT3 RA (palonosetron preferred) + Dex Dex MASCC Palonosetron + Dex Dex
- 37. Guidelines for Low& Minimal Emetic Risk 37 Low risk Minimal Risk NCCN 5-HT3 RA Or Dex Or Metoclopramide Or Prochlorperazine No routine prophylaxis ASCO Dex No routine prophylaxis MASCC 5-HT3 RA Or Dex Or Doapmine RA No routine prophylaxis
- 38. 38 Minimal Low ModerateHigh Rescue Therapy Rescue Therapy 5-HT3 receptor antagonist with or without dexamethasone 5-HT3 receptor antagonist and dexamethasone Summary
- 39.
Editor's Notes
- #6 5-HT3 is ligand gated ion channel Glucocorticoids may act via the following mechanisms: (1) anti-inflammatory effect; (2) direct central action at the solitary tract nucleus, (3) interaction with the neurotransmitter serotonin, and receptor proteins tachykinin NK1 and NK2, alpha-adrenaline, etc.; (4) maintaining the normal physiological functions of organs and systems; (5) regulation of the hypothalamic-pituitary-adrenal axis; and (6) reducing pain and the concomitant use of opioids, which in turn reduces opioid-related nausea and vomiting
- #8 Common Terminology Criteria for Adverse Events
- #10 *No direct evidence found for intravenous temozolomide; as all sources indicate a similar safety profile to the oral formulation; the classification was based on oral temozolomide. †Classification refers to individual evidence from pediatric trials.
- #11 Classified emetic potential of oral agents based on a full course of therapy and not a single dose.
- #26 neurokinin 1 serotonin
- #27 neurokinin 1 serotonin
- #28 neurokinin 1 serotonin
- #29 For patients who receive multiday chemotherapy, clinicians must first determine the emetic risk of the agent(s) included in the regimen. Patients should receive the agent of the highest therapeutic index daily during chemotherapy and for 2 days thereafter. Patients can also be offered the granisetron transdermal patch or granisetron extended-release injection that deliver therapy over multiple days rather than taking a 5-HT3 receptor antagonist daily
- #30 For patients who receive multiday chemotherapy, clinicians must first determine the emetic risk of the agent(s) included in the regimen. Patients should receive the agent of the highest therapeutic index daily during chemotherapy and for 2 days thereafter. Patients can also be offered the granisetron transdermal patch or granisetron extended-release injection that deliver therapy over multiple days rather than taking a 5-HT3 receptor antagonist daily
- #31 The dexamethasone dose is for patients who are receiving the recommended four-drug regimen for highly emetic chemotherapy. If patients do not receive an NK1 receptor antagonist, the dexamethasone dose should be adjusted to 20 mg on day 1 and to 16 mg on days 2-4.
- #32 ‡In non–breast cancer populations—for example, non-Hodgkin lymphoma—receiving a combination of an anthracycline and cyclophosphamide with treatment regimens incorporating corticosteroids, the addition of palonosetron without the use of an NK1 receptor antagonist, and olanzapine is an option.
- #34 The dexamethasone dose is for patients who are receiving the recommended four-drug regimen for highly emetic chemotherapy. If patients do not receive an NK1 receptor antagonist, the dexamethasone dose should be adjusted to 20 mg on day 1 and to 16 mg on days 2-4.
- #36 European Society of Medical Oncology (ESMO) and the Multinational Association of Supportive Care in Cancer (MASCC)
- #37 European Society of Medical Oncology (ESMO) and the Multinational Association of Supportive Care in Cancer (MASCC)
- #38 European Society of Medical Oncology (ESMO) and the Multinational Association of Supportive Care in Cancer (MASCC)