Updated Guideline on the Use of Antiemetics to Prevent Vomiting and Nausea after Chemotherapy and Radiation Issued
The American Society of Clinical Oncology has issued an update to its clinical practice guideline on the use of antiemetic medications to prevent vomiting and nausea resulting from treatment with chemotherapy or radiation. The new guideline includes comprehensive, stratified recommendations on the use of antiemetics during treatment with chemotherapy drugs that are classified as high, moderate, minimal, and low risk for causing vomiting and nausea.
The updated guideline, American Society of Clinical Oncology Clinical Practice Guideline Update on Antiemetics, was published in the Journal of Clinical Oncology. The new recommendations were developed by ASCO’s Antiemetics Guideline Panel and are based on a systematic review of new and existing medical literature.
More than half of all people with cancer experience nausea or vomiting during the course of their treatment. If nausea or vomiting becomes severe enough, dehydration and other health problems can occur. In some cases, these side effects can cause cancer treatments to be delayed, halted, or changed, which may have a detrimental effect on overall treatment outcomes. In the past two decades, newer approaches and better antiemetic medications have reduced the incidence of both nausea and vomiting in people undergoing cancer therapy.
More than half of all people with cancer experience nausea or vomiting during the course of their treatment.
“Antiemetics serve a vital role in reducing the risk of nausea and vomiting in cancer care, and when used appropriately, can vastly improve patients’ treatment experience and enable them to carry on with their lives,” says panel cochair and study author Ethan Basch, md, associate attending physician at Memorial Sloan-Kettering Cancer Center in New York, NY. “Over the past two decades, major strides have been made in recognizing the scope of this problem. There have been improvements in stratifying the risk of side effect risks according to the type of drug treatment used. This guideline update reflects further progress refining antiemetic approaches and minimizing these side effects.”
The guideline provides detailed information about the risk of vomiting and nausea associated with various anticancer agents and radiation therapy, as well as the specific recommended antiemetic regimens for each. Dr. Basch points out that a major goal in cancer care is to personalize therapy to each individual, and that this guideline helps physicians do so by stratifying each person’s antiemetics needs based on his or her particular treatments.
One key recommendation in this update is the reclassification of the risk for vomiting and nausea from the combination of an anthracycline and cyclophosphamide, a commonly used chemotherapy regimen. Each drug alone is classified as having a moderate risk, but based on continued scientific data, the combination now is considered highrisk. This chemotherapy combination is widely used in people with breast cancer and non-Hodgkin lymphoma. This change is significant because of the widespread use of this combination, and the potential to improve the individual’s experience during treatment and avoid treatment delays or dose reductions.
In addition, the guideline provides direction on the use of fosaprepitant, a relatively new intravenous formulation of aprepitant. Data suggest that fosaprepitant is equivalent to aprepitant in terms of control and prevention of nausea and vomiting. However, fosaprepitant is given for one day, while aprepitant is given for three days to people undergoing chemotherapy that present a high risk of vomiting and nausea. This may represent a more convenient or feasible option for some people. These drugs are part of the guideline-recommended three-drug combination (which includes a 5-HT3 receptor antagonist and the corticosteroid dexamethasone) for everyone who receives high-risk chemotherapy.
“In general, we have more effective and better tolerated antiemetic agents today, and we have also learned how to use the available agents in more effective ways,” says panel cochair Gary Lyman, md, mph, professor of medicine at Duke University and the Duke Cancer Institute in Durham, NC. “Overall, oncologists have a better understanding and an increasing number of tools to reduce the side effects of cancer treatment. In addition to better strategies for preventing vomiting, we’ve made tremendous progress in preventing infection and managing pain, as well as addressing the psychological and emotional challenges of cancer.”
Some of the guideline’s other recommendations include the following:
- For people who receive chemotherapy with a moderate risk of causing nausea and vomiting, the two-drug combination of palonosetron and dexamethasone is recommended. If palonosetron is unavailable, a first generation 5-HT3 serotonin antagonist may be substituted.
- For chemotherapy agents that carry a low risk of inducing vomiting or nausea, the panel recommends a single dose of dexamethasone prior to chemotherapy. It recommends that no antiemetic agent be routinely given before or after chemotherapy to prevent nausea or vomiting brought on by minimal-risk chemotherapy drugs.
- For people who receive high-risk radiation therapy, the panel recommends that they receive a 5-HT3 antagonist before each radiation fraction, and at least 24 hours after completing radiation therapy. They should also be given a five-day course of dexamethasone during fractions one to five.
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For the full ASCO guidelines, visit ASCO.org
This article was originally published in Coping® with Cancer magazine, November/December 2011.