Paul J. Hesketh, MD

Mark G. Kris, MD

AS REPORTED BY Paul J. Hesketh, MD, of Lahey Hospital and Medical Center, Burlington, Massachusetts, and colleagues in the Journal of Clinical Oncology, ASCO has updated its clinical practice guideline on the use of antiemetics in patients with cancer.¹ The update was based on an expert panel review of medical literature from November 2009 to June 2016. The panel was co-chaired by Dr. Hesketh and Mark G. Kris, MD, of Memorial Sloan Kettering Cancer Center, New York. 

Key updates cover the following topics: addition of olanzapine to antiemetic regimens in adults receiving high–emetic-risk antineoplastic agents or who experience breakthrough nausea and vomiting; administration of dexamethasone on day 1 only for adults receiving an anthracycline and cyclophosphamide; and addition of a neurokinin 1 (NK1) receptor antagonist for adults receiving carboplatin at area under the curve (AUC) ≥ 4 mg/mL/min or high-dose chemotherapy as well as for pediatric patients receiving high–emetic-risk antineoplastic agents. The panel emphasizes the importance of using the most effective antiemetic regimens appropriate for the antineoplastic agents or radiotherapy being administered and that such regimens should be used with initial treatment rather than after assessing emetic response with less-effective treatment. 

Key new or updated guidelines are summarized or reproduced below. Recommendations that were unchanged, reworded for clarity, or strengthened have been omitted. The strength of individual recommendations is shown in brackets. 

Adult Patients 

KEY NEW or updated recommendations in adult patients include the following guidelines: 

High–Emetic-Risk Antineoplastic Agents 

• (Updated) Adult patients treated with cisplatin and other high– emetic-risk single agents should be offered a four-drug combination that includes an NK1 receptor antagonist, a serotonin (5-HT3) receptor antagonist, dexamethasone, and olanzapine. Dexamethasone and olanzapine should be continued on days 2 to 4. [Strong] 
• (Updated) Adult patients treated with an anthracycline combined with cyclophosphamide should be offered a four-drug combination that includes an NK1 receptor antagonist, a 5-HT3 receptor antagonist, dexamethasone, and olanzapine. Olanzapine should be continued on days 2 to 4. [Strong] 

Moderate–Emetic-Risk Antineoplastic Agents 

• (Updated) Adult patients treated with carboplatin at AUC ≥ 4 mg/mL/min should be offered a three-drug combination of an NK1 receptor antagonist, a 5-HT3 receptor antagonist, and dexamethasone. [Strong] 
• (Updated) Adult patients treated with moderate–emetic-risk antineoplastic agents, excluding carboplatin at AUC ≥ 4 mg/ mL/min, should be offered a two-drug combination of a 5-HT3 receptor antagonist (day 1) and dexamethasone (day 1). [Strong] 
• (Updated) 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. [Moderate] 

Low–Emetic-Risk Antineoplastic Agents 

• (Updated) Adult patients should be offered a single dose of a 5-HT3 receptor antagonist or a single 8-mg dose of dexamethasone before antineoplastic treatment. [Moderate] 

Adjunctive Drugs 

• (Updated) Lorazepam is a useful adjunct to antiemetic drugs but is not recommended as a single-agent antiemetic. [Moderate] 

Cannabinoids 

• (New) Evidence remains insufficient for a recommendation regarding treatment with medical marijuana for the prevention of nausea and vomiting in patients with cancer who receive chemotherapy or radiation therapy. Evidence is also insufficient for a recommendation regarding the use of medical marijuana in place of the tested and U.S. Food and Drug Administration–approved cannabinoids dronabinol and nabilone (Cesamet) for the management of treatment-related nausea and vomiting. 

High-Dose Chemotherapy With Stem Cell or Bone Marrow Transplantation 

• (Updated) 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. [Strong] 

Breakthrough Nausea and Vomiting 

• (Updated) 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. [Moderate] 
• (Updated) 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, a benzodiazepine (lorazepam or alprazolam), a dopamine receptor antagonist, a cannabinoid (dronabinol or nabilone)—in addition to continuing the standard antiemetic regimen. [Moderate] 

High–Emetic-Risk Radiation Therapy 

• (Updated) Adult patients should be offered a two-drug combination of a 5-HT3 receptor antagonist and dexamethasone before each radiotherapy fraction and on the day after each fraction if radiation therapy is not planned for that day. [Strong] 

Low–Emetic-Risk Radiation Therapy 

• (Updated) 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. [Weak] 

Minimal–Emetic-Risk Radiation Therapy 

• (Updated) Adult patients should be offered rescue therapy with a 5-HT3 receptor antagonist, dexamethasone, or a dopamine receptor antagonist. [Weak] 

Concurrent Radiation and Antineoplastic Agent Therapy 

• (Updated) Adult patients 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. During periods when prophylactic antiemetic therapy for antineoplastic agents has ended and ongoing radiation therapy would normally be managed with its own prophylactic therapy, patients should receive prophylactic therapy that is appropriate for the emetic risk of the radiation therapy until the next period of antineoplastic therapy, rather than receiving rescue therapy for antineoplastic agents as needed. [Moderate] 

Pediatric Patients 

FOR PEDIATRIC patients, key updates include the following recommendations: 

High–Emetic-Risk Antineoplastic Agents 

• (Updated) Pediatric patients who are treated with high–emetic-risk antineoplastic agents should be offered a three-drug combination of a 5-HT3 receptor antagonist, dexamethasone, and aprepitant. [Strong] 
• (New) Pediatric patients who are unable to receive aprepitant should be offered a two-drug combination of a 5-HT3 receptor antagonist and dexamethasone. [Strong] 
• (New) Pediatric patients who are unable to receive dexamethasone should be offered a two-drug combination of palonosetron and aprepitant. [Strong] 

Moderate–Emetic-Risk Antineoplastic Agents 

• (New) Pediatric patients who are 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. [Weak] 

Low–Emetic-Risk Antineoplastic Agents 

• (New) Pediatric patients who are treated with low–emetic-risk antineoplastic agents should be offered ondansetron or granisetron. [Strong] 

Minimal–Emetic-Risk Antineoplastic Agents 

• (New) Pediatric patients who are treated with minimal–emetic-risk antineoplastic agents should not be offered routine antiemetic prophylaxis. [Strong] 

Additional information is available at www.asco.org/supportive-careguidelines and www.asco.org/guidelineswiki. ■ 

DISCLOSURE: For full disclosures of the guidelines panel, visit jco.ascopubs.org. 

REFERENCE 

1. Hesketh PJ, Kris MG, Basch E, et al: Antiemetics: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol 35:3240- 3261, 2017.