Key Points
Choose antiemetics for CINV prevention based on emetic risk of chemotherapy agent; for multidrug regimens, select antiemetic tx based on drug w/ highest emetic risk (per NCCN, ASCO recs). View reference table here.
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Candidate for CINV prophylaxis
High-emetic risk chemotherapy Start before chemotherapy on day 1 Options include: - 5-HT3 RA + NK1 RA + dexamethasone1-3
- 5-HT3 RA + NK1 RA + dexamethasone + oilanzapine1,2
- Palonosetron + dexamethasone + olanzapine1-3
5-HT3-RA (INSERT TABLE 1) View epocrates 5-HT3 RA drug info: View epocrates NK1-RA drug info: Corticosteroids (INSERT TABLE 3) View epocrates corticosteroid drug info: Atypical antipsychotics (INSERT TABLE 4) View epocrates atypical antipsychotic drug info: Combination NK1 RA/5-HT3 RA (INSERT TABLE 5) View epocrates combination NK1 RA/5-HT3 RA drug info
Start before chemotherapy and continue daily 5-HT3-RA (INSERT TABLE 6) View epocrates 5-HT3 RA drug info:
Moderate-emetic risk chemotherapy Start before chemotherapy on day 1 Options include: - 5-HT3 RA (granisetron SC or palonosetron preferred) + dexamethasone1-3
- 5-HT3 RA + NK1 RA + dexamethasone1-3
- Palonosetron + dexamethasone + olanzapine1
5-HT3 RA (INSERT TABLE 7) View epocrates 5-HT3 RA drug info: View epocrates NK1 RA drug info: Corticosteroids (INSERT TABLE 9) View epocrates corticosteroid drug info: Atypical antipsychotics (INSERT TABLE 10) View epocrates atypical antipsychotic drug info: Combination NK1 RA/5-HT3 RA (INSERT TABLE 11) View epocrates combination NK1 RA/5-HT3 RA info:
Start before chemotherapy and continue daily 5-HT3 RA (INSERT TABLE 12) View epocrates 5-HT3 RA drug info:
Low-emetic risk chemotherapy Start before chemotherapy on day 1 and repeat daily for multi-day chemotherapy Options include: - 5-HT3 RA1-3
- dexamethasone1-3
- prochlorperazine1
- metoclopramide1,3
5-HT3 RA/Corticosteroids/Phenothiazines/Prokinetics (INSERT TABLE 13) View epocrates 5-HT3 RA/corticosteroids/phenothiazines/prokinetics drug info:
Prescribe PRN antiemetic1
Minimal-emetic risk chemotherapy Prescribe PRN antiemetics1
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Experiencing breakthrough CINV despite appropriate prophylaxis
General principle: Add 1 agent from a different drug class to the current regimen - When N/V is controlled →continue breakthrough medications on a schedule, not PRN
- When N/V is uncontrolled →re-evaluate and consider dose adjustments and/or sequentially add 1 agent from a different drug class
Options include: - 5-HT3 RA1
- scopolamine transdermal patch1
- olanzapine1,2
- haloperidol1
- corticosteroid1
- lorazepam1,2
- dronabinol1,2
- nabilone1
- phenothiazines1
- metoclopramide1-3
CINV tx options when appropriate prophylaxis doesn't work (INSERT TABLE 14) View epocrates CINV tx drug info:
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Epocrates researched Rx drug content. Peer-reviewed.
Epocrates Guideline Synopsis Last Update:
Jun 9, 2020