NCCN Guidelines Insights: Antiemesis, Version 2.2017

Pneumocystis jirovecii in a patient on dose‐dense chemotherapy for early breast cancer

“…The introduction of modern anti-emetic agents has transformed the landscape of CINV prevention, with many consensus guidelines (Table 1) now recommending a combination of a second-generation 5-HT 3 receptor antagonist, an NK 1 receptor antagonist, and dexamethasone on the day of chemotherapy administration. The recommendation for dexamethasone, however, is inconsistent across the various guidelines, with the American Society of Clinical Oncology (ASCO) [11] and the Multinational Association of Supportive Care in Cancer and European Society of Medical Oncology (MASCC-ESMO) [12] guidelines recommending limiting dexamethasone to the day of chemotherapy only, whilst the National Comprehensive Cancer Network (NCCN) [13] guideline recommends a 3-day course of dexamethasone. EviQ, the Australian point-of-care resource of evidence-based, consensus-driven cancer treatment protocols and information, recommends a 4-day course of dexamethasone in combination with Akynzeo ® on Day 1 for patients undergoing ddAC, although in June 2018, a footnote was added to allow the dosage and duration of dexamethasone from Days 2 to 4 to be reduced or omitted at physicians' discretion [14].…”

“…Of note, the Phase III study comparing Akynzeo ® with palonosetron in over 1400 women receiving AC utilized 12 mg of dexamethasone on ASCO [10] In patients receiving the combination of an anthracycline and cyclophosphamide, dexamethasone can be limited to the day of chemotherapy administration. A four-drug combination of an NK 1 receptor antagonist, a 5-HT 3 receptor antagonist, dexamethasone, and olanzapine should be used, with olanzapine continued on Days 2-4 MASCC-ESMO [11] In women with breast cancer, a three-drug regimen, including single doses of a 5-HT3 receptor antagonist, dexamethasone, and an NK 1 receptor antagonist (aprepitant, fosaprepitant, netupitant or rolapitant), given before chemotherapy is recommended If fosaprepitant, netupitant, or rolapitant has been used on Day 1, no additional dexamethasone is required on subsequent days NCCN [12] When used with netupitant/palonosetron, use 12 mg dexamethasone on Day 1 and 8 mg on Days 2 and 3, although "emerging data and clinical practice suggests dexamethasone dose may be individualized" EviQ [13] Recommended supportive medication for ddAC: Akynzeo and 12 mg dexamethasone on Day 1 8 mg dexamethasone on Days 2-4 (June 2018 update: may be reduced or omitted at physicians' discretion) Day 1 only [15]. Further lending support to a dexamethasone-sparing regimen was the randomized double-blinded, placebo-controlled, Phase III study by Ito et al [16], which demonstrated the non-inferiority of a dexamethasone-sparing regimen over a 3-day regimen in patients receiving highly emetogenic chemotherapy (HEC), when given with palonosetron and aprepitant.…”

Comparative efficacy and tolerability of antiemetic prophylaxis for adult highly emetogenic chemotherapy: A network meta‐analysis of 143 randomized controlled trials

“…Currently, 5CN still serves as the first-choice antiemetic for acute-phase CINV induced by highly emetogenic chemotherapy. [8][9][10] However, a large-scale randomized trial by Navari et al has discovered that the addition of olanzapine to 5CN could greatly enhance its prophylactic function against highly emetogenic chemotherapy, irrespective of acute emesis or nausea. 11 Consistently, our network calculation has confirmed the predominance of 5CNO inside both hierarchies of acute emesis and nausea, providing a more comprehensive and reliable evidence that 5CNO may probably supersede 5CN as the prior regimen.…”

“…1,6,7 Therefore, based on current knowledge of mechanisms, antagonists of serotonin, dopamine or neurokinin receptor are widely prescribed, either as monotherapy or combined regimens. 1 In terms of highly emetogenic chemotherapy, the combination of serotonin receptor antagonist plus corticosteroid plus neurokinin receptor antagonist is consistently recommended by the up-to-date NCCN, 8 ESMO 9 and ASCO 10 guidelines for acute phase prophylaxis, while dexamethasone plus aprepitant is preferred in situation of delayed onset. However, novel investigations have revealed that some non-traditional antiemetics display extra prevention when added to first-line treatments, such as olanzapine of classical antipsychotics.…”

What occurs in the other 20% of cancer patients with chemotherapy-induced nausea and vomiting (CINV)? A single-institution qualitative study

“…Moreover, national and international organizations have developed clinical guidelines for the prevention and treatment of CINV; some of these organizations, such as the Oncology Nursing Society, have also provided important patient and healthcare provider resources to target CINV. [2–5] These guidelines match the emetogenic potential of each chemotherapy regimen to the most appropriate antiemetic regimen, thus enabling patients to receive the most effective prophylactic palliation up front and thus eliminating what had previously been a trial and error approach. Today, an estimated 80% of cancer patients who receive moderately to severely emetogenic chemotherapy have no nausea and vomiting or, at most, experience markedly attenuated symptoms.…”