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The Antiemetics Update Committee reported ASCO's 2006 practice guideline update for the use of antiemetics in oncology (J Clin Oncol 24:2932-2947, 2006). The Committee conducted a literature review and analyzed data from 1998 through February 2006.
The 2006 update revised the original emetic risk categories for antineoplastic agents and radiation therapy to specify four rather than three categories (available online only). Also added is information on the NK1 receptor antagonist, aprepitant, and a new 5-HT3 serotonin receptor antagonist, palonosetron. See Table 1 for a summary of the updated 2006 recommendations; Table 2 groups the antineoplastic agents by specific emetic risk category.
Antiemetic agents of the highest therapeutic index (3 classes). 5-HT3 serotonin receptor antagonists (dolasetron, granisetron, ondansetron, palonosetron, and tropisetron); corticosteroids (dexamethosone and methylprednisolone); and the neurokinin 1 (NK1) receptor antagonist aprepitant. These classes are highly effective, have few significant side effects when used appropriately, and can be given safely in combination. Dexamethasone is the recommended corticosteroid because of the extensive published experience with this agent.
Antiemetic agents of a lower therapeutic index. These agents include metoclopramide, butyrophenones, phenothiazines, and cannabinoids.
Adjunctive drugs for use with antiemetic agents. Benzodiazepines (lorazepam and alprazolam) and antihistamines (diphenhydramine) are considered adjunctive drugs for antiemetic agents.
The risk of emesis varies with the treatment administered. Using available data and clinical experience, the committee reached consensus on definitions of four radiotherapy-induced emetic risk groups (see Table 3). This represents a modification from the 1999 guideline, which defined three radiotherapy-induced emesis risk groups.
Because published data on drugs that cause emesis are insufficient, the committee considered carefully the guidelines and consensus statements that emerged from the 2004 International Antiemetic Consensus Conference hosted by the Multinational Association of Supportive Care (MASCC). This meeting established a guideline process conducted by representatives from nine international oncology organizations, including ASCO. The MASCC consensus conference classifications were adopted for the 2006 update.
The 2006 Update literature review focused on published randomized controlled trials, and systematic reviews and meta-analyses of published phase II and phase III randomized controlled trials. Prepublication copies of two systematic reviews were made available to the committee by the Cancer Care Ontario Program in Evidence-based Care and the Oregon Evidence-based Practice Center.
The 2006 Update is available in the June 20, 2006, print edition of JCO and also at www.jco.org (J Clin Oncol 24:2932-2947, 2006). In addition to the full text of the guideline recommendations, available online at http://www.asco.org/guidelines/ antiemetics, further resources from ASCO include a patient guide, a PowerPoint slide set, and an antiemetics dose and schedule table.
It is important to realize that many management questions have not been comprehensively addressed in randomized trials and guidelines cannot always account for individual variation among patients. A guideline is not intended to supplant physician judgment with respect to particular patients or special clinical situations and cannot be considered inclusive of all proper methods of care or exclusive of other treatments reasonably directed at obtaining the same results.
Accordingly, ASCO considers adherence to this guideline to be voluntary, with the ultimate determination regarding its application to be made by the physician in light of each patient's individual circumstances. In addition, the guideline describes administration of therapies in clinical practice; it cannot be assumed to apply to interventions performed in the context of clinical trials, given that clinical studies are designed to test innovative and novel therapies in a disease and setting for which better therapy is needed. Because guideline development involves a review and synthesis of the latest literature, a practice guideline also serves to identify important questions for further research and those settings in which investigational therapy should be considered.
The Antiemetics in Oncology Practice Guideline was developed and written by Mark G. Kris, Paul J. Hesketh, Mark R. Somerfield, Petra Feyer, Rebecca Clark-Snow, James M. Koeller, Gary R. Morrow, Lawrence W. Chinnery, Maurice J. Chesney, Richard J. Gralla, and Steven M. Grunberg