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J Oncol Pract. 2011 November; 7(6): 395–398.
Published online 2011 October 21. doi:  10.1200/JOP.2011.000397
PMCID: PMC3219469

Antiemetics: American Society of Clinical Oncology Clinical Practice Guideline Update

Abstract

ASCO's update to its antiemetics guideline now includes an evaluation of evidence on complementary antiemetic therapy.

Journal of Clinical Oncology recently published ASCO's update to its antiemetics guideline.1 ASCO first published an evidence-based clinical practice guideline on the use of antiemetics for patients with cancer in 1996. ASCO previously updated this guideline in 2006. For its current update, the scope remained largely unchanged and includes nausea and vomiting induced by chemotherapy, radiotherapy, and combination chemotherapy and radiation therapy. The scope now includes an evaluation of evidence on complementary antiemetic therapy.

The guideline is based on a systematic search and review of the literature. The Antiemetics Guideline Update Committee considered literature identified by a systematic review funded by the Agency for Healthcare Research and Quality. In addition to articles from the medical literature, both presentations and posters from the Multinational Association for Supportive Care in Cancer and ASCO Annual Meetings were eligible for inclusion. The primary efficacy outcomes of interest were complete response, emetic control, nausea control, and use of rescue antiemetics.

This most recent update reviews optimal therapy for patients receiving highly emetic chemotherapy, and 5-hydroxytryptamine 3 (5-HT3) antagonist equivalency in the moderately emetogenic setting. Other key questions included the use of neurokinin 1 (NK1) receptor antagonists in the moderately emetogenic and high-dose chemotherapy setting, treatment of radiation-induced nausea and vomiting, and antiemetic therapy for children. The update also reviews evidence regarding three new drug formulations approved by the US Food and Drug Administration since the 2006 update: fosaprepitant, an aprepitant prodrug (an NK1 receptor antagonist); the granisetron transdermal system; and the ondansetron orally disintegrating tablet.

Other changes to recommendations for this update include those listed below. All of the 2006 and 2011 recommendations are listed in Table 1.

Table 1.
Summary of Recommendations

For chemotherapy-induced nausea and vomiting:

  • Anthracyclines-cyclophosphamide combinations are reclassified as highly emetogenic.
  • Palonosetron is preferred for use with patients receiving moderately emetogenic agents.
  • Olanzapine may be added to the antiemetic regimen for patients who experience emesis or nausea despite optimal prophylaxis.
  • In the evaluation of complementary therapy, the Update Committee found no published randomized trial data that met the inclusion and exclusion criteria.

For radiation-induced nausea and vomiting:

  • A 5-day course of dexamethasone during fractions 1 to 5 is recommended for patients receiving high-risk radiotherapy.
  • An optional 5-day course of dexamethasone during fractions 1 to 5 is recommended for patients receiving moderate-risk radiotherapy.
  • For patients receiving low-risk radiotherapy, a 5-HT3 receptor antagonist is recommended as either prophylaxis or rescue. In addition, patients requiring rescue should receive subsequent prophylactic antiemetic therapy.

Journal of Clinical Oncology published an Executive Summary of the Guideline Update1. The Executive Summary is brief overview of the complete ASCO Clinical Practice Guideline Update (available online only) and provides a brief discussion of the relevant literature for each recommendations. The complete Guideline Update—including expanded discussion of the literature, a description of methodology, and all cited references—and a Data Supplement with evidence tables and a patient guide are available at www.asco.org/guidelines/antiemetics. A slide set and a table with dosing information are provided in an online Data Supplement to this JOP article.

Authors

Antiemetics: ASCO Clinical Practice Guideline Update was developed and written by Ethan Basch, Ann Alexis Prestrud, Paul J. Hesketh, Mark G. Kris, Petra C. Feyer, Mark R. Somerfield, Maurice Chesney, Rebecca Anne Clark-Snow, Anne Marie Flaherty, Barbara Freundlich, Gary Morrow, Kamakshi V. Rao, Rowena N. Schwartz, and Gary H. Lyman.

THE BOTTOM LINE

ASCO GUIDELINE UPDATE

Intervention

  • Antiemetics for patients receiving cancer therapy

Target Audience

  • Medical oncologists, radiation oncologists, oncology nurses

Key Recommendations

  • Patients who receive highly emetic chemotherapy regimens should receive the three-drug combination of a neurokinin 1 (NK1) antagonist, 5-hydroxytryptamine-3 (5-HT3) receptor antagonist, and dexamethasone.
  • The preferred 5-HT3 receptor antagonist for patients who receive moderate emetic chemotherapy regimens is palonosetron; antiemetic treatment includes that agent combined with a corticosteroid.
  • Antiemetic treatment for patients who receive combination chemotherapy should be determined according to the agent with the greatest degree of emetic risk.
  • Both dexamethasone and a 5-HT3 antagonist are recommended for patients undergoing high-dose chemotherapy.
  • Pediatric patients receiving either high or moderate emetic risk chemotherapy should be treated with a 5-HT3 antagonist and corticosteroids; higher weight-based dosing may be required.
  • For those treated with high emetic risk radiation therapy, a 5-HT3 antagonist before each fraction and a 5-day course of dexamethasone are recommended.
  • A 5-HT3 antagonist before each fraction is also recommended before moderate-risk radiation; a 5-day course of dexamethasone is optional.
  • For patients who receive combination chemoradiotherapy, antiemetic therapy is dictated by the emetogenicity of chemotherapy, unless the emetic risk of radiation therapy is higher.

Methods

  • A systematic review of the literature published since the last update of the guideline.

Additional Information

  • An Executive Summary of this guideline was published in Journal of Clinical Oncology

Data supplements, including evidence tables, and clinical tools and resources can be found at www.asco.org/guidelines/antiemetics.

Supplementary Material

Data Supplements:

Authors' Disclosures of Potential Conflicts of Interest

Although all authors completed the disclosure declaration, the following author(s) indicated a financial or other interest that is relevant to the subject matter under consideration in this article. Certain relationships marked with a “U” are those for which no compensation was received; those relationships marked with a “C” were compensated. For a detailed description of the disclosure categories, or for more information about ASCO's conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors.

Employment or Leadership Position: None Consultant or Advisory Role: Paul Joseph Hesketh, Merck (C), Eisai (C), GlaxoSmithKline (C), Helsinn (C); Mark G Kris, Sanofi-Aventis (C), GlaxoSmithKline (C) Stock Ownership: None Honoraria: None Research Funding: None Expert Testimony: None Other Remuneration: None

Author Contributions

Conception and design: Ethan Basch, Paul J. Hesketh, Mark G. Kris, Ann Alexis Prestrud, Gary H. Lyman

Administrative support: Ann Alexis Prestrud, Sarah Temin

Provision of study materials or patients: Mark G. Kris

Collection and assembly of data: Ethan Basch, Paul J. Hesketh, Mark G. Kris, Ann Alexis Prestrud, Gary H. Lyman

Data analysis and interpretation: Ethan Basch, Paul J. Hesketh, Mark G. Kris, Ann Alexis Prestrud, Gary H. Lyman

Manuscript writing: All authors

Final approval of manuscript: All authors

Reference

1. Basch E, Prestrud AA, Hesketh P, et al. Antiemetics: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. [epub ahead of print on September 26, 2011] [PubMed]

Articles from Journal of Oncology Practice are provided here courtesy of American Society of Clinical Oncology