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 .
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 Update
1. 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.
See commentary "Commentary: Should Cost and Comparative Value of Treatments Be Considered in Clinical Practice Guidelines?" on page 398.