Table 2. Comparison of Aprepitant and Standard Regimens continued...
Although these results are encouraging, the study was limited by a small sample size, lack of stratification by antiemetic regimen, and no intra- or interindividual reporting. Subsequent studies are needed to confirm these preliminary findings.
Management of CINV
Current guidelines [129,130] recommend that prechemotherapy management of CINV be based on the emetogenic potential of the chemotherapy agent(s) selected. For patients receiving regimens with high emetogenic potential, the combination of a 5-HT3 receptor antagonist, aprepitant, and dexamethasone is recommended prechemotherapy; lorazepam may also be used. Aprepitant and dexamethasone are recommended postchemotherapy for the prevention of delayed emesis.
For patients receiving moderately emetogenic chemotherapy, the combination of a 5-HT3 receptor antagonist and dexamethasone should be used prechemotherapy, with or without lorazepam. Patients receiving the combination of an anthracycline and cyclophosphamide and select patients receiving certain other agents of moderate emetic risk, such as cisplatin (<50 mg/m2) or doxorubicin, should also receive aprepitant. Postchemotherapy, a 5-HT3 receptor antagonist, dexamethasone, or both are recommended for the prevention of delayed emesis.
For regimens with low emetogenic potential, dexamethasone is recommended with or without lorazepam. For regimens with minimal emetogenic risk, no prophylaxis is recommended.[129,130]
Antiemetic guidelines [129,130] have included the available oral 5-HT3 receptor antagonists as optional therapy for the prevention of delayed emesis, but the level of evidence supporting this practice is low.
Clinicians and other health care professionals who are involved in administering chemotherapy should be aware that studies have strongly suggested that patients experience more acute and delayed CINV than is perceived by practitioners.[48,131,132] One study suggested that patients who are highly expectant of experiencing nausea appear to experience more postchemotherapy nausea. In addition, the current and new agents have been used as prophylaxis for acute and delayed CINV and have not been studied for use in established CINV.[48,49] One study reported the effective use of IV palonosetron and dexamethasone for the prevention of CINV in patients receiving multiple-day chemotherapy.
Pre- and postchemotherapy recommendations by emetogenic potential are summarized in Table 3.
Table 3. Antiemetic Recommendations by Emetic Risk Categoriesa
|Emetic Risk Category||ASCO Guidelines||NCCN Guidelines|
|ASCO = American Society of Clinical Oncology; NCCN = National Comprehensive Cancer Network.|
|a Adapted from Navari.|
|b Order of listed antiemetics does not reflect preference.|
|High (>90%) risk||Three-drug combination of a 5-HT3 receptor antagonist, dexamethasone, and aprepitant recommended prechemotherapy.||Prechemotherapy, a 5-HT3 receptor antagonist (ondansetron, granisetron, dolasetron, or palonosetronb), dexamethasone (12 mg), and aprepitant (125 mg) recommended, with or without lorazepam.|
|For patients receiving cisplatin and all other agents of high emetic risk, the two-drug combination of dexamethasone and aprepitant recommended for prevention of delayed emesis.||For prevention of delayed emesis, dexamethasone (8 mg) on days 2–4 plus aprepitant (80 mg) on days 2 and 3 recommended, with or without lorazepam on days 2–4.|
|Moderate (30%–90%) risk||For patients receiving an anthracycline and cyclophosphamide, the three-drug combination of a 5-HT3 receptor antagonist, dexamethasone, and aprepitant recommended prechemotherapy; single-agent aprepitant recommended on days 2 and 3 for prevention of delayed emesis.||For patients receiving an anthracycline and cyclophosphamide and selected patients receiving other chemotherapies of moderate emetic risk (e.g., carboplatin, cisplatin, doxorubicin, epirubicin, ifosfamide, irinotecan, or methotrexate), a 5-HT3 receptor antagonist (ondansetron, granisetron, dolasetron, or palonosetronb), dexamethasone (12 mg), and aprepitant (125 mg) recommended, with or without lorazepam, prechemotherapy; for other patients, aprepitant is not recommended.|
|For patients receiving other chemotherapies of moderate emetic risk, the two-drug combination of a 5-HT3 receptor antagonist and dexamethasone recommended prechemotherapy; single-agent dexamethasone or a 5-HT3 receptor antagonist recommended on days 2 and 3 for prevention of delayed emesis.||For prevention of delayed emesis, dexamethasone (8 mg) or a 5-HT3 receptor antagonist on days 2–4 or, if used on day 1, aprepitant (80 mg) on days 2 and 3, with or without dexamethasone (8 mg) on days 2–4, recommended, with or without lorazepam on days 2–4.|
|Low (10%–30%) risk||Dexamethasone (8 mg) recommended; no routine preventive use of antiemetics for delayed emesis recommended.||Metoclopramide, with or without diphenhydramine; dexamethasone (12 mg); or prochlorperazine recommended, with or without lorazepam.|
|Minimal (<10%) risk||No antiemetic administered routinely pre- or postchemotherapy.||No routine prophylaxis; consider using antiemetics listed under primary prophylaxis as treatment.|