chemo-induced nausea/vomiting

Delayed CINV

occurs more often with highly emetogenic chemo

Anticipatory CINV

learned reflex or psychological response, often related by poor control of CINV

Breakthrough CINV

occurs despite proper chemoprophylaxis

Refractory CINV

occurs during subsequent treatment cycles due to poor response with multiple antiemetic prophylaxis/rescue meds in previous cycles

CINV risk factors

anxiety, female, <50 y/o, hx motion sickness, pregnancy-induced N/V

CINV risk reduction

hx >5 drinks/week

CINV risk category

based on single agent with highest emetogenic potential

Minimal IV emetogenicity

monoclonal antibodies, vinca alkaloids, bleomycin

Low IV emetogenicity

taxanes, 5-FU, gemcitabine, permetrexed, topotecan

Moderate IV emetogenicity

carboplatin, oxaliplatin, anthracyclines, busulfan, irinotecan, methotrexate,

High IV emetogenicity

anthracycline (doxorubicin + cyclophosphamide), cisplatin, dacarbazine

Prophylaxis recommended PO chemotherapy

etoposide, lomustine, temozolomide

As needed prophylaxis PO chemotherapy

capecitabine, tyrosine kinase inhibitors, methotrexate

Minimal emetic risk prophylaxis duration

none

Low emetic risk prophylaxis duration

1 day

Moderate emetic risk prophylaxis duration

3 days

High emetic risk prophylaxis duration

4 days

5HT₃ RAs

end in -setron

5HT₃ RAs

workhorse drug: indicated for both acute and delayed CINV

5HT₃ RAs

headache, fatigue, constipation, dose related QTc prolongation

Palonosetron

t1/2 = 40 hours

preferred agent in class

Granisetron

comes as once weekly patch, among other routes

Neurokinin-1 receptor antagonists

end in -pitant

Neurokinin-1 receptor antagonists

fatigue, diarrhea, weakness

Neurokinin-1 receptor antagonists

inhibit 3A4

Dexamethasone

3A4 substrate

Neurokinin-1 receptor antagonists

indicated for prevention of acute and delayed CINV (moderate-high emetogenicity)

Aprepitant

only drug in class ever dosed past day 1

Corticosteroids

increase effectiveness of other CINV agents

Dexamethasone

used for prevention of acute and delayed CINV (low-high emetogenicity)

Dexamethasone

insomnia, GI upset, dyspepsia, agitation, weight gain, hyperglycemia, hiccups

Dopamine antagonists

prochlorperazine, haloperidol, metoclopramide

Dopamine antagonists

used for breakthrough treatment and prevention (low emetogenicity)

Dopamine antagonists

sedation, hypotension, anticholinergic, dystonia, EPS, QTc prolongation, neutropenia

Olanzapine

drowsiness, dizziness, hyperglycemia, EPS, weight gain, QTc prolongation, orthostatic hypotension

black box increased risk of death in elderly with dementia-related psychosis

Olanzapine

used for prevention of acute, delayed, breakthrough, and anticipatory CINV (moderate-high emetogenicity)

Dronabinol

dizziness, somnolence, increased appetite

avoid abrupt discontinuation

Lorazepam

used for anticipatory CINV

High IV emetogenicity prophylaxis

NK1 RA and/or olanzapine + 5HT₃ RA + dexamethasone

Moderate IV emetogenicity prophylaxis

5HT₃ RA + dexamethasone + NK1 RA or olanzapine

Low IV emetogenicity prophylaxis

5HT₃ RA or dexamethasone or dopamine antagonist

Minimal IV emetogenicity prophylaxis

none