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ACUTE EMESIS PROPHYLAXIS1-4
Minimally Emetogenic Regimes (< 10%)
• Prophylactic antiemetic therapy generally is not • If the patient experiences nausea or vomiting, use prophylactic therapy prior to subsequent • Patients who do not respond to a 2-drug combination may benefit from the following:  One of the following regimens is recommended:  Dexamethasone 8 to 20 mg PO, given 30  A corticosteroid, dopamine antagonist, and  Addition of a neurokinin antagonist to their diphenhydramine 25 to 50 mg PO if needed, Mildly Emetogenic Regimens (10% to 30%)
diphenhydramine 25 to 50 mg PO if needed, • For most patients, prophylactic antiemetic therapy, particularly with a serotonin antagonist, generally is diphenhydramine 25 to 50 mg PO if needed, • If needed, one of the following regimens may be • If patient still experiences significant nausea  Dexamethasone 8 to 20 mg PO, given 30 or vomiting, add an agent from a different diphenhydramine 25 to 50 mg PO if needed,  The following regimens are recommended:  Patients who received a corticosteroid only: diphenhydramine 25 to 50 mg PO if needed, antagonist only: Add a corticosteroid.
 Patients who received a corticosteroid and diphenhydramine 25 to 50 mg PO if needed, dopamine antagonist: Substitute a serotonin antagonist for the dopamine antagonist.
• If patient still experiences significant nausea  If a corticosteroid and dopamine antagonist or vomiting, add an agent from a different combination is not effective, a serotonin antagonist and corticosteroid combination may  The following regimens are recommended:  The following regimens are recommended:  Patients who received a corticosteroid only: antagonist only: Add a corticosteroid.
 Patients who received a corticosteroid and dopamine antagonist: Substitute a serotonin antagonist for the dopamine antagonist.
 If a corticosteroid and dopamine antagonist combination is not effective, a serotonin antagonist and corticosteroid combination may  The following regimens are recommended: • Antiemetic therapy should continue for at least 3  Prolonged (more than 24 hours) use of serotonin antagonists is NOT recommended.6
 A corticosteroid or corticosteroid and dopamine antagonist combination is recommended for  One of the following regimens is suggested:  Dexamethasone 4 mg PO twice a day for 3 days ± metoclopramide 0.5 to 2 mg/kg PO every 4 to 6 hours ± diphenhydramine 25 to • Patients who do not respond to a 2-drug 50 mg PO every 6 hours if needed, starting combination may benefit from the following:  A corticosteroid, dopamine antagonist, and  Dexamethasone 4 mg PO twice a day for 3 days ± prochlorperazine 10 mg PO every 4  Addition of a neurokinin antagonist to their to 6 hours ± diphenhydramine 25 to 50 mg PO every 6 hours if needed, starting on day 2 of chemotherapy Moderately Emetogenic Regimens (30% to 90%)
 Dexamethasone 4 mg PO twice a day for 3 • Prophylactic antiemetic therapy with a serotonin days ± promethazine 25 to 50 mg PO every antagonist is recommended but may not be 4 to 6 hours ± diphenhydramine 25 to 50 mg PO every 6 hours if needed, starting on day 2 • One of the following regimens may be given 30  If a neurokinin antagonist is used, one of the dexamethasone 20 mg PO, given 30 minutes  Ondansetron 16 to 24 mg, dexamethasone 12 mg, and aprepitant 125 mg given PO 30  Granisetron 1 to 2 mg PO and dexamethasone  Granisetron 1 to 2 mg, dexamethasone 12  Dolasetron 100 mg PO and dexamethasone 20 mg PO, given 30 minutes before chemotherapy  Dolasetron 100 mg, dexamethasone 12 mg,  Palonosetron 0.25 mg IV and dexamethasone and aprepitant 125 mg given PO 30 minutes  Palonosetron 0.25 mg IV (day 1 only),  Use of a neurokinin (NK ) antagonist is recommended for regimens that include both  The following regimens are suggested:  Patients who experience significant nausea should receive an agent from a different  Substituting granisetron for ondansetron been shown to be effective and is NOT
A Guide to Combination Cancer Chemotherapy Regimens Highly Emetogenic Regimes (>90%)
if needed, ± diphenhydramine 25 to 50 mg PO  Prochlorperazine 25 mg rectally every 4 to 6 hours if needed, ± diphenhydramine 25 to 50  Promethazine 25 to 50 mg PO every 4 to 6 hours if needed, ± diphenhydramine 25 to 50  ± a dopamine or serotonin antagonist SPECIAL CONSIDERATIONS
Serotonin (5HT ) antagonists
 Aprepitant 125 mg, dexamethasone 12 mg, • Meta-analysis recommends against use of these and ondansetron 16 to 24 mg PO 30 minutes • There is no benefit to using granisetron in patients  Aprepitant 125 mg, dexamethasone 12 mg, and granisetron 2 mg PO 30 minutes before • High-dose granisetron (3 mg IV or 40 to 240 mcg/kg)7-11 for breakthrough nausea provides no mg, and dolasetron 100 to 200 mg PO 30 minutes before chemotherapy Carboplatin
 Aprepitant 125 mg, dexamethasone 12 mg, • Causes delayed nausea or emesis similar to  Mechanism of action and clinical course differ  A neurokinin antagonist and corticosteroid  Urinary 5-hydroxyindole acetic acid (5-HIAA) or neurokinin antagonist, corticosteroid, and appropriate for follow-up therapy. One of the • The clinical course of nausea or vomiting  Reflects this pattern of serotonin release.
 Usually begins 6 to 7 hours after drug  May persist for up to 120 hours.
 Prochlorperazine 10 mg PO every 4 to • Some clinicians divide the daily antiemetic dose into 2 doses on days when carboplatin is administered.
Cisplatin
• Doses > 50 mg/m2 (single dose or cumulative over  Patients with significant nausea or vomiting should receive an agent from a different  Peak severity occurs at 48 to 72 hours after Breakthrough Nausea and Vomiting1-4
 Usually abates between 96 to 168 hours • Patients should have an antiemetic for Cyclophosphamide
• Emesis is often delayed for up to 12 hours after  Metoclopramide 0.5 to 2 mg/kg PO every 4 to drug administration and may persist for up to 120 6 hours if needed, ± diphenhydramine 25 to 50 • Divide the daily antiemetic dose into 2 doses on  Prochlorperazine 10 mg PO every 4 to 6 hours days when cyclophosphamide is administered.
HYDRATION
Carboplatin
• If doses are adjusted for renal function (as in AUC dosing), no prophylactic hydration or diuretic use is Cisplatin
Bleomycin19
• Can cause irreversible kidney damage by acute • Can induce acute hypersensitivity reactions. • Maintain a urine output ≥ 75 to 100 mL/h for several hours before and after each dose. • Numerous hydration and diuretic regimens have • Except possibly the first treatment cycle, diuretics 30 minutes prior to each dose of bleomycin have no benefit over vigorous hydration.
• One suggested regimen is D5W-NS or NS at 250 mL/h for 2 to 4 hours before and after each dose. • Oral hydration regimens are also used, but Docetaxel21,22
increased chloride from IV solutions may offer • Less likely to cause hypersensitivity reactions than • Manufacturer recommends the following:  Intuitively supports their use to prevent  Dexamethasone 8 mg PO twice daily for 3 days  Begin the day before the docetaxel infusion  There is no evidence to recommend diuretics • Some clinicians add a histamine H antagonist ± a Cyclophosphamide
 If used, the following regimen is suggested: • Risk of hemorrhagic cystitis increases with  Cimetidine 300 mg or ranitidine 50 mg  All given IV over 30 minutes prior to • Patients should empty their bladder frequently.
• Hydration reduces the risk of cystitis.
Doxorubicin, Liposome Encapsulated23-26
• Encourage liberal fluid consumption (3 to 4 L/day) • Infusion-related reactions, particularly with the first  Recommended prophylactic medications prior to the first dose, and if necessary, prior to • Cystitis has been reported following a single IV  Hydrocortisone 100 mg IV or dexamethasone
HYPERSENSITIVITY PRECAUTIONS
 Diphenhydramine 25 mg or 50 mg IV
Anthracyclines
 Cimetidine 300 mg or famotidine 20 mg IV
• Daunorubicin/doxorubicin/epirubicin/idarubicin • Can cause acute hypersensitivity reactions Oxaliplatin27-30
• Reactions occur in 5% to 25% of patients.
• Moderate to severe reactions occur in < 1% to 9% • Most reactions occur at or after the seventh to ninth • Lengthening the infusion time to 6 hours may reduce the incidence of hypersensitivity reactions.

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