Guidelines for Use of Antiemetics
- Introduction
- Common antiemetics
- Basic Science and Drug Delivery
- Comparison of Clinical Guidelines from Major Clinical Trials Groups
- MASCC/ESMO
- NCCN
- ASCO
- Children
Introduction
- Nausea and vomiting are common during and after radiation therapy of certain areas (e.g., whole brain, whole body, hemi-body, cranio-spinal, upper abdomen), as well as during certain anti-cancer chemotherapies.
- Prevention and treatment of nausea and vomiting in these clinical oncology settings has a long history. Many clinical practice guidelines have been published on antiemetics, with periodic updates as new drugs are introduced.
- Nausea and vomiting are also key signs of exposure to whole-body or significant partial-body radiation during radiation accidents. Time-to-vomiting appears to correlate with whole body dose.
- During a mass casualty radiation emergency, diagnosis and treatment of radiation-induced nausea and vomiting in the general public will always be after the incident has occurred and after medical responders have accessed patients. At least initially, there may not be adequate resources to treat all who may need anti-emetic treatment.
- Clinical antiemetic guidance on REMM focuses on mass casualty radiation emergencies. In the absence of formal, prospective research on optimal guidelines for antiemetic clinical treatment during large radiation emergencies, antiemetic information on REMM derives from experience in oncology practice and expert opinion. Links on this page serve as background information only. No uniformly accepted clinical guidance exists for optimal use of anti-emetics during large mass casualty radiation emergencies.
- The links on this page represent peer-reviewed content about nausea and vomiting in the oncology setting for children and adults.
- See REMM’s antiemetics section in the Template for Hospital Orders in adults and children for guidance on post radiation antiemetic therapies considered by REMM and RITN experts.
Common antiemetics
- Antiemetics are given both as prophylactic and rescue therapies in radiation induced nausea and vomiting
- 5-HT3 receptor antagonists are the mainstay of therapy due to high therapeutic index and reasonable side effect profile.
- Other medications include dopamine receptor antagonists
- Below are examples of antiemetics commonly used in clinical practice. Note that this table is not exhaustive.
|
Drug Class |
Example |
Route |
|
5-HT3 receptor antagonist |
Ondansetron |
Oral, intravenous |
|
Granisetron |
Oral, intravenous, transdermal |
|
|
Dopamine Receptor Antagonist |
Prochlorperazine |
Oral, intravenous |
|
Metoclopramide |
Oral, intravenous |
Basic science and drug delivery
- Sanger GJ, Andrews PLR. A History of Drug Discovery for Treatment of Nausea and Vomiting and the Implications for Future Research. Front Pharmacol. 2018 Sep 4;9:913. [PubMed Citation]
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Comparison of clinical guidelines from major clinical trials Groups
- McKenzie E, Zaki P, Raman S, Olson R, McFarlane T, DeAngelis C, Chan S, Pidduck W, Razvi Y, Bushehri A, Chow E. Radiation-induced nausea and vomiting: a comparison between MASCC/ESMO, ASCO, and NCCN antiemetic guidelines. Support Care Cancer. 2019 Mar;27(3):783-791.
- Salvo N, Doble B, Khan L, Amirthevasar G, Dennis K, Pasetka M, Deangelis C, Tsao M, Chow E. Prophylaxis of radiation-induced nausea and vomiting using 5-hydroxytryptamine-3 serotonin receptor antagonists: a systematic review of randomized trials. Int J Radiat Oncol Biol Phys. 2012 Jan 1;82(1):408-17. [PubMed Citation]
- Li WS, van der Velden JM, Ganesh V, Vuong S, Raman S, Popovic M, Lam H, Wong KH, Ngan RK, Burbach JPM, DeAngelis C, Xxxx RM, Chow E. Prophylaxis of radiation-induced nausea and vomiting: a systematic review and meta-analysis of randomized controlled trials. Ann Palliat Med. 2017 Apr;6(2):104-117. [PubMed Citation]
- Chow R, Tsao M, Chiu L, Popovic M, Milakovic M, Lam H, DeAngelis C. Efficacy of the combination neurokinin-1 receptor antagonist, palonosetron, and dexamethasone compared to others for the prophylaxis of chemotherapy-induced nausea and vomiting: a systematic review and meta-analysis of randomized controlled trials. Ann Palliat Med. 2018 Apr;7(2):221-233. [PubMed Citation]
Multinational Association for Supportive Care in Cancer / European Society for Medical Oncology (MASCC/ESMO)
MASCC/ESMO Antiemetic Guidelines
- Antiemetic Guidelines© - Updated March 2016
- Antiemetic Guideline Presentations - Methodology & Statistical Analysis
- Acute AINV Guideline - MASCC partnership. From the Pediatric Oncology Group of Ontario (POGO)
- MASCC Antiemesis Tool© (MAT)
About the MASCC/ESMO Antiemetic Guidelines Update
MASCC/ESMO guidance from peer-reviewed journals- Ruhlmann CH, Jahn F, Jordan K, Dennis K, Maranzano E, Molassiotis A, Roila F, Feyer P. 2016 updated MASCC/ESMO consensus recommendations: prevention of radiotherapy-induced nausea and vomiting. Support Care Cancer. 2017 Jan;25(1):309-316. [PubMed Citation]
- Herrstedt J, Roila F, Warr D, Celio L, Navari RM, Hesketh PJ, Chan A, Aapro MS. 2016 Updated MASCC/ESMO Consensus Recommendations: Prevention of Nausea and Vomiting Following High Emetic Risk Chemotherapy. Support Care Cancer. 2017 Jan;25(1):277-288. [PubMed Citation]
- Roila F, Warr D, Hesketh PJ, Gralla R, Herrstedt J, Jordan K, Aapro M, Ballatori E, Rapoport B. 2016 updated MASCC/ESMO consensus recommendations: Prevention of nausea and vomiting following moderately emetogenic chemotherapy. Support Care Cancer. 2017 Jan;25(1):289-294. [PubMed Citation]
- Olver I, Ruhlmann CH, Jahn F, Schwartzberg L, Rapoport B, Rittenberg CN, Clark-Snow R. 2016 Updated MASCC/ESMO Consensus Recommendations: Controlling nausea and vomiting with chemotherapy of low or minimal emetic potential. Support Care Cancer. 2017 Jan;25(1):297-301. [PubMed Citation]
- Einhorn LH, Rapoport B, Navari RM, Herrstedt J, Brames MJ. 2016 updated MASCC/ESMO consensus recommendations: prevention of nausea and vomiting following multiple-day chemotherapy, high-dose chemotherapy, and breakthrough nausea and vomiting. Support Care Cancer. 2017 Jan;25(1):303-308. [PubMed Citation]
- Dupuis LL, Sung L, Molassiotis A, Orsey AD, Tissing W, van de Wetering M. 2016 updated MASCC/ESMO consensus recommendations: Prevention of acute chemotherapy-induced nausea and vomiting in children. Support Care Cancer. 2017 Jan;25(1):323-331. [PubMed Citation]
National Comprehensive Cancer Network NCCN®
-
NCCN Clinical Practice Guidelines in Oncology:
Antiemesis, Version 1.2019 – February 28, 2019
- Navigation to antiemetic guideline page: Home page > NCCN Guidelines® > NCCN Guidelines for Supportive Care > Antiemesis (Requires registration to access the pdf guideline.)
- See Radiation-induced Emesis Prevention/Treatment (page AE-11) which focuses on regimens for pre-radiotherapy treatment, which is not equivalent to responding after a radiation mass casualty emergency.
American Society for Clinical Oncology (ASCO)
- Hesketh PJ, Kris MG, Basch E, Bohlke K, Barbour SY, Clark-Snow RA, Danso MA, Dennis K, Dupuis LL, Dusetzina SB, Eng C, Feyer PC, Jordan K, Noonan K, Sparacio D, Somerfield MR, Lyman GH. An tiemetics: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol. 2017 Oct 1;35(28):3240-3261. [PubMed Citation]
Children
- Ruggiero A, Rizzo D, Catalano M, Coccia P, Triarico S, Attiná G. Acute chemotherapy-induced nausea and vomiting in children with cancer: Still waiting for a common consensus on treatment. J Int Med Res. 2018 Jun;46(6):2149-2156. [PubMed Citation]
- Dupuis LL, Sung L, Molassiotis A, Orsey AD, Tissing W, van de Wetering M. 2016 updated MASCC/ESMO consensus recommendations: Prevention of acute chemotherapy-induced nausea and vomiting in children. Support Care Cancer. 2017 Jan;25(1):323-331. [PubMed Citation]
- Phillips RS, Friend AJ, Gibson F, Houghton E, Gopaul S, Craig JV, Pizer B. Antiemetic medication for prevention and treatment of chemotherapy-induced nausea and vomiting in childhood. Cochrane Database Syst Rev. 2016 Feb 2;2:CD007786. [PubMed Citation]
- Managing Chemotherapy-induced Nausea and Vomiting in Children (Pediatric Oncology Group of Ontario, Canada)