Chemotherapy-Induced Nausea and Vomiting
Highly and moderately emetogenic antineoplastic agents have the potential to induce both acute (≤24 hours) and delayed (>24 hours) nausea and vomiting after chemotherapy. The guideline recommendations include prophylaxis for both types of nausea and vomiting where appropriate.
This guideline update includes the most recent recommendations (see Table 1 in the original guideline document) developed by the Update Committee. A table with intravenous agents organized by emetic risk is included below. The intravenous risk stratification schema was originally published in 1997 and was updated at the Multinational Association of Supporting Care in Cancer (MASCC)/European Society for Medical Oncology 2009 consensus conference. The modified stratification from MASCC was adopted by ASCO for this guideline update. Dosing schedules are also detailed (see Table 3 in the original guideline document).
Table. Emetic Risk of Intravenous Antineoplastic Agents
Cyclophosphamide ≥1,500 mg/m2
Cyclophosphamide <1,500 mg/m2
Cytarabine >1,000 mg/m2
Cytarabine ≤1,000 mg/m2
Doxorubicin HCL liposome injection
- Data adapted from Gralla RJ, Roila F, Tonato M, et al: MASCC/ESMO antiemetic guideline 2010. http://www.mascc.org/mc/page.do?sitePageId88041
- Note: This list of agents is not exhaustive.
- *These anthracyclines, when combined with cyclophosphamide, are now designated as high emetic risk.
Clinical Question 1
What is the optimal treatment to prevent nausea and vomiting from highly emetogenic antineoplastic agents?
Recommendation 1. The three-drug combination of a neurokinin 1 (NK1) receptor antagonist (days 1 through 3 for aprepitant; day 1 only for fosaprepitant), a 5-hydroxytryptamine-3 (5-HT3) receptor antagonist (day 1 only), and dexamethasone (days 1 through 3 or 1 to 4) is recommended for patients receiving highly emetogenic chemotherapy. This recommendation remains unchanged since the 2006 update but has been reworded for clarification. The Update Committee also recommended reclassification of the combined anthracycline and cyclophosphamide (AC) regimen as highly emetogenic.
Clinical Question 2
What is the optimal treatment to prevent nausea and vomiting from moderately emetogenic antineoplastic agents?
Recommendation 2. The two-drug combination of palonosetron (day 1 only) and dexamethasone (days 1 through 3) is recommended for patients receiving moderately emetogenic chemotherapy. If palonosetron is not available, clinicians may substitute a first generation 5-HT3 receptor antagonist, preferably granisetron or ondansetron.
Limited evidence also supports adding aprepitant to the combination. Should clinicians opt to add aprepitant for patients receiving moderate-risk chemotherapy, any one of the 5-HT3 receptor antagonists is appropriate.
Clinical Question 3
What is the optimal treatment to prevent nausea and vomiting from low emetogenic antineoplastic agents?
Recommendation 3. A single 8-mg dose of dexamethasone before chemotherapy is suggested. No change from 2006.
Clinical Question 4
What is the optimal treatment to prevent nausea and vomiting from minimally emetogenic antineoplastic agents?
Recommendation 4. No antiemetic should be administered routinely before or after chemotherapy. No change from the original guideline.
Clinical Question 5
What is the optimal treatment to prevent nausea and vomiting from combination chemotherapy?
Recommendation 5. Patients should be administered antiemetics appropriate for the component chemotherapeutic (antineoplastic) agent of greatest emetic risk. No change from the original guideline. Anthracycline-cyclophosphamide combinations are now classified as highly emetogenic.
Clinical Question 6
What is the role of adjunctive drugs for nausea and vomiting induced by cancer treatments?
Recommendation 6. Lorazepam and diphenhydramine are useful adjuncts to antiemetic drugs but are not recommended as single agent antiemetics. No change from 2006.
Clinical Question 7
What is the role of complementary and alternative medicine therapies to prevent or control nausea and vomiting induced by chemotherapy?
Recommendation 7. No published randomized controlled trial data meeting the inclusion criteria are currently available to support a recommendation about such therapies.
Clinical Question 8
What is the optimal treatment to prevent nausea and vomiting associated with cancer therapy for pediatric patients?
Recommendation 8. The combination of a 5-HT3 receptor antagonist plus a corticosteroid is suggested before chemotherapy in children receiving chemotherapy of high or moderate emetic risk. Because of the variation of pharmacokinetic parameters in children, weight-based doses of 5-HT3 receptor antagonists higher than those used in adults may be required for antiemetic protection. No change from 2006.
Clinical Question 9
What is the optimal treatment to prevent nausea and vomiting in patients who are undergoing high-dose chemotherapy with stem-cell or bone marrow transplantation?
Recommendation 9. A 5-HT3 receptor antagonist combined with dexamethasone is recommended. Aprepitant should be considered, although evidence to support its use is limited.
Clinical Question 10
What is the optimal treatment to prevent nausea and vomiting for patients receiving multiday chemotherapy?
Recommendation 10. It is suggested that antiemetics appropriate for the emetogenic risk class of the chemotherapy be administered for each day of the chemotherapy and for 2 days after, if appropriate. No change from the original guideline. The Update Committee suggests, on the basis of limited data, that patients receiving 5-day cisplatin regimens be treated with a 5-HT3 receptor antagonist in combination with dexamethasone and aprepitant.
Clinical Question 11
What is the optimal antiemetic regimen for patients who experience nausea and vomiting secondary to cancer therapy despite optimal prophylaxis?
Recommendation 11. Language from the 2006 guideline was reformatted for clarity. Clinicians should (1) re-evaluate emetic risk, disease status, concurrent illnesses, and medications; (2) ascertain that the best regimen is being administered for the emetic risk; (3) consider adding lorazepam or alprazolam to the regimen; and (4) consider adding olanzapine to the regimen or substituting high-dose intravenous metoclopramide for the 5-HT3 receptor antagonist or adding a dopamine antagonist to the regimen.
Clinical Question 12
What treatment options are available for patients who experience anticipatory nausea and vomiting?
Recommendation 12. Use of the most active antiemetic regimens appropriate for the chemotherapy being administered to prevent acute or delayed emesis is suggested. Such regimens should be used with initial chemotherapy, rather than assessing the patient's emetic response with less effective treatment. If anticipatory emesis occurs, behavioral therapy with systematic desensitization is effective and suggested. No change from the original guideline.
Radiation-Induced Nausea and Vomiting
This guideline update includes an updated risk stratification table according to site of radiation treatment. The Multinational Association of Supportive Care in Cancer (MASCC) updated the radiation therapy emetic risk table at the MASCC/European Society for Medical Oncology 2009 consensus conference (see Table, below); this was adopted by the American Society for Clinical Oncology (ASCO) for this guideline update. Dosing schedules, according to risk level, are detailed in Table 2 in the original guideline document.
Table. Emetic Risk by Site of Radiation Therapy
||Site of Radiation Therapy
Total nodal irradiation
Upper body irradiation
Head and neck
Lower thorax region
Data adapted from Gralla RJ, Roila F, Tonato M, et al: MASCC/ESMO antiemetic guideline 2010. http://www.mascc.org/mc/page.do?sitePageId88041
Clinical Question 13
What is the optimal prophylaxis for nausea and vomiting caused by high emetic risk radiation therapy?
Recommendation 13. On the basis of extrapolation from indirect evidence, the Update Committee recommends that all patients receive a 5-HT3 receptor antagonist before each fraction and for at least 24 hours after completion of radiotherapy. Patients should also receive a 5-day course of dexamethasone during fractions 1 to 5.
Clinical Question 14
What is the optimal prophylaxis for nausea and vomiting caused by moderate emetic risk radiation therapy?
Recommendation 14. The Update Committee recommends that patients receive a 5-HT3 receptor antagonist before each fraction for the entire course of radiotherapy. Patients may be offered a short course of dexamethasone during fractions 1 to 5.
Clinical Question 15
What is the optimal treatment to manage nausea and vomiting associated with low emetic risk radiation therapy?
Recommendation 15. The Update Committee recommends a 5-HT3 receptor antagonist alone as either prophylaxis or rescue. For patients who experience radiation-induced nausea and vomiting (RINV) while receiving rescue therapy only, prophylactic treatment should continue until radiotherapy is complete.
Clinical Question 16
What is the optimal treatment to manage nausea and vomiting associated with minimal emetic risk radiation therapy?
Recommendation 16. Patients should receive rescue therapy with either a dopamine receptor antagonist or a 5-HT3 receptor antagonist. Prophylactic antiemetics should continue throughout radiation treatment if a patient experiences RINV while receiving rescue therapy.
Clinical Question 17
What is the optimal treatment to manage nausea and vomiting during concurrent radiation and chemotherapy?
Recommendation 17. Patients should receive antiemetic prophylaxis according to the emetogenicity of chemotherapy, unless the emetic risk with the planned radiotherapy is higher. No change from the original guideline.