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ASCO updates antiemetic guidelines for cancer treatment
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An expert panel recommended two new anti-nausea medications and offered updated recommendations to improve chemotherapy- and radiation-induced nausea and vomiting in patients with cancer.
“The development of increasingly effective antiemetic regimens over the last quarter century has greatly reduced the incidence of nausea and vomiting due to chemotherapy,” Gary H. Lyman, MD, MPH, co-director of the Hutchinson Institute for Cancer Outcomes Research at the Fred Hutchinson Cancer Research Center, and colleagues wrote. “The recommended approach to preventing nausea and vomiting varies by the emetic risk of the treatment regimen. Adherence to antiemetic guidelines has been linked to improved control of nausea and vomiting.”
To update the ASCO clinical practice guidelines, an expert panel addressed the antiemetic efficacy of olanzapine; the expanded use of neurokinin 1 (NK) receptor antagonists; cannabinoids; and refinements in the anatomic regions, risk levels and antiemetic management recommendations for radiation therapy.
In addition, the panel added two new antiemetic medications to prevent and manage nausea and vomiting caused by antineoplastic agents or radiotherapy for cancer treatment: rolapitant (Varubi, Tesaro), an FDA-approved NK receptor antagonist, and granisetron, a drug that blocks the actions of chemicals in the body that can trigger nausea and vomiting.
Lyman and colleagues conducted a systematic review of medical literature from 41 publications from Nov. 2009 to June 2016.
Updated guidelines following chemotherapy
The expert panel added olanzapine to the antiemetic regimen for patients treated with high-emetic-risk chemotherapy. These patients should be offered a four-drug combination of an NK receptor antagonist, a serotonin receptor antagonist, dexamethasone and olanzapine.
With this regimen, dexamethasone and olanzapine should be continued on days 2 to 4.
The panel also added an NK inhibitor to the standard regimen for patients treated with moderate-emetic-risk chemotherapy, and they recommend use of dexamethasone on days 2 and 3 among patients receiving agents known to cause delayed nausea and vomiting.
For adults treated with low-emetic-risk antineoplastic agents, the panel recommended a single dose of a serotonin receptor antagonist or 8 mg dexamethasone before antineoplastic treatment.
In adults treated with high-dose chemotherapy and stem cell or bone marrow transplantation, the panel recommended a three-drug combination of an NK receptor antagonist, a serotonin receptor antagonist and dexamethasone.
The panel found olanzapine provided a benefit for breakthrough nausea setting for patients who did not receive it prophylactically and, therefore, recommended it be offered in addition to continuing the standard antiemetic regimen.
Updated guidelines following radiation
In adults treated with high-emetic-risk radiation therapy, the updated recommendation allowed the duration of dexamethasone to match that of a serotonin antagonist, given before each fraction and on the day after each fraction if radiation therapy is not planned for that day.
Adults treated with radiation therapy to the brain should be offered rescue dexamethasone, whereas patients treated with radiation therapy to the head and neck, thorax or pelvis should be offered rescue therapy with a serotonin receptor antagonist, dexamethasone or a dopamine receptor antagonist.
The panel added dexamethasone as a rescue therapy option in addition to a serotonin receptor antagonist or a dopamine receptor antagonist for patients receiving minimal-emetic-risk radiation.
To address the gap between the end of prophylaxis for antineoplastic agent-induced nausea and vomiting and ongoing radiation therapy, the panel recommended patients receive risk-appropriate prophylactic therapy until the next period of antineoplastic therapy.
Guidelines for pediatric patients
The panel added aprepitant to the regimen for children who receive high-emetic-risk chemotherapy. Patients who are unable to receive aprepitant should be offered a two-drug combination of a serotonin receptor antagonist and dexamethasone.
Children who receive high- and moderate-emetic-risk chemotherapy who are unable to receive dexamethasone should be offered palonosetron and aprepitant.
Those treated with low-emetic-risk antineoplastic agents should receive ondansetron or granisetron.
However, the panel recommended against routine antiemetic prophylaxis in children treated with minimal-emetic-risk antineoplastic agents.
Adjunctive drugs, cannabinoids
The panel noted that lorazepam is a useful adjunct to antiemetic drugs but did not recommend it as a single-agent antiemetic.
Lastly, a 2015 meta-analysis of cannabinoids in chemotherapy-induce nausea and vomiting concluded cannabis-based medications may be useful; however, methodological limitations existed.
The panel concluded that insufficient evidence exists on whether medical marijuana prevents nausea and vomiting with in patients who receive chemotherapy or radiation therapy.
Clinical implications
Because health care providers underestimate the incidence and severity of radiation- and chemotherapy-induced nausea and vomiting, the panel called for efforts to improve patient-clinician communication.
“To ensure optimal symptom management, clinicians should assess symptoms throughout therapy,” Lyman and colleagues wrote. “Patient response to antiemetic therapy may change over time, requiring reassessments and modifications to antiemetic strategies as warranted. Clinicians are encouraged to provide patients with a prescription for a rescue antiemetic before the patient begins the first day of treatment.”
direct patient reporting systems, including checklists and mobile chemotherapy diaries.
The panel acknowledged the guidelines may be affected by health disparities and patients’ limited access to care.
“Racial and ethnic disparities in health care contribute significantly to this problem in the United States,” they wrote. “Patients with cancer who are members of racial and/or ethnic minorities suffer disproportionately from comorbidities, experience more substantial obstacles to receiving care, are more likely to be uninsured and are at greater risk [for] receiving care of poor quality than other Americans.”
Lastly, because cost implications may affect these guidelines, the panel recommended for shared decision-making.
“Clinicians should exercise judgment and, whenever it is practical and feasible, discuss with patients the use of less expensive alternatives when considering two or more treatment options that are comparable in terms of benefits and harms,” Lyman and colleagues wrote.
“When discussing financial issues and concerns, patients should be made aware of any financial counseling services that are available to address this complex and heterogeneous landscape.” – by Kristie L. Kahl
Disclosure: Lyman reports he is a consultant/adviser for Halozyme and G1 Therapeutics; and receives research funding from Amgen. Please see the guidelines for a list of all other authors’ relevant financial disclosures.
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