What are the antiemetic medications for chemotherapy-induced nausea and vomiting?

From the Guidelines

For chemotherapy-induced nausea and vomiting, the most effective regimen is a three-drug combination of an NK1 receptor antagonist, a 5-HT3 receptor antagonist, and dexamethasone, as recommended by the American Society of Clinical Oncology in 2011 1. This regimen is particularly important for highly emetogenic chemotherapy, where the combination of aprepitant, a 5-HT3 antagonist such as palonosetron or ondansetron, and dexamethasone is recommended to prevent nausea and vomiting. The choice of antiemetic regimen depends on the emetogenic potential of the chemotherapy, with highly emetogenic treatments requiring more aggressive prevention. Key considerations include:

• The use of an NK1 receptor antagonist such as aprepitant on days 1-3, or fosaprepitant on day 1 only
• A 5-HT3 receptor antagonist such as palonosetron or ondansetron on day 1 only
• Dexamethasone on days 1-3 or 1-4
• The addition of lorazepam or diphenhydramine as adjunctive therapy to enhance the effectiveness of the antiemetic regimen
• The importance of staying well-hydrated, eating small frequent meals, and avoiding strong odors to complement medication effectiveness. In cases where nausea and vomiting occur despite optimal prophylaxis, clinicians should re-evaluate emetic risk, disease status, concurrent illnesses, and medications, and consider adding olanzapine to the regimen or substituting high-dose intravenous metoclopramide for the 5-HT3 antagonist 1.

From the FDA Drug Label

Aprepitant capsules, in combination with other antiemetic agents, are indicated in patients 12 years of age and older for the prevention of: • acute and delayed nausea and vomiting associated with initial and repeat courses of highly emetogenic cancer chemotherapy (HEC) including high-dose cisplatin • nausea and vomiting associated with initial and repeat courses of moderately emetogenic cancer chemotherapy (MEC).

The recommended oral dosage of aprepitant capsules, dexamethasone, and a 5-HT3 antagonist in adults and pediatric patients 12 years of age and older who can swallow oral capsules for the prevention of nausea and vomiting associated with administration of HEC or MEC is shown in Table 1 or Table 2, respectively

In 2 randomized, double-blind, monotherapy trials, a single 24 mg oral dose of ondansetron tablets was superior to a relevant historical placebo control in the prevention of nausea and vomiting associated with highly emetogenic cancer chemotherapy, including cisplatin greater than or equal to 50 mg/m 2

• Aprepitant and ondansetron are two anti-nausea medications that can be used for chemotherapy-induced nausea and vomiting.
• Aprepitant is used in combination with other antiemetic agents for the prevention of acute and delayed nausea and vomiting associated with highly emetogenic cancer chemotherapy and moderately emetogenic cancer chemotherapy.
• Ondansetron is used for the prevention of nausea and vomiting associated with highly emetogenic cancer chemotherapy, including cisplatin.
• The recommended dosage of aprepitant is 125 mg orally on Day 1,80 mg orally on Days 2 and 3, in combination with a 5-HT3 antagonist and dexamethasone.
• The recommended dosage of ondansetron is a single 24 mg oral dose, administered 30 minutes prior to chemotherapy. 2 3

From the Research

Antinausea Medications for Chemotherapy

• The use of a combination of a 5-HT3 receptor antagonist, dexamethasone, and a neurokinin-1 (NK-1) receptor antagonist has significantly improved the control of acute and delayed emesis in single-day chemotherapy 4.
• For patients receiving high-dose chemotherapy with stem cell transplant, a combination of a 5-HT3 receptor antagonist with dexamethasone and aprepitant is recommended before chemotherapy 5.
• For patients undergoing multiple-day chemotherapy-induced nausea and vomiting, a 5-HT3 receptor antagonist, dexamethasone, and aprepitant, are recommended before chemotherapy for the prophylaxis of acute emesis and delayed emesis 5.
• Olanzapine has shown efficacy for CINV prophylaxis and the treatment of breakthrough CINV, with a recommended dose of 10 mg oral olanzapine, daily for 3 days 5, 6, 4.
• Neurokinin-1 receptor antagonists have been shown to increase the complete response rate in the overall phase from 54% to 72% 7.
• The new combination therapy, netupitant/palonosetron (NEPA), has been shown to be efficacious for the prevention of acute, delayed, and overall CINV 6.

Specific Medications

• Ondansetron, a serotonin receptor (5-HT3) antagonist, has marked activity against emesis associated with cisplatin and other highly emetogenic drugs 8.
• Palonosetron, a second generation 5-HT3 receptor antagonist, appears to be the most effective agent in its class for the control of chemotherapy induced emesis 4.
• Aprepitant, a neurokinin-1 receptor antagonist, is recommended in combination with a 5-HT3 receptor antagonist and dexamethasone for the prophylaxis of acute and delayed emesis 5, 6.