What is the recommended treatment for chemotherapy-induced nausea and vomiting (CINV)?

Treatment of Chemotherapy-Induced Nausea and Vomiting (CINV)

The recommended treatment for chemotherapy-induced nausea and vomiting (CINV) is a combination therapy of 5-HT3 receptor antagonists, corticosteroids, and NK1 receptor antagonists, with the specific regimen tailored to the emetogenic potential of the chemotherapy agent. 1

Classification of Antiemetic Regimens Based on Chemotherapy Emetogenicity

For Highly Emetogenic Chemotherapy (HEC):

• First-line regimen: Triple therapy with:
  • 5-HT3 receptor antagonist (e.g., ondansetron 8 mg IV or 16-24 mg PO)
  • Dexamethasone (20 mg IV/PO)
  • NK1 receptor antagonist (e.g., aprepitant 125 mg PO on day 1, followed by 80 mg on days 2-3) 1, 2

For Moderately Emetogenic Chemotherapy (MEC):

• First-line regimen:
  • 5-HT3 receptor antagonist
  • Dexamethasone (12 mg PO/IV)
  • Consider adding NK1 receptor antagonist for higher-risk patients 1, 2

For Low Emetogenic Chemotherapy:

• Single antiemetic agent (typically dexamethasone or 5-HT3 antagonist) is often sufficient 1

Timing of Administration

• Prophylactic administration: 30-60 minutes before chemotherapy 1
• Acute phase (0-24 hours): Full antiemetic regimen
• Delayed phase (24-120 hours): Continue with:
  • Dexamethasone twice daily
  • NK1 receptor antagonist (if part of initial regimen) 1, 2

Specific Dosing Guidelines

5-HT3 Receptor Antagonists:

• Ondansetron: 8 mg IV or 16-24 mg PO once daily
• Granisetron: 1 mg IV or 2 mg PO once daily
• Palonosetron: 0.25 mg IV (no oral formulation available) 1

Corticosteroids:

• Dexamethasone: 20 mg IV/PO for cisplatin-based regimens; 8 mg for cyclophosphamide/anthracycline regimens on day 1
• For delayed emesis: Dexamethasone twice daily on subsequent days 1

NK1 Receptor Antagonists:

• Aprepitant: 125 mg PO on day 1, followed by 80 mg on days 2-3
• Important: When combining with corticosteroids, reduce dexamethasone dose by 50% due to drug interactions 2

Management of Breakthrough CINV

If prophylactic regimen fails:

1. Add a medication from a different class than those used in prophylaxis 3
2. Consider adding dopamine antagonists (e.g., metoclopramide 20-30 mg PO 3-4 times daily) 1
3. Consider olanzapine for breakthrough CINV (recent evidence suggests effectiveness) 3
4. Administer antiemetics IV rather than PO if patient is actively vomiting 1

Management of Refractory CINV

For patients who develop CINV during subsequent cycles despite prophylaxis:

1. Consider changing prophylactic regimen for future cycles 3
2. Consider adding benzodiazepines (e.g., lorazepam 1-2 mg) for patients with significant anxiety 1, 3
3. For HEC, consider adding olanzapine to the prophylactic regimen 3
4. For MEC, consider adding either olanzapine or an NK1 receptor antagonist if not already included 3

Special Considerations

• Multiple-day chemotherapy: Treat each day as acute CINV, followed by delayed CINV management 1
• Anticipatory CINV: Consider lorazepam or behavioral techniques 1
• High-dose chemotherapy: Use full doses of corticosteroids, serotonin and dopamine antagonists intravenously 1

Important Caveats

• Recent evidence suggests olanzapine-containing regimens may be the most effective for HEC-induced CINV and could be a cost-effective alternative to NK1 receptor antagonists 4
• Prolonged use of NK1 receptor antagonists (e.g., fosaprepitant on days 1 and 3) may better control delayed CINV than single-day administration 5
• Always rule out other causes of nausea and vomiting in cancer patients (e.g., radiation therapy, electrolyte disturbances, brain metastases, opioid use) 1

Remember that effective CINV control is crucial for maintaining chemotherapy dose intensity and preserving patient quality of life. Prophylactic antiemetic therapy is superior to treating symptoms after they develop.