From the Guidelines
The most effective antiemetic medication is a combination of palonosetron, dexamethasone, and aprepitant for highly emetogenic chemotherapy, and palonosetron and dexamethasone for moderately emetogenic chemotherapy, as supported by recent studies 1.
Key Points:
- Palonosetron has been shown to be more effective than other 5-HT3 antagonists in preventing acute and delayed nausea and vomiting for both highly and moderately emetogenic chemotherapy agents 1.
- The addition of dexamethasone improves the efficacy of the antiemetic regimen containing 5-HT3 antagonists, but is associated with side effects such as insomnia 1.
- Aprepitant is effective in preventing delayed emesis and is recommended for use in combination with dexamethasone and a 5-HT3 antagonist for highly emetogenic chemotherapy 1.
- The dose of dexamethasone can be decreased to 8 mg on day 1 and eliminated on days 2 to 3 when used with palonosetron for moderately emetic chemotherapy 1.
Recommendations:
- For highly emetogenic chemotherapy, use a combination of palonosetron, dexamethasone, and aprepitant.
- For moderately emetogenic chemotherapy, use a combination of palonosetron and dexamethasone.
- Consider adding lorazepam or other adjunctive agents to the antiemetic regimen as needed.
- Monitor patients for side effects and adjust the antiemetic regimen accordingly.
From the FDA Drug Label
Aprepitant has been shown in animal models to inhibit emesis induced by cytotoxic chemotherapeutic agents, such as cisplatin, via central actions. Animal and human studies show that aprepitant augments the antiemetic activity of the 5-HT3-receptor antagonist ondansetron and the corticosteroid dexamethasone and inhibits both the acute and delayed phases of cisplatin-induced emesis. Ondansetron was significantly more effective than placebo in preventing nausea and vomiting.
The most effective antiemetic medication is not explicitly stated in the provided drug labels. However, aprepitant and ondansetron are both shown to be effective in preventing nausea and vomiting in various clinical settings.
- Aprepitant is effective in inhibiting emesis induced by cytotoxic chemotherapeutic agents.
- Ondansetron is effective in preventing postoperative nausea and vomiting. Since the FDA label does not directly compare the effectiveness of these two medications, no conclusion can be drawn about which one is more effective 2, 3.
From the Research
Antiemetic Medications
The most effective antiemetic medication is often a combination of multiple agents.
- A combination of a serotonin (5-HT)3-receptor antagonist, dexamethasone, and a neurokinin (NK)1-receptor antagonist is recommended for highly emetogenic chemotherapy (HEC) 4.
- The addition of olanzapine, a multireceptor targeting agent, can be useful in cisplatin-based and anthracycline-cyclophosphamide-based chemotherapy, particularly if the main problem is nausea 4.
- Aprepitant is an effective antiemetic agent for chemotherapy-induced nausea and vomiting (CINV) and is often used in combination with dexamethasone and a 5-HT3 receptor antagonist 5.
5-HT3 Receptor Antagonists
- Ondansetron is a highly selective 5-HT3 receptor antagonist that has been shown to be effective in reducing nausea and vomiting induced by cytotoxic drugs and radiation 6.
- Granisetron, another 5-HT3 receptor antagonist, has been shown to be equivalent to ondansetron in terms of efficacy, and may have an advantage over tropisetron in non-cisplatin-based studies 7.
- Dolasetron and tropisetron are also effective 5-HT3 receptor antagonists, but may not be as effective as granisetron or ondansetron in certain situations 7.
Dexamethasone Dosage
- The optimal dosage of dexamethasone in combination with 5-HT3 antagonists for antiemetic prophylaxis is not clearly established, but 8 mg or its equivalent may be sufficient 8.
- High-dose dexamethasone (20 mg) may not have an advantage over medium-dose dexamethasone in terms of antiemetic efficacy, and may even impair the control of delayed nausea and emesis 8.