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

Recommended Medications for Chemotherapy-Induced Nausea and Vomiting

The most effective antiemetic regimen for chemotherapy-induced nausea and vomiting (CINV) is a combination of 5-HT3 receptor antagonists, dexamethasone, and aprepitant, with the specific regimen tailored to the emetogenic potential of the chemotherapy. 1

Antiemetic Selection Based on Chemotherapy Emetogenic Risk

High Emetogenic Risk Chemotherapy

• Start before chemotherapy with a three-drug combination: 1
  • Aprepitant 125 mg PO day 1, followed by 80 mg PO days 2-3
  • Dexamethasone 12 mg PO or IV days 1-4
  • 5-HT3 antagonist (preferably palonosetron 0.25 mg IV day 1)

Moderate Emetogenic Risk Chemotherapy

• Start before chemotherapy with: 1
  • Aprepitant 125 mg PO day 1, followed by 80 mg PO days 2-3 (in select patients)
  • Dexamethasone 12 mg PO or IV day 1
  • 5-HT3 antagonist (options include ondansetron, granisetron, dolasetron, or palonosetron)

Low Emetogenic Risk Chemotherapy

• Single antiemetic agent is often sufficient as prophylaxis 1
• No routine prophylaxis needed after day 1 1

Key Antiemetic Medications

5-HT3 Receptor Antagonists

• First-line treatment for moderately and highly emetogenic chemotherapy 2
• Options include:
  • Ondansetron: 16-24 mg PO or 8-12 mg IV day 1 1
  • Granisetron: 1-2 mg PO or 1 mg PO twice daily or 0.01 mg/kg IV (maximum 1 mg) 1
  • Dolasetron: 100 mg PO or 1.8 mg/kg IV 1
  • Palonosetron: 0.25 mg IV (preferred for high emetogenic risk) 1

Corticosteroids

• Dexamethasone is the preferred corticosteroid 1
• Dosing:
  • For cisplatin-induced emesis: 20 mg IV single dose before chemotherapy 1
  • For cyclophosphamide/anthracycline-based chemotherapy: 8 mg IV single dose 1
  • For delayed emesis: given twice daily 1

NK1 Receptor Antagonists

• Aprepitant: 125 mg PO day 1, followed by 80 mg PO days 2-3 1, 3
• Fosaprepitant: 115 mg IV can be substituted for aprepitant on day 1 1, 3
• Note: When combined with aprepitant, reduce dexamethasone dose by 50% due to drug interaction 1, 3

Management of Specific CINV Types

Acute CINV (within 24 hours)

• Optimal control of acute CINV is critical as it correlates with control of delayed emesis 2
• For high emetogenic risk: triple therapy with 5-HT3 antagonist + dexamethasone + aprepitant 1

Delayed CINV (persisting 1-5 days after therapy)

• Dexamethasone plus metoclopramide provides the best protection, though >40% still experience delayed symptoms 4
• Continue aprepitant on days 2-3 if used on day 1 1, 3

Refractory Nausea and Vomiting

• Add dopamine antagonists (e.g., metoclopramide) to 5-HT3 antagonists and corticosteroids 1
• Consider switching to a different 5-HT3 antagonist 5

Anticipatory Nausea and Vomiting

• Lorazepam 0.5-2 mg PO or IV or sublingual 1
• Behavioral techniques may be helpful 1

Important Clinical Considerations

• Oral and IV antiemetic formulations have equivalent efficacy 1
• For routine use, oral doses are recommended when possible 1
• 5-HT3 antagonists of the same class are of comparable efficacy 1
• High-dose ondansetron (32 mg IV) has been associated with QT interval prolongation 5
• When administering aprepitant with corticosteroids, reduce corticosteroid dose to 50% due to CYP3A4 interaction 1, 3

Pediatric Considerations

• 5-HT3 antagonists with dexamethasone are effective in pediatric patients receiving highly emetogenic chemotherapy 6
• For patients 12 years and older who can swallow capsules, adult dosing of aprepitant can be used 3