What is the recommended preparation and administration of Palonosetron (5-HT3 receptor antagonist) for the prevention of Chemotherapy-Induced Nausea and Vomiting (CINV) or Postoperative Nausea and Vomiting (PONV) in adult and pediatric patients with varying degrees of renal function?

Palonosetron Preparation and Administration

For chemotherapy-induced nausea and vomiting (CINV), administer palonosetron 0.25 mg IV as a single dose over 30 seconds, approximately 30 minutes before chemotherapy initiation; for postoperative nausea and vomiting (PONV), administer 0.075 mg IV over 10 seconds immediately before anesthesia induction. 1

Dosing for CINV

Standard Adult Dose

• Single dose of 0.25 mg IV administered over 30 seconds 1
• Timing: Give approximately 30 minutes before the start of chemotherapy 1, 2
• No repeat dosing is needed - a single dose is as effective as multiple doses 3
• The 0.25 mg and 0.75 mg doses show equivalent efficacy based on meta-analysis of eight trials 3

Combination Therapy Requirements

For Highly Emetogenic Chemotherapy (HEC):

• Palonosetron 0.25 mg IV (Day 1 only) 3
• PLUS Dexamethasone 12 mg IV/PO (Day 1) 3
• PLUS NK1 receptor antagonist (aprepitant 125 mg PO or fosaprepitant 150 mg IV on Day 1, then aprepitant 80 mg PO on Days 2-3) 3
• 5-HT3 antagonists like palonosetron are given on Day 1 only, not continued for delayed emesis 3

For Moderately Emetogenic Chemotherapy (MEC) - Non-AC regimens:

• Palonosetron 0.25 mg IV (Day 1) 3
• PLUS Dexamethasone (Days 1-3) 3
• Palonosetron is the preferred 5-HT3 antagonist for MEC due to superior delayed emesis control 3

For AC Chemotherapy (Anthracycline + Cyclophosphamide):

• Add NK1 receptor antagonist to the palonosetron/dexamethasone combination 3
• If NK1 antagonist unavailable, palonosetron is the preferred 5-HT3 antagonist over other options 3

Dosing for PONV

• Single dose of 0.075 mg IV administered over 10 seconds 1
• Timing: Give immediately before induction of anesthesia 1
• Efficacy is established only for the first 24 hours following surgery 1

Preparation and Administration Details

Formulation Available

• Intravenous formulation only - no oral formulation is currently available in most markets 3, 2
• Supplied as 0.25 mg/5 mL single-use vial (for CINV) 1
• Supplied as 0.075 mg/1.5 mL single-use vial (for PONV) 1

Administration Technique

• For CINV: Administer over 30 seconds 1
• For PONV: Administer over 10 seconds 1
• Can be given as direct IV push or through running IV line 1
• No dilution is required, though compatible with normal saline if dilution is preferred 1

Special Populations

Renal Impairment

• No dose adjustment is required for any degree of renal impairment 1
• Palonosetron can be safely used in patients with renal dysfunction without modification 1

Pediatric Patients

• Safety and effectiveness have not been established in patients below 18 years of age 1
• Current FDA approval is limited to adult patients only 1, 4

Hepatic Impairment

• No specific dose adjustments are mentioned in the FDA label, suggesting standard dosing applies 1

Important Clinical Considerations

Timing is Critical

• Must be given before chemotherapy or anesthesia - not effective if given after nausea/vomiting has already started 1
• The 30-minute window before chemotherapy allows adequate receptor binding 2

Single Dose Strategy

• Do not repeat palonosetron dosing on subsequent days for delayed CINV 3
• The long half-life (approximately 40 hours) provides extended protection from a single dose 5, 4
• Other antiemetics (dexamethasone, NK1 antagonists) continue on Days 2-3, but not palonosetron 3

Common Pitfalls to Avoid

• Do not use the higher 0.75 mg dose - it offers no additional benefit over 0.25 mg and is not FDA-approved 3
• Do not confuse CINV and PONV dosing - they require different doses (0.25 mg vs 0.075 mg) 1
• Do not use palonosetron alone for HEC - it must be combined with dexamethasone and NK1 antagonist 3
• Do not give 5-HT3 antagonists on Days 2-4 for HEC - this is outdated practice 3

Hypersensitivity Precautions

• Contraindicated in patients with known hypersensitivity to palonosetron or any component 1
• May cause hypersensitivity reactions in patients who have reacted to other 5-HT3 antagonists 1

Most Common Adverse Effects

• Headache and constipation are the most frequently reported adverse events (incidence ≥5%) 1, 5
• For PONV, additional common effects include QT prolongation and bradycardia (incidence ≥2%) 1