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Chemotherapy- and radiotherapy-induced nausea and vomiting

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Updated 2024 JSCO guidelines for the prevention and management of chemotherapy-induced nausea and vomiting.

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of chemotherapy- and radiotherapy-induced nausea and vomiting are prepared by our editorial team based on guidelines from the American Society of Clinical Oncology (ASCO 2024,2020), the Japan Society of Clinical Oncology (JSCO 2024), the Multinational Association of Supportive Care in Cancer (MASCC/ESMO 2024,2016), the Pediatric Oncology Group of Ontario (POGO 2023,2022,2021,2019), ...
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Diagnostic investigations

Clinical assessment: as per JSCO 2024 guidelines, use patient-reported outcomes to assess NV.
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Medical management

Management of breakthrough NV, first-line therapy: as per ESMO/MASCC 2024 guidelines, consider administering olanzapine 10 mg for 3 days, if not used for primary prophylaxis, in patients with breakthrough NV.
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More topics in this section

  • Management of breakthrough NV (second-line therapy)

  • Management of breakthrough NV (cannabinoids)

  • Management of anticipatory NV (prevention)

  • Management of anticipatory NV (benzodiazepines)

  • Management of anticipatory NV (behavioral therapy)

Specific circumstances

Pediatric patients, classification of emetogenicity: as per POGO 2019 guidelines, recognize that the following chemotherapy regimens are classified as follows:
Situation
Guidance
Highly emetogenic
Asparaginase erwinia IV ≥ 20,000 IU/m²/dose
Busulfan IV ≥ 0.8 mg/kg/dose
Busulfan PO ≥ 1 mg/kg/dose
Carboplatin IV ≥ 175 mg/m²/dose
Cisplatin IV ≥ 12 mg/m²/dose
Cyclophosphamide IV ≥ 1,200 mg/m²/dose
Cytarabine IV ≥ 3 g/m²/day
Dactinomycin IV ≥ 1.35 mg/m²/dose
Doxorubicin IV ≥ 30 mg/m²/dose
Idarubicin PO ≥ 30 mg/m²/dose
Melphalan IV
Methotrexate IV ≥ 12 g/m²/dose
Cyclophosphamide ≥ 600 mg/m²/dose + dactinomycin ≥ 1 mg/m²/dose
Cyclophosphamide ≥ 400 mg/m²/dose + doxorubicin ≥ 40 mg/m²/dose
Cytarabine ≥ 90 mg/m²/dose IV + methotrexate IV ≥ 150 mg/m²/dose
Cytarabine IV + teniposide IV
Dacarbazine ≥ 250 mg/m²/dose IV + doxorubicin IV ≥ 60 mg/m²/dose
Sactinomycin 900 µg/m²/dose IV + ifosfamide 3 g/m²/dose
Etoposide IV ≥ 60 mg/m²/dose + ifosfamide IV ≥ 1.2 g/m²/dose
Etoposide IV ≥ 250 mg/m²/dose + thiotepa IV ≥ 300 mg/m²/dose
Moderately emetogenic
Cyclophosphamide IV 1,000 mg/m²/dose
Cytarabine IV 75 mg/m²/dose
Dactinomycin IV 10 µg/kg/dose
Doxorubicin IV 25 mg/m²/dose
Gemtuzumab IV 3-9 mg/m²/dose
Imatinib PO > 260 mg/m²/day
Interferon alpha IV 15-30 million U/m²/day
Ixabepilone IV 3-10 mg/m²/dose
Methotrexate IV 5 g/m²/dose
Methotrexate intrathecal
Topotecan orallt 0.4-2.3 mg/m²/day
Cytarabine IV 100 mg/m²/dose + daunorubicin IV 45 mg/m²/dose + etoposide IV 100 mg/m²/dose + prednisolone PO + thioguanine PO 80 mg/m²/dose
Cytarabine 60 or 90 mg/m²/dose + methotrexate 120 mg/m²/dose
Liposomal doxorubicin IV 20-50 mg/m²/dose + topotecan PO 0.6 mg/m²/day
Low emetogenic
Cyclophosphamide IV 500 mg/m²/dose
Cyclophosphamide PO 2-3 mg/kg/dose
Dasatinib PO 60-120 mg/m²/dose
Erlotinib PO 35-150 mg/m²/day
Everolimus PO 0.8-9 mg/m²/day
Gefitinib PO 150-500 mg/m²/day
Imatinib PO 260 mg/m²/day
Mafosfamide intrathecal 1-6.5 mg/dose
Melphalan PO 0.2 mg/kg/dose
Mercaptopurine PO ≤ 4.2 mg/kg/dose
Methotrexate IV 38-83 mg/m²/dose
Mitoxantrone IV ≤ 33 mg/m²/dose
Procarbazine PO 50-100 mg/m²/day
Ruxolitinib PO 15-21 mg/m²/dose
Selumetinib PO 20-30 mg/m²/dose
Sorafenib PO 150-325 mg/m²/dose
Temozolomide PO 200 mg/m²/dose
Cytarabine IV 60 mg/m²/dose + methotrexate IV 90 mg/m²/dose
Minimally emetogenic
Asparaginase (E. coli) IM ≤ 6,000 IU/m²/dose
Asparaginase erwinia IM ≤ 25,000 IU/m²/dose
Chlorambucil PO ≤ 0.2 mg/kg/day
Doxorubicin IV 10 mg/m²/dose
Liposomal doxorubicin IV ≤ 50 mg/m²/dose
Mercaptopurine PO ≤ 4.2 mg/kg/dose
Methotrexate PO/SC ≤ 10 mg/m²/dose
Pracinostat 25-45 mg/m²/dose PO
Vincristine IV ≤ 1.5 mg/m²/dose
Cisplatin ≤ 60 mg/m²/dose intra-arterially + doxorubicin ≤ 30 mg/m²/dose intra-arterially
Cisplatin ≤ 60 mg/m²/dose intra-arterially + pirarubicin ≤ 30 mg/m²/dose intra-arterially
Mercaptopurine PO ≤ 2.5 mg/kg/dose + methotrexate orallt ≤ 0.1 mg/kg/day
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More topics in this section

  • Pediatric patients (prophylactic antiemetics, highly emetogenic chemotherapy)

  • Pediatric patients (prophylactic antiemetics, moderately emetogenic chemotherapy)

  • Pediatric patients (prophylactic antiemetics, low/minimally emetogenic chemotherapy)

  • Pediatric patients (management of breakthrough NV)

  • Pediatric patients (management of anticipatory NV)

  • Patients with advanced cancer

  • Patients with malignant bowel obstruction

Patient education

Nutritional counseling: as per ESMO/MASCC 2024 guidelines, consider providing nutritional advice/education on healthy eating practices and personalized diet plans, delivered by a dietitian or other healthcare practitioners, for the prevention and management of chemotherapy-induced NV.
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Preventative measures

Prophylactic antiemetics, highly emetogenic chemotherapy: as per ESMO/MASCC 2024 guidelines, administer a 4-drug combination of single doses of a 5-HT3-RA, dexamethasone, an NK1-RA (aprepitant, fosaprepitant, netupitant, fosnetupitant, or rolapitant), and olanzapine before non-anthracycline-cyclophosphamide highly emetogenic chemotherapy to prevent acute NV.
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More topics in this section

  • Prophylactic antiemetics (moderately emetogenic chemotherapy)

  • Prophylactic antiemetics (low/minimally emetogenic chemotherapy)

  • Prophylactic antiemetics (combination chemotherapy)

  • Prophylactic antiemetics (multiday chemotherapy)

  • Prophylactic antiemetics (chemotherapy and stem-cell/bone marrow transplantation)

  • Prophylactic antiemetics (chemotherapy and radiotherapy)

  • Prophylactic antiemetics (highly emetogenic radiotherapy)

  • Prophylactic antiemetics (moderately emetogenic radiotherapy)

  • Prophylactic antiemetics (low/minimally emetogenic radiotherapy)

  • Prophylactic antiemetics (opioids)

  • Prophylactic benzodiazepines

  • Prophylactic cannabinoids

  • Alternative and complementary therapies