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Chemotherapy- and radiotherapy-induced nausea and vomiting

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 Multinational Association of Supportive Care in Cancer (MASCC/ESMO 2024; 2016), the Pediatric Oncology Group of Ontario (POGO 2023; 2022; 2021; 2019), the Multinational Association of Supportive Care in Cancer (MASCC 2022), the European Society of Medical Oncology (ESMO 2021), and the American Society of Clinical Oncology (ASCO 2020).
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Guidelines

1.Diagnostic investigations

Clinical assessment: re-evaluate emetic risk, disease status, concurrent illnesses, and medications in patients with breakthrough nausea or vomiting. Ascertain that the best regimen is being administered for the emetic risk.
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2.Medical management

Management of breakthrough nausea and vomiting, first-line therapy, ESMO/MASCC: 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)

3.Specific circumstances

Pediatric patients, classification of emetogenicity: 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

4.Patient education

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

Prophylactic antiemetics, highly emetogenic chemotherapy, ESMO/MASCC: 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/BMT)

  • 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