clinical recommendations
Annals of Oncology 20 (Supplement 4): iv156–iv158, 2009 doi:10.1093/annonc/mdp160
Chemotherapy-induced nausea and vomiting: ESMO Clinical Recommendations for prophylaxis J. Herrstedt1 & F. Roila2 On behalf of the ESMO Guidelines Working Group* 1
Department of Oncology, Odense University Hospital, Odense, Denmark; 2Department of Medical Oncology, S. Maria Hospital, Terni, Italy
other causes of nausea and vomiting to be considered in cancer patients Radiotherapy, radiosensitizers, infection, metabolic disorders, electrolyte disturbances, constipation, gastrointestinal obstruction, cachexia syndrome, metastases (brain, liver, bone), paraneoplasia, other emetogenic medication (e.g. opioids, antibiotics, antifungals, amifostine) and psychological.
note Levels of evidence [I–V] and grades of recommendation [A–D] as used by the American Society of Clinical Oncology are given in square brackets. Statements without grading were considered justified standard clinical practice by the expert authors and the ESMO faculty.
antiemetics
literature
5-Hydroxytryptamine type 3 receptor (5HT3) (serotonin) antagonists, corticosteroids and aprepitant are usually given once daily. However, for delayed emesis corticosteroids are given twice daily Dopamine antagonists are given three or four times daily. For routine use oral doses are recommended [I, A]. Palonosetron is only available as an i.v. formulation. Substances of the same class are of comparable efficacy [I, A].
1. The Antiemetic Subcommittee of the Multinational Association of Supportive Care in Cancer. Prevention of chemotherapy- and radiotherapy-induced emesis: results of the 2004 Perugia International Antiemetic Consensus Conference. Ann Oncol 2006; 17: 20–28. 2. Antiemetic resource center at www.mascc.org.
antiemetic administration Antiemetics are given prophylactically 30–60 min before the start of chemotherapy. If a patient has nausea and vomiting, treatment should be given intravenously. Recommendations concern chemotherapy-naive patients. The oral agents are those with the lowest emetic risk. A single antiemetic is often sufficient as prophylaxis. The oral agents rarely induce delayed nausea and vomiting and no routine prophylaxis after day 1 is recommended.
*Correspondence to: ESMO Guidelines Working Group, ESMO Head office, Via L. Taddei 4, CH-6962 Viganello-Lugano, Switzerland; E-mail:
[email protected] Approved by the ESMO Guidelines Working Group: April 2002, last update September 2008. This publication supercedes the previously published version—Ann Oncol 2008; 19 (Suppl 2): ii110–ii112.
Table 1. Definitions of nausea and vomiting Definition
Time of onset
Acute nausea and vomiting Delayed nausea and vomiting Anticipatory nausea and vomiting
Initial 24 h after chemotherapy Later than 24 h after chemotherapy Days to hours before chemotherapy
Table 2. Relative emetogenic potential of chemotherapy (if no antiemetic prophylaxis is used) High (emetic risk ‡90%)
Conflict of interest: Professor Herrstedt has reported that he performs ad hoc advisory board activity for Merck, GSK, Helsinn, Schering-Plough and Amgen; he is currently conducting research sponsored by Merck; Dr Roila has reported that he is a member of the advisory board on Palonosetron for Helsinn Healthcare, on Aprepitant for Merck, Sharp & Dohme; he is conducting research sponsored by GSK and Merck, Sharp & Dohme on casopitant and fosaprepitant; he has been a speaker at a Satellite Symposium organized by Merck, Helsinn and Italfarmaco.
ª The Author 2009. Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved. For permissions, please email:
[email protected]
Intravenous agents Cisplatin Mechloretamine Streptozotocin Carmustine Cyclophosphamide ‡1500 mg/m2 Dacarbazine Oral agents Hexamethylmelamine Procarbazine
clinical recommendations
Annals of Oncology
Table 3. Antiemetics: schedules and doses
Table 2. (Continued) Moderate (emetic risk 30–90%)
Low (emetic risk 10–30%)
Minimal (emetic risk 1 g/m2 Carboplatin Ifosfamide Cyclophosphamide
