ANTIEMETICS GUIDELINESS

Changes clinical practice: 1. Patients receiving adriamycin and cytoxan (AC) should receive the three-drug anti-emetic combination used for patients receiving highly emetogenic chemotherapy including 12mg of dexamethasone oral or intravenous (IV) on day 1, and 8mg dexamethasone oral or IV on days 2-3 or 2-4.
2. Patients receiving moderately emetogenic chemotherapy should receive palonosetron on day 1, along with Dexamethasone 8mg oral or IV on days 1-3.
I am endorsing this article because it includes the executive summary of the recently (2011) updated American Society of Clinical Oncology (ASCO) anti-emetic guidelines for patients receiving emetogenic chemotherapy or radiotherapy, and therefore it affects the well-being of millions of cancer patients and their families.
The article updates the 2006 ASCO Anti-emetic guidelines for adults and children who are receiving emetogenic chemotherapy (highly or moderately emetogenic, or of low or minimal emetogenic potential), high dose chemotherapy with stem-cell or bone marrow transplantation, multiday chemotherapy, anticipatory nausea and vomiting, or radiation with emetogenic potential (high, moderate, low or minimal risk) or receiving combined chemotherapy and radiation.
It contains an updated list of the chemotherapeutic agents and sites of radiation that fall into each of the categories, as well as a useful table of key recommendations on page 4190, called 'The Bottom Line'.
Key recommendations that I think have immediate impact for clinical practice include the following:

1. The role of dexamethasone for patients receiving chemotherapy or radiation
   1. Standard chemotherapy: A three drug combination of a NK-1 antagonist, a 5-HT3 antagonist and dexamethasone is still recommended for patients receiving highly emetogenic chemotherapy (adriamycin and cytoxan [AC] therapy is now considered highly emetogenic chemotherapy). Of note, the 5-HT3 antagonist should be given ONLY on day 1, but the dexamethasone should be given on days 1-3 or 1-4. Informal polling of practicing oncologists and, I think, a study by Dr Steven Grunberg (I am unable to find the reference for this) indicated that dexamethasone was often omitted on days 2-4. Studies clearly show that the dexamethasone enhances the antiemetic efficacy of NK-1 inhibitors and of 5-HT3 inhibitors; if given early in the day, it is usually well-tolerated for the 2 to 3 days following chemotherapy.
   2. High-dose chemotherapy: both dexamethasone and a 5-HT3 antagonist are recommended for patients undergoing stem-cell or bone marrow transplant.
   3. Radiation: a 5-HT3 antagonist is indicated daily before each fraction of high or moderate emetic risk radiation, along with a 5-day course of dexamethasone (for moderate risk, the dexamethasone is optional). This remains unchanged from the 2006 guideline.
2. Palonosetron (day 1) is the preferred 5-HT3 antagonist for patients receiving moderately emetogenic chemotherapy, along with a corticosteroid (day 1-3). One day of dexamethasone may be enough, but additional trials are needed before the recommendation for a 3-day course is changed.
3. Multi-day chemotherapy: as in the 2006 guideline, anti-emetics appropriate for the risk class should be given each day and up to 2 days following the end of therapy. A 5-HT3 antagonist can be included with dexamethasone and aprepitant for regimens containing cisplatin (limited data).
4. Complementary therapy: data were not felt strong enough for an endorsement of any specific complementary therapy.
5. Adjunctive lorazepam and diphenhydramine were still recommended as useful.