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Acute emesis: moderately emetogenic chemotherapy

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Abstract

This paper is a review of the recommendations for the prophylaxis of acute emesis induced by moderately emetogenic chemotherapy as concluded at the Perugia Consensus Conference, which took place at the end of March 2004. The review focuses on new studies appearing since the last consensus conference in 1997. The following issues are addressed: dose and schedule of antiemetics, different groups of antiemetics such as corticosteroids, serotonin (5-HT3)-receptor antagonists, dopamine D2 receptor antagonists, and neurokinin (NK1) receptor antagonists. Antiemetic prophylaxis in patients receiving multiple cycles of moderately emetogenic chemotherapy is also reviewed. Consensus statements are given, including optimal dose and schedule of 5-HT3-receptor antagonists and of dexamethasone. The new 5-HT3-receptor antagonist, palonosetron, is a reasonable alternative to the well-established agents of this class—ondansetron, granisetron, tropisetron and dolasetron. It is concluded that the best prophylaxis in patients receiving moderately emetogenic chemotherapy is still the combination of one of the 5-HT3-receptor antagonists and dexamethasone. The results of studies adding a NK1-receptor antagonist to this combination are awaited and might change future recommendations.

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Author information

Authors and Affiliations

  1. Department of Oncology 54 B1, Copenhagen University Hospital, DK-2730, Herlev, Denmark

    Jørn Herrstedt

  2. University of Texas Health Science Center at San Antonio, San Antonio, TX, USA

    Jim M. Koeller

  3. Policlinico Hospital, Perugia, Italy

    Fausto Roila

  4. Caritas St. Elizabeth’s Medical Center of Boston, Boston, MA, USA

    Paul J. Hesketh

  5. Princess Margaret Hospital, University of Toronto, Canada

    David Warr

  6. Rittenberg Oncology Consulting, Metairie, LA, USA

    Cynthia Rittenberg

  7. Luxembourg Medical Center, Luxembourg

    Mario Dicato

Authors
  1. Jørn Herrstedt
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  2. Jim M. Koeller
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  3. Fausto Roila
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  4. Paul J. Hesketh
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  5. David Warr
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  6. Cynthia Rittenberg
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  7. Mario Dicato
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Corresponding author

Correspondence to Jørn Herrstedt.

Appendix: Consensus statements

Appendix: Consensus statements

  1. 1.

    A 5-HT3-receptor antagonist plus dexamethasone is recommended for prophylaxis of acute nausea and vomiting in the first course of MEC.

    MASCC Level of confidence: high. Level of consensus: high

    ASCO Level of evidence: I. Grade of recommendation: A

  2. 2.

    There is no difference in the effectiveness of oral or i.v. administration of a 5-HT3-receptor antagonist (palonosetron is only available as an i.v. formulation).

    MASCC Level of confidence: high. Level of consensus: high

    ASCO Level of evidence: I. Grade of recommendation: A

  3. 3.

    Recommended doses of 5-HT3-receptor antagonists in MEC (palonosetron is only available as an i.v. formulation).

    • The recommended oral dose of ondansetron is 16 mg (randomized studies have tested the 8 mg twice-daily schedule).

      MASCC Level of confidence: high. Level of consensus: high

      ASCO Level of evidence: I. Grade of recommendation: A

    • The recommended i.v. dose of ondansetron is 8 mg or 0.15 mg/kg as a single dose.

      MASCC Level of confidence: moderate. Level of consensus: high

      ASCO Level of evidence: III. Grade of recommendation: B

    • The recommended oral dose of granisetron is 2 mg as a single dose.

      MASCC Level of confidence: high. Level of consensus: high

      ASCO Level of evidence: I. Grade of recommendation: A

    • The recommended i.v. dose of granisetron is 1 mg or 0.01 mg/kg as a single dose.

      MASCC Level of confidence: high. Level of consensus: high

      ASCO Level of evidence: I. Grade of recommendation: A

    • The recommended oral dose of dolasetron is 100 mg as a single dose.

      MASCC Level of confidence: moderate. Level of consensus: high

      ASCO Level of evidence: II. Grade of recommendation: A

    • The recommended i.v. dose of dolasetron is 100 mg or 1.8 mg/kg as a single dose.

      MASCC Level of confidence: moderate. Level of consensus: high

      ASCO Level of evidence: II. Grade of recommendation: A

    • The recommended oral dose of tropisetron is 5 mg as a single dose.

      MASCC Level of confidence: low. Level of consensus: high

      ASCO Level of evidence: III. Grade of recommendation: B

    • The recommended i.v. dose of tropisetron is 5 mg as a single dose.

      MASCC Level of confidence: moderate. Level of consensus: high

      ASCO Level of evidence: III. Grade of recommendation: B

    • The recommended i.v. dose of palonosetron is 0.25 mg as a single dose.

      MASCC Level of confidence: high. Level of consensus: high

      ASCO Level of evidence: I. Grade of recommendation: A

  4. 4.

    Effectiveness and toxicity of the 5-HT3-receptor antagonists.

    • There are no clinically relevant differences in the effectiveness of the 5-HT3-receptor antagonists in the prophylaxis of acute nausea and vomiting when given according to guidelines in the first cycle of MEC.

      MASCC Level of confidence: high. Level of consensus: high

      ASCO Level of evidence: I. Grade of recommendation: A

    • There are no clinically relevant differences in the toxicity of the 5-HT3-receptor antagonists.

      MASCC Level of confidence: high. Level of consensus: high

      ASCO Level of evidence: I. Grade of recommendation: A

  5. 5.

    The recommended dose of dexamethasone for prophylaxis of acute nausea and vomiting from MEC is 8 mg i.v. as a single dose.

    MASCC Level of confidence: moderate. Level of consensus: high

    ASCO Level of evidence: II. Grade of recommendation: B

  6. 6.

    The antiemetic effect of the standard prophylaxis (5-HT3-receptor antagonist plus dexamethasone) declines during multiple cycles (more than 3) of MEC.

    MASCC Level of confidence: high. Level of consensus: high

    ASCO Level of evidence: I. Grade of recommendation: A

  7. 7.

    A dopamine antagonist can be used as supplement in the subsequent cycles in patients who experience nausea/emesis from MEC after treatment with standard antiemetic therapy (5-HT3-receptor antagonist plus dexamethasone).

    MASCC Level of confidence: moderate. Level of consensus: high

    ASCO Level of evidence: II. Grade of recommendation: B

  8. 8.

    A benzodiazepine can be used as supplement in the subsequent cycles in patients who experience nausea/emesis from MEC after treatment with standard antiemetic therapy (5-HT3-receptor antagonist plus dexamethasone).

    MASCC Level of confidence: moderate. Level of consensus: moderate

    ASCO Level of evidence: II. Grade of recommendation: B

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Herrstedt, J., Koeller, J.M., Roila, F. et al. Acute emesis: moderately emetogenic chemotherapy. Support Care Cancer 13, 97–103 (2005). https://doi.org/10.1007/s00520-004-0701-7

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