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MASCC antiemetics in advanced cancer updated guideline

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Abstract

Background

Nausea and vomiting are a common clinical symptom in the advanced cancer patient. Pharmacologic management is important. Evidence for drug choices and guidelines are needed to help clinicians manage nausea and vomiting in this population

Methods

Evidence from a systematic review published in 2010, initial MASCC guidelines developed from a systematic review of literature to 2015, and a new systematic review of randomized trials published between 2015 and February 2, 2021, was combined to establish a new guideline.

Results

A search of the literature between 2015 and February 2, 2021, revealed 257 abstracts of which there was one systematic review and 4 randomized trials which were used to modify the guideline. The new guideline is as follows: First Line: Metoclopramide (II) multiple small RCTs including a placebo-controlled trial, haloperidol (II) multiple non-placebo-controlled RCTs, high consensus. Second line: Methotrimeprazine (II) 1 well-powered non-placebo-controlled RCT, olanzapine (II) 1 placebo-controlled pilot RCT, high consensus. Third line: Tropisetron (II) large unblinded lower quality non-placebo-controlled RCT, levosulpiride (II) 1 blinded non-placebo-controlled pilot RCT, high consensus.

Discussion

Haloperidol, metoclopramide, methotrimeprazine, olanzapine tropisetron, and levosulpiride have been antiemetics used in randomized trials with antiemetic activity demonstrated. There are only three placebo-controlled randomized trials we could find in our literature review. Placebo responses varied significantly between two randomized trials. More randomized placebo-controlled trials with either metoclopramide or haloperidol rescue are needed to clarify antiemetic choices in advanced cancer.

Conclusion

First-line antiemetics for nausea and vomiting in advanced cancer are metoclopramide and haloperidol, and second-line medications are methotrimeprazine and olanzapine.

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Author information

Authors and Affiliations

  1. Geisinger Health System, Danville, PA, USA

    Mellar Davis

  2. Department of Palliative, Rehabilitation and Integrative Medicine, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

    David Hui & Eduardo Bruera

  3. Trinity College Dublin, University College Dublin, and Our Lady’s Hospice Dublin, Dublin, Ireland

    Andrew Davies

  4. Supportive Care in Cancer Unit, Fondazione IRCCS, Istituto Nazionale dei Tumori, Onco-Haematology, Milan, Italy

    Carla Ripamonti & Giulia DeFeo

  5. Associação de Investigação de Cuidados de Suporte em Oncologia (AICSO) and Centro Hospitalar Vila Nova de Gaia, Espinho, Portugal

    Andreia Capela

  6. Palliative Care Endowed Chair Division of Hematology, Oncology & Palliative Care Virginia Commonwealth University Massey Cancer Center, Richmond, VA, USA

    Egidio Del Fabbro

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  1. Mellar Davis
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  2. David Hui
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Contributions

Systematic search: Mellar Davis, David Hui; manuscript development and writing: Mellar Davis, Andrew Davies; editing and critiquing: David Hui, Andrew Davies, Carla Ida Ripamonti, Andreia Capela, Giulia DeFeo, Egidio Del Fabbro, Eduardo Bruera.

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Correspondence to Mellar Davis.

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David Hui grant from Helsinn.

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Davis, M., Hui, D., Davies, A. et al. MASCC antiemetics in advanced cancer updated guideline. Support Care Cancer 29, 8097–8107 (2021). https://doi.org/10.1007/s00520-021-06437-w

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