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  • Antiemesis

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    NCCN Clinical Practice Guidelines in Oncology

    AntiemesisV.2.2008

    www.nccn.org

  • Version 2.2008, 01/11/08 2008 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.

    Guidelines Index

    Antiemesis Table of Contents

    MS, ReferencesAntiemesisPractice Guidelinesin Oncology v.2.2008NCCN

    NCCN Antiemesis Panel Members

    Steve Kirkegaard, PharmDHuntsman Cancer Institute at the Universityof Utah

    Mark G. Kris, MD Memorial Sloan-Kettering Cancer Center

    Dean Lim, MD City of Hope

    Michael Anne Markiewicz, PharmDUniversity of Alabama at BirminghamComprehensive Cancer Center

    Lida Nabati, MD Dana-Farber/Brigham and Women's CancerCenter | Massachusetts General HospitalCancer Center

    Dwight D. Kloth, PharmD, FCCP, BCOPFox Chase Cancer Center

    Carli Nesheiwat, PharmD, BCOPSt. Jude Children's ResearchHospital/University of TennesseeCancer Institute

    Hope S. Rugo, MD UCSF Helen Diller FamilyComprehensive Cancer Center

    Steven M. Sorscher, MD

    Barbara Todaro, PharmDRoswell Park Cancer Institute

    Susan Urba, MD University of MichiganComprehensive Cancer Center

    Siteman Cancer Center at Barnes-Jewish Hospital and WashingtonUniversity School of Medicine

    #

    *

    Hematology/hematology oncology

    Internal medicine

    Medical Oncology

    Nurse

    Pharmacology

    Supportive Care including Palliative, Pain management,Pastoral care and Oncology social work

    Writing Committee member

    *David S. Ettinger, MD/Chair

    The Sidney Kimmel Comprehensive

    Cancer Center at Johns Hopkins

    Duke Comprehensive Cancer Center

    Michael J. Berger, PharmD, BCOPArthur G. James & Richard J. Solove

    Research Institute at The Ohio State

    University

    Sally Barbour, PharmD, BCOP

    Philip J. Bierman, MD

    UNMC Eppley Cancer Center at The

    Nebraska Medical Center

    Bob Bradbury, BCPSH. Lee Moffitt Cancer Center & ResearchInstitute at the University of South Florida

    Georgianna Ellis, MD Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance

    *

    *

    Continue

  • Version 2.2008, 01/11/08 2008 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.

    Guidelines Index

    Antiemesis Table of Contents

    MS, ReferencesAntiemesisPractice Guidelinesin Oncology v.2.2008NCCN

    Table of Contents

    CHEMOTHERAPY INDUCED:

    RADIATION-INDUCED:

    ANTICIPATORY:

    NCCN Antiemesis Panel Members

    High Emetic Risk Chemotherapy - Emesis Prevention (AE-2)

    Moderate Emetic Risk Chemotherapy - Emesis Prevention (AE-3)

    Low and Minimal Emetic Risk Chemotherapy - Emesis Prevention (AE-4)

    Breakthrough Treatment for Chemotherapy Induced Nausea and Vomiting (AE-5)

    Emetogenic Potential of Antineoplastic Agents (AE-6)

    Principles of Managing Multi-Day Emetogenic Chemotherapy Regimens (AE-A)

    Principles For Managing Breakthrough Emesis (AE-B)

    Radiation-induced nausea and vomiting (AE-8)

    Anticipatory nausea and vomiting (AE-9)

    Summary Of Guidelines Updates

    Priniciples Of Emesis Control (AE-1)

    Guidelines Index

    Print the Antiemesis Guideline

    Order the Patient Version of the Antiemesis Guideline

    These guidelines are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment.Any clinician seeking to apply or consult these guidelines is expected to use independent medical judgment in the context of individual clinicalcircumstances to determine any patient's care or treatment. The National Comprehensive Cancer Network makes no representations nor warrantiesof any kind whatsoever regarding their content, use, or application and disclaims any responsibility for their application or use in any way. Theseguidelines are copyrighted by National Comprehensive Cancer Network. All rights reserved. These guidelines and the illustrations herein may notbe reproduced in any form without the express written permission of NCCN. 2008.

    For help using thesedocuments, please click here

    Manuscript

    References

    Clinical Trials:

    Categories of Evidence andConsensus:NCCN

    Thebelieves that the best managementfor any cancer patient is in a clinicaltrial. Participation in clinical trials isespecially encouraged.

    To find clinical trials online at NCCNmember institutions,

    All recommendationsare Category 2A unless otherwisespecified.

    See

    NCCN

    click here:nccn.org/clinical_trials/physician.html

    NCCN Categories of Evidenceand Consensus

  • Version 2.2008, 01/11/08 2008 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.

    Guidelines Index

    Antiemesis Table of Contents

    MS, ReferencesAntiemesisPractice Guidelinesin Oncology v.2.2008NCCN

    SUMMARY OF GUIDELINES UPDATES

    Change in the 2.2008 version of the NCCN Antiemesis Guidelines from the 1.2008 version is the addition of the 2008 manuscript.

    Deleted recommendation prochlorperazine for 15 mg Spansule PO every 8 or every 12 h throughout the guidelines.

    Added Vorinostat to the list of agents with low emetic risk.

    Added Cetuximab, Lapatinib, Panitumumab, and Temsirolimus to the list of agents with minimal emetic risk.

    The general principle of breakthrough treatment is to give an additional agent from a different drug class. Added the following

    statement: No one treatment is better than the other for managing breakthrough emesis.

    Multiple concurrent agents, perhaps in alternating schedules or by alternating routes, may be necessary. Added the following

    statement: Dopamine antagonists (eg, metoclopramide), haloperidol, corticosteroids and agents such as lorazepam may be required.

    Summary of changes in the 1.2008 version of the NCCN Antiemesis Guidelines from the 1.2007 version include:

    Added footnote g: "Monitor for dystonic reactions; use diphenhydramine for dystonic reactions."

    General

    AE-4

    AE-7

    AE-B Principles for Managing Breakthrough Emesis

    UPDATES

    Note: All recommendations are category 2A unless otherwise indicated.

    Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.

  • Version 2.2008, 01/11/08 2008 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.

    Guidelines Index

    Antiemesis Table of Contents

    MS, ReferencesAntiemesisPractice Guidelinesin Oncology v.2.2008NCCN

    PRINCIPLES OF EMESIS CONTROL IN THE CANCER PATIENT

    Note: All recommendations are category 2A unless otherwise indicated.

    Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.

    AE-1

    Prevention of nausea/vomiting is the goal.

    The risk of emesis and nausea for persons receiving chemotherapy of high

    and moderate emetic risk lasts for at least 4 days. Patients need to be

    protected throughout the full period of risk.

    Oral and IV antiemetic formulations have equivalent efficacy.

    Consider the toxicity of the specific antiemetic(s) .

    Choice of antiemetic(s) used should be based on the emetic risk of the

    therapy, prior experience with antiemetics, as well as patient factors.

    There are other potential causes of emesis in cancer patients.

    These may include:Partial or complete bowel obstructionVestibular dysfunctionBrain metastasesElectrolyte imbalance: hypercalcemia, hyperglycemia, hyponatremiaUremiaConcomitant drug treatments including opiatesGastroparesis, tumor or chemotherapy (vincristine etc) induced.Psychophysiologic:

    AnxietyAnticipatory nausea and vomiting

    For use of antiemetics for nausea and vomiting that is not related to

    radiation and/or chemotherapy, See NCCN Palliative Care Guidelines

  • Version 2.2008, 01/11/08 2008 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.

    Guidelines Index

    Antiemesis Table of Contents

    MS, ReferencesAntiemesisPractice Guidelinesin Oncology v.2.2008NCCN

    Note: All recommendations are category 2A unless otherwise indicated.

    Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.

    AE-2

    HIGH EMETIC RISK CHEMOTHERAPY - EMESIS PREVENTIONb,c

    Higha

    Start before chemotherapyAprepitant 125 mg PO day 1, 80 mg PO daily days 2-3

    andDexamethasone 12 mg PO or IV day 1, 8 mg PO or IV daily days 2-4

    and

    Lorazepam 0.5-2 mg PO or IV or sublingual either every 4 or every 6 h days 1-4

    b,c

    5-HT3 antagonist:

    Ondansetron 16-24 mg PO or 8-12 mg (maximum 32 mg) IV day 1

    or

    Granisetron 2 mg PO or 1 mg PO bid or 0.01 mg/kg (maximum 1 mg) IV day 1

    or

    Dolasetron 100 mg PO or 1.8 mg/kg IV or 100 mg IV day 1

    or

    Palonosetron 0.25 mg IV day 1

    and

    d

    a

    d

    Data for post-cisplatin ( 50 mg/m ) emesis prevention