NCCN Antiemetic Clinical Practice Guidelines 2022.2 (Chinese)

Table of contents for this article

Adapted with permission:

a.
Proportion
of patients who developed vomiting without effective antiemetic prophylaxis.

b.
These drugs may be highly emetogenic in some patients
.

c.
For some drugs with low risk of vomiting, factors related to dosing regimens (especially continuous administration) and clinical experience suggest that routine pretreatment
is not required.
Whether pretreatment is required or antiemetics prescribed as needed should be individualized
.

d.
Corticosteroid antiemetic pretreatment
should be avoided for 3 to 5 days before chimeric antigen receptor (CAR) T-cell therapy and for 90 days after.
Antiemetic regimens used in chemotherapy regimens for lymphocyte clearance should also be prophylactic antiemetic
using a corticosteroid-free approach.

Asparaginase includes pegasparaginase, asparaginase erwinia chrysanthemi, and asparaginase erwinia chrysanthemi (recombinant)-rywm.

See Emetogenic potential of parenteral anticancer drugs (AE-2).

Antiemetic regimens
should be selected based on the drug with the highest risk of vomiting and patient-specific risk factors.

See Principles of Management of Multi-Day Emetogenic Chemotherapy Regimens (AE-A).

i.
Lorazepam 0.
5–1 mg PO or IV or sublingually every 6 hours on days 1-4 as needed
.
For patients taking lorazepam for the first time, start
with 0.
5 mg.
If the patient presents with reflux symptoms, with or without H2 blockers or proton-pump inhibitors
.
See Principles of Vomiting Control in Cancer Patients (AE-1).

See Pharmacological Considerations for Antiemetic Prescription (AE-B)

k.
Data suggest that olanzapine at a dose of 5 mg is effective
.
Consider this dose
especially in older or overly sedated patients.
Hashimoto H, et al.
Lancet Oncol 2020; 21:242-249.
Mukhopadhyay S, et al.
Future Oncol 2021; 17:2041-2056.
See Pharmacological Precautions for Antiemetic Prescribing (AE-B).

When vomiting occurs during a previous chemotherapy cycle with triple regimen [olanzapine regimen (B, E) or NK1 RA regimen (C or F)], consider upgrading to quadruple regimen (A) [if not previously used].

Olanzapine-containing regimens may be useful
in patients with severe nausea.
See Principles for the Management of Breakthrough Vomiting (AE-C).

m.
Aprepitant injection emulsion is a unique dosage form of aprepitant and is not interchangeable
with the intravenous form of fosapitant.

n.
Available
as a fixed combination product only.

o.
Rolapitan has a long half-life, and the interval between administrations should not be less than 2 weeks
.

p.
If a fixed combination of netuppitant/palonosetron or fornetupitam/palonosetron is used, no further 5-HT3 RA
is required.

q.
When used in combination with NK1 RA, there is no preferred 5-HT3 RA.

See Principles of Management of Multi-Day Emetogenic Chemotherapy Regimens (AE-A).

R.
granisetron sustained-release injection is a unique formulation of granisetron that uses a polymer-based drug delivery system
.
This preparation is intended exclusively for subcutaneous administration and is not interchangeable
with intravenous preparations.
The half-life of granisetron sustained-release injection is prolonged, and the interval between administrations should not be less than 1 week
.

Emerging data and clinical practice suggest that dexamethasone doses may need to be individualized
.
Higher doses may be considered, especially when NK1RA is not given
at the same time.
Depending on patient characteristics, lower doses, shorter duration of administration, or even no dexamethasone in subsequent days may be acceptable (for delayed nausea and vomiting prophylaxis).

If dexamethasone is not used in subsequent days to prevent delayed nausea and vomiting, other alternative antiemetics (e.
g.
, olanzapine)
should be considered.
See discussion
.

When receiving cell therapy, corticosteroids should be avoided for pretreatment drugs
.
See Pharmacological Considerations for Antiemetic Prescription (AE-B).

If paronosetron or granisetron extended-release injection, or transdermal glasetron patch, is given on day 1, no further 5-HT3 treatment
is required.

v.
A 3-drug prophylaxis (E or F) is recommended for patients with other patient-relevant risk factors (see AE-1)
or who have failed prior therapy with glucocorticoids + 5-HT3 RA.
See Emetogenic potential of parenteral anticancer drugs (AE-3)

Antiemetic regimens
should be selected based on the drug with the highest risk of vomiting and patient-specific risk factors.

See Principles of Management of Multi-Day Emetogenic Chemotherapy Regimens (AE-A).

i.
Lorazepam 0.
5–1 mg PO or IV or sublingual every 6 hours on days 1-4 as required
.
For patients taking lorazepam for the first time, start
with 0.
5 mg.
If the patient presents with reflux symptoms, with or without H2 blockers or proton-pump inhibitors
.
See Principles of Vomiting Control in Cancer Patients (AE-1).

j.
See Pharmacological Considerations for Antiemetic Prescription (AE-B) adapted with permission from:

a.
Proportion
of patients who developed vomiting without effective antiemetic prophylaxis.

For some drugs at moderate to high risk of vomiting, factors related to dosing regimen (especially continuous administration) and clinical experience suggest that routine pretreatment
is not required.
Whether pretreatment is required or antiemetics prescribed as needed should be individualized
.

x.
The latest data and clinical practice suggest that the addition of low-dose olanzapine and/or NK1 RA or 5-HT3 RA prevents nausea
.

y.
When temozolomide ≤ 75 mg/m2/day is synchronized with radiotherapy, it should be considered a moderate risk
of vomiting.
Antiemetic regimens
should be selected based on the drug with the highest risk of vomiting and patient-specific risk factors.

See Principles of Management of Multi-Day Emetogenic Chemotherapy Regimens (AE-A).

i.
Lorazepam 0.
5–1 mg PO or IV or sublingual every 6 hours on days 1-4 as required
.
For patients taking lorazepam for the first time, start
with 0.
5 mg.
If the patient presents with reflux symptoms, with or without H2 blockers or proton-pump inhibitors
.
See Principles of Vomiting Control in Cancer Patients (AE-1).

See Pharmacological Considerations for Antiemetic Prescription (AE-B).

For some drugs at moderate to high risk of vomiting, factors related to dosing regimen (especially continuous administration) and clinical experience suggest that routine pretreatment
is not required.
Whether pretreatment is required or antiemetics prescribed as needed should be individualized
.

z.
See Emetogenic Potential of Oral Anticancer Drugs (AE-7).

aa.
These antiemetic recommendations are only available to patients with
oral chemotherapy.
When combined with intravenous chemotherapy, antiemetic recommendations
for drugs with the highest risk of emetogenesis should be followed.
If multiple oral medications are used in combination, the risk of vomiting may increase and preventive measures
may be required.

See Principles of Management of Multi-Day Emetogenic Chemotherapy Regimens (AE-A).

i.
Lorazepam 0.
5–1 mg PO or IV or sublingual every 6 hours on days 1-4 as required
.
For patients taking lorazepam for the first time, start
with 0.
5 mg.
If the patient presents with reflux symptoms, with or without H2 blockers or proton-pump inhibitors
.
See Principles of Vomiting Control in Cancer Patients (AE-1).

See Pharmacological Considerations for Antiemetic Prescription (AE-B).

bb.
See Principles for the Management of Breakthrough Vomiting (AE-C).

cc.
Not as part of a program for the prevention of
acute and delayed vomiting.

DD.
The oral bioavailability of dronabinol oral liquid is higher than that of dronabinol capsule; 2.
1mg oral liquid = 2.
5mg capsule
.

See Pharmacological Considerations for Antiemetic Prescription (AE-B)

i.
Lorazepam 0.
5–1 mg PO or IV or sublingual every 6 hours on days 1-4 as required
.
For patients taking lorazepam for the first time, start
with 0.
5 mg.
If the patient presents with reflux symptoms, with or without H2 blockers or proton-pump inhibitors
.
See Principles of Vomiting Control in Cancer Patients (AE-1).

See Pharmacological Considerations for Antiemetic Prescription (AE-B).

a.
The panel noted that there is a lack of evidence to support every clinical scenario
.
For each chemotherapy regimen and each patient, individual decisions
should be made.
Extensive knowledge of available clinical data, pharmacology, pharmacodynamics, and pharmacokinetics of antiemetic and chemotherapy agents, as well as patient experience (regarding tolerability and efficacy), is critical
to the successful implementation of these guidelines in clinical practice.

a.
Patients with other risk factors for QT interval prolongation should use this product with caution and monitor ECG
.

Treatment of dystonic response
with diphenhydramine 25-50 mg PO/IV every 4 or 6 hours.
If diphenhydramine is allergic, benztropine 1-2 mg IV or IM x 1 dose is used, followed by oral administration of 1-2 mg or 2 times a
day as needed.
Amantadine 100 mg BID-TID may be considered for the treatment of dystonia-induced dystonia in
patients who do not tolerate anticholinergic agents.