Recommendations for preventing nausea and vomiting after chemotherapy

When comparing the efficacy of antiemetics, the "gold standard" is the 5-HT3 antagonist ondansetron. Unless otherwise stated, antiemetic regimens are used to prevent nausea and vomiting after one-day chemotherapy with one of the cytostatics that has the specified degree of emetogenicity. When using a combination of cytostatics, the emetogenicity of therapy is usually (unless otherwise stated) determined by the most emetogenic drug included in its composition; a distinction is made between highly, moderately, lowly, and minimally emetogenic drugs.

[ 1 ], [ 2 ], [ 3 ], [ 4 ]

Highly emetogenic chemotherapy

When conducting highly emetogenic therapy, the risk of developing vomiting without adequate antiemetic therapy is >90%. Drugs with highly emetogenic potential:

• drugs for intravenous administration cisplatin, cyclophosphamide >1500 mg/m2 ^, carmustine, dacarbazine,
• Oral medications procarbazine (Natulan).

Algorithm for prescribing antiemetic therapy when aprepitant (emend) can be used

Preparation	Prevention of acute vomiting (day of chemotherapy)	Prevention of delayed vomiting
		Day + 1	Day + 2	Day + 3
Ondansetron*	8 mg intravenously by drip 15 minutes before chemotherapy or 8 mg taken orally 1 hour before chemotherapy and 8 mg taken orally 12 hours later	-**	-**	-**
Dexamethasone	12 mg intravenously by jet stream 15 minutes before chemotherapy	8 mg intake	8 mg orally	8 mg orally
Aprepitant	125 mg orally one hour before chemotherapy	80 mg orally in the morning	80 mg orally in the morning	-

• * From here on, granisetron at a dose of 3 mg intravenously, 2 mg taken orally, tropisetron at a dose of 5 mg intravenously or taken orally may be used as an alternative.
• ** From here on, it is permissible to use it as an alternative to dexamethasone in case of its intolerance or to use an additional dose, for example, in case of nausea and/or vomiting.

Algorithm for prescribing when aprepitant (emend*) cannot be used

Preparation	Prevention of acute vomiting (day of chemotherapy)	Prevention of delayed vomiting
		Day + 1	Day + 2	Day + 3
Ondansetron*	8 mg intravenously by drip 15 minutes before chemotherapy or 8 mg taken orally 1 hour before chemotherapy and 8 mg taken orally 12 hours later	-**	-**	-**
Dexamethasone	20 mg intravenously by jet stream 15 minutes before chemotherapy	8 mg orally 2 times daily	8 mg orally 2 times daily	8 mg orally 2 times daily

*,** - see previous table.

Algorithm for the prevention of vomiting during multi-day highly emetogenic chemotherapy

Preparation	Prevention of acute vomiting (day of chemotherapy)	Prevention of delayed vomiting
		Day + 1	Day + 2	Day + 3
Ondansetron*	8 mg intravenously by drip 15 minutes before chemotherapy or 8 mg taken orally 1 hour before chemotherapy and 8 mg taken orally 12 hours later	-**	-**	-**
Dexamethasone	20 mg intravenously by jet stream 15 minutes before chemotherapy	8 mg orally 2 times daily	8 mg orally 2 times daily	4 mg orally 2 times daily

Moderately emetogenic chemotherapy

The risk of developing vomiting during moderately emetogenic chemotherapy without adequate antiemetic therapy is 30-90%.

Medicines with moderate emetogenic effect

• drugs for intravenous administration oxaliplatin, cytarabine >1000 mg/m2 ^, carboplatin, ifosfamide, cyclophosphamide <1500 mg/m2 ^, doxorubicin, daunorubicin, epirubicin, idarubicin, irinotecan,
• Oral medications: cyclophosphamide, etoposide, imatinib.

Algorithm for prescribing antiemetic drugs during chemotherapy with the inclusion of anthracyclines and cyclophosphamide (for other types of moderately emetogenic chemotherapy - at the discretion of the physician)

Preparation	Prevention of acute vomiting (day of chemotherapy)	Prevention of delayed vomiting
		Day + 1	Day + 2
Ondansetron*	8 mg intravenously by drip 15 minutes before chemotherapy or 8 mg taken orally 1 hour before chemotherapy and 8 mg taken orally 12 hours later	-**	-**
Dexamethasone	8-12 mg intravenously by jet stream 15 minutes before chemotherapy or taken orally 30 minutes before	-	-
Aprepitant	125 mg orally 1 hour before chemotherapy	80 mg orally in the morning***	80 mg orally in the morning***

Algorithm for prescribing antiemetic drugs for other types of moderately emetogenic chemotherapy

Preparation	Prevention of acute vomiting (day of chemotherapy)	Prevention of delayed vomiting
		Don +1	Day +2
Ondansetron*	8 mg intravenously by drip 15 minutes before chemotherapy or 8 mg taken orally 1 hour before chemotherapy and 8 mg taken orally 12 hours later	-**	-**
Dexamethasone	8-12 mg intravenously by jet stream 15 minutes before chemotherapy or taken orally 30 minutes before	8 mg orally	8 mg orally

Low emetogenic chemotherapy

The risk of developing vomiting during low-emetogenic chemotherapy without adequate antiemetic therapy is 10-30%.

Medicines with low emetogenic effect:

• intravenous drugs paclitaxel, docetaxel, topotecan, etoposide, methotrexate, mitomycin, cytarabine <100 mg/m2, 5-fluorouracil, cetuximab, trastuzumab,
• Oral drugs capecitabine, fludarabine.

Minimally emetogenic chemotherapy

When minimally emetogenic chemotherapy is administered, the risk of vomiting without antiemetic therapy is <10%. Drugs with minimally emetogenic action:

• intravenous drugs bleomycin, busulfan, fludarabine, vinblastine, vincristine, bevacizumab,
• Oral medications thioguanine, phenylalanine, methotrexate, gefitinib, erlotinib.

When taking these drugs, routine antiemetic prophylaxis is not used. It should be noted that the recommendations provided apply only to prophylaxis in patients receiving the first course of chemotherapy with these drugs. If the patient experiences nausea and vomiting against the background of the recommended prophylaxis, antiemetic prophylaxis recommended for a higher level of emetogenicity should be used during subsequent courses.