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Mount Vernon
Cancer Network
GUIDELINES FOR THE MANAGEMENT OF NAUSEA AND
VOMITING IN ADULT PATIENTS RECEIVING
CHEMOTHERAPY AND/OR RADIOTHERAPY
Applicable to
Principal authors(s)
Written / Updated
Review Date
Version number
Approved by
Signed (Chair)
Date
All staff involved in the care of patients receiving systemic
anticancer therapy or radiotherapy within the Mount
Vernon Cancer Network
Reviewed by Ruk Parkar
January 2013
January 2016
2.0
MVCN SACT Group
24 March 2014
1
GUIDELINES FOR THE MANAGEMENT OF NAUSEA AND
VOMITING IN ADULT PATIENTS RECEIVING
CHEMOTHERAPY AND/OR RADIOTHERAPY
SCOPE
The following guidelines have been designed for use within Mount Vernon Cancer Network
for adult oncology and haemato-oncology patients receiving chemotherapy and/or
radiotherapy.
AIM


To ensure appropriate prescription and administration of antiemetics for patients
receiving chemotherapy and/or radiotherapy.
To reduce the risk of emesis and minimise the side effects and complications of
antiemetic drugs.
RISK FACTORS
Certain risk factors exist which predict those patients likely to be more susceptible to the
emetogenic effects of chemotherapy or radiotherapy:

Female gender

Young (<30 years old)

History of nausea and vomiting (e.g. sickness in pregnancy, motion sickness)

Poor control of emesis with prior chemotherapy or radiotherapy

Anxiety
There should be a low threshold for increasing the level of antiemetic cover for patients with
more than two of any of these risk factors.
CHEMOTHERAPY
Section 1: Notes on Use of Guidelines
1.1 Choice of antiemetics






Consult section 2 for the antiemetic category of the relevant individual cytotoxic drugs
or specific oncology/haemato-oncology chemotherapy regimen being prescribed. The
categories represent minimal (category A), low (category B), moderate (category C) or
high (category D) levels of emetogenicity.
Choose and prescribe the appropriate pre and post chemotherapy antiemetic regimen
from the relevant category listed in section 3.
For combination chemotherapy regimens not specifically listed in section 2, choose the
appropriate antiemetic regimen for the most emetogenic drug in the regimen.
For multiple day chemotherapy regimens, prescribe the appropriate pre chemotherapy
antiemetics for each day of the highest emetogenic drug and prescribe post
chemotherapy antiemetics from the day after the final dose of the highest emetogenic
drug.
Many chemotherapy regimens for haemato-oncology patients incorporate corticosteroid
treatment (commonly with prednisolone or dexamethasone). These patients should
NOT receive dexamethasone as part of their antiemetic regimen even if the
chemotherapy regimen falls into Category B, C or D in section 2. Generally no patient
with acute leukaemia should receive dexamethasone as an antiemetic even if the
drug/regimen falls into category B, C or D (although some of these regimen may
include a corticosteroid as part of the anti-cancer treatment).
Note: A chemotherapy regimen named in section 2 does not imply approval to
prescribe, if that regimen contains a non-NICE approved high cost drug.
2

Domperidone – Although the benefits of domperidone continue to outweigh the
risks, some epidemiology studies have shown that domperidone may be
associated with an increased risk of serious ventricular arrhythmias or sudden
cardiac death. These risks may be higher in patients older than 60 years and in
patients who receive daily oral doses of more than than 30mg. Domperidone
should be used at the lowest effective dose, and patients should be advised to
seek prompt medical attention if symptoms such as syncope or tachyarrhythmia
appear during treatment. Domperidone should be avoided in patients who are
taking concomitant medication know to cause QT prolongation (such as
ketoconazole and erythromycin)
1.2 Anticipatory nausea and vomiting

Prescribe lorazepam 1-2mg orally/sublingually at least 1 hour prior to chemotherapy, in
addition to standard antiemetics. If severe, consider 1mg night before chemotherapy
and 1mg on the morning of chemotherapy.
3
Section 2: Categorisation of Individual Chemotherapy Drugs and Specific
Chemotherapy Regimens
Notes:
(a) This list is in alphabetical order based on the name of the drug or regimen.
(b) Check comments column for any special instructions related to the antiemetic or
chemotherapy regimen.
(c) In the “tumour site” column, “various” denotes that the drug or regimen is used in more
than two tumour sites.
Drug / Regimen
Tumour Site
Antiemetic
Category
(refer to
section 3)
ABCM
ABCM
ABVD
AC
ACE
ADE (AML 15)
Alemtuzumab
Amsacrine
Asparaginase
Axitinib
Azacitidine
BCG intravesical
Bendamustine
BEP
Bevacizumab
Bleomycin
Haemato-onc
Haemato-onc
Haemato-onc
Breast
Germ cell
Haemato-onc
Haemato-onc
Haemato-onc
Haemato-onc
Renal
Haemato-onc
Urology
Haemato-onc
Germ cell
Lower GI
Various
C
A
D
C
D
C
A
A
A
A
A
A
A
D
A
A
Bortezomib
Cabazitaxel
Haemato-onc
Prostate
B
B
Capecitabine
Carboplatin
Lower GI
Germ cell /
gynaecology
Lung
Head & neck
Haemato-onc /
CNS
Lung
Haemato-onc
Lower GI
Haemato-onc
Haemato-onc
Haemato-onc
Various
Gynaecology
Gynaecology
A
C
Various
Lung
D
D
Haemato-onc
Haemato-onc
Breast
Haemato-onc
A
B
B
C
Carboplatin / Etoposide
Carboplatin / 5-FU
Carmustine
CAV
CDT
Cetuximab
Chlorambucil
ChlVPP
CHOP
Cisplatin
Cisplatin / Doxorubicin
Cisplatin weekly/oral
etoposide (Van Der Burg
regimen)
Cisplatin / 5-FU
Cisplatin/ Pemetrexed
Cladribine
CMD
CMF
C-VAMP
Comments or special instructions
AB week only
CM week only
No dexamethasone as antiemetic
Dexamethasone 8mg PO pre-medication to
prevent reactions
Dexamethasone not needed post chemo as on
continuous prednisolone
C
C
C
C
A
A
A
A
C
D
D
D
No Dexamethasone as antiemetic.
All regimens
Dexamethasone 4mg PO BD for 3 days
starting day before pemetrexed + ondansetron/
domperidone/ aprepitant as per section 3.
2-CDA
No Dexamethasone as antiemetic.
No Dexamethasone as antiemetic.
4
CVP
Cyclophosphamide
Cyclophosphamide
Haemato-onc
Various
Various
Drug / Regimen
Tumour Site
Cyclophosphamide
Cytarabine
Haemato-onc
Haemato-onc
D
B
Cytarabine
Haemato-onc
C
C-Z-DEX
DA (AML 15/16)
Dacarbazine
Daunorubicin / Clofarabine
(AML 16)
Daunorubicin
De Gramont
(standard/modified)
Deoxycoformycin
Docetaxel
Haemato-onc
Haemato-onc
Melanoma
Haemato-onc
C
C
D
C
Haemato-onc
Lower GI
C
A
Haemato-onc
Breast
A
B
Urology
(prostate)
B
Docetaxel / Capecitabine
Breast
B
Docetaxel / Carboplatin
Lung /
gynaecology
C
Lung
D
Head & Neck
D
Various
C
EC
Breast
C
ECF
Upper GI
D
ECX
Upper GI
D
Germ cell / lung
D
Epi-CMF
Breast
C
Epirubicin only
Epi-CMF
Breast
B
CMF only
Epirubicin
Eribulin
Breast
Breast
C
B
Erlotinib
Lung
A
ESHAP
Haemato-onc
D
No Dexamethasone as antiemetic.
Various
A
Oral only
Docetaxel
Docetaxel / Cisplatin
Docetaxel/Cisplatin/5Fluorouracil
Doxorubicin
EP
Etoposide
C
A
C
Antiemetic
Category
(refer to
section 3)
No Dexamethasone as antiemetic.
Oral only
IV doses <1500mg/m2
Comments or special instructions
IV doses >1500mg/m2
IV doses <1000mg/m2 (No dexamethasone as
antiemetic if AML)
IV doses >1000mg/m2 (No dexamethasone as
antiemetic if AML)
No Dexamethasone as antiemetic.
No dexamethasone as antiemetic
No dexamethasone as antiemetic
Pentostatin
Dexamethasone 8mg PO BD for 3 days
starting day before docetaxel + post chemo
domperidone as per section 3.
Given the concurrent use of prednisolone, the
recommended premedication regimen is oral
dexamethasone 8 mg, 12 hours, 3 hours and 1
hour before the docetaxel + domperidone as
per section 3
Dexamethasone 8mg PO BD for 3 days
starting day before docetaxel + domperidone
as per section 3
Dexamethasone 8mg PO BD for 3 days
starting day before docetaxel + ondansetron /
domperidone as per section 3
Dexamethasone 8mg PO BD for 3 days
starting day before docetaxel + ondansetron /
domperidone/ aprepitant as per section 3
Docetaxel 8mg PO BD for 3 days
starting day before docetaxel + ondansetron /
domperidone/ aprepitant as per section 3
5
Etoposide
Drug / Regimen
Etoposide
Everolimus
Various
Tumour Site
B
Antiemetic
Category
(refer to
section 3)
Germ cell
Renal
C
A
Lung
B
FAD
Haemato-onc
C
FC (Fludarabine /
Cyclophosphamide)
FEC 60
FEC 75
FEC100
Haemato-onc
C
Breast
Breast
Breast
C
C
D
FLAG-Ida (AML 15)
Fludarabine
5-Fluorouracil
Haemato-onc
Haemato-onc
Various
C
A
A
FMD
GCP
Haemato-onc
Germ cell
B
C
Gefitinib
Gemcitabine
Gemcitabine / Carboplatin
Gemcitabine / Cisplatin
Gem-TIP
Lung
Various
Lung
Lung / Urology
Germ cell
A
A
C
D
D
Gemtuzumab Ozogamicin
Haemato-onc
A
Haemato-onc
Haemato-onc
Haemato-onc
Various
Sarcoma
GIST / Haematoonc
Renal
Melanoma
Lower GI
A
C
C
C
C
A
EV
Hydroxycarbamide
Hyper-CVAD + Rituxumab
Idarubicin
Ifosfamide
Ifosfamide / Doxorubicin
Imatinib
Interferon alfa
Ipilimumab
Irinotecan
A
A
C
Irinotecan / De Gramont
(FOLFIRI)
Irinotecan / Mitomycin C
IVE
Lapatinib
Lower GI
C
Upper GI
Haemato-onc
Breast
C
C
A
Liposomal Doxorubicin
Lomustine
MACE (AML 15)
Melphalan
Gynaecology
CNS
Haemato-onc
Haemato-onc
B
A
B
A
Mercaptopurine
Haemato-onc
A
IV only (except high dose etoposide for germ
cell)
Comments or special instructions
High dose 1.6gm/m2 etoposide for germ cell
If needed
No Dexamethasone as antiemetic.
All epirubicin doses
In patients with high risk of N&V or
experiencing grade 3 or 4 N&V during
epirubicin doses, aprepitant may be
considered.
No dexamethasone as antiemetic
Oral and IV
Includes continuous infusional 5-FU and 5-FU
+ RT regimens.
No Dexamethasone as antiemetic.
Dexamethasone 20mg IV pre 3 weekly
paclitaxel (instead of 8mg) plus other
antiemetics as per section 3.
Dexamethasone 20mg IV pre 3 weekly
paclitaxel (instead of 8mg) plus other
antiemetics as per section 3.
Hydroxyurea
No Dexamethasone as antiemetic.
No dexamethasone as antiemetic if AML
If needed
No dexamethasone as antiemetic
Including PO melphalan + prednisolone; IV
melphalan + dexamethasone.
No dexamethasone as antiemetic if ALL
6
Methotrexate
Drug / Regimen
Various
Tumour Site
A
Antiemetic
Category
(refer to
section 3)
Oral and IV doses <300mg/m2 only.
Comments or special instructions
IV doses > 300mg/m2 (No dexamethasone as
antiemetic if ALL)
No dexamethasone as antiemetic
Day 1 & 6 only
Day 2 – 5 only
Intravesical only
For Mitomycin C weeks only
All regimens. For Mitomycin C weeks only
Methotrexate
Haemato-onc
C
MidAC (AML 15)
MiniBEAM
MiniBEAM
Mitomycin C
Mitomycin C / Capecitabine
Mitomycin C / 5-FU
Mitoxantrone
MM
MMM
MVC
MVP
Ofatumumab
OMB
Oral C-weekly
Oxaliplatin
Oxaliplatin / Capecitabine
(XELOX)
Oxaliplatin / De Gramont
(FOLFOX)
Paclitaxel (weekly)
Haemato-onc
Haemato-onc
Haemato-onc
Urology
Lower GI
Lower GI
Various
Breast
Breast
Urology
Mesothelioma
Haemato-onc
Germ cell
Haemato-onc
Lower GI
Lower GI
C
C
B
A
B
B
B
B
B
D
D
A
C
A
C
C
Lower GI
C
Breast
B
(On paclitaxel weeks only if
regimen in combination with
other agents.)
Paclitaxel (every 3 weeks)
Gynae
B
Various
B
Paclitaxel / Carboplatin (every
3 weeks)
Gynaecology /
lung
C
PCV
Pemetrexed
CNS
Lung /
mesothelioma
A
B
PMB
PMitCEBO
Gynaecology
Haemato-onc
D
C
PMitCEBO
POMB
Procarbazine
Raltitrexed
Haemato-onc
Germ cell
Haemato-onc
Lower GI
A
D
A
B
R-CHOP
R-CVP
Haemato-onc
Haemato-onc
C
C
No Dexamethasone as antiemetic.
No Dexamethasone as antiemetic.
R-ESHAP
Haemato-onc
D
No Dexamethasone as antiemetic.
R-FC
Haemato-onc
C
Rituximab
R-IVE
Haemato-onc
Haemato-onc
A
C
R-MiniBEAM
Haemato-onc
C
If needed
Dexamethasone 8mg (or 6.6mg) IV pre
weekly paclitaxel.
Dexamathasone post chemotherapy may be
omitted or given 4mg b.d.for 1 day only
Dexamethasone 20mg (or 19.8mg) IV pre
three weekly paclitaxel and other antiemetics
as per section 3.
Dexamethasone 20mg (or 19.8mg) IV pre
three weekly paclitaxel plus other antiemetics
as per section 3.
Dexamethasone 4mg PO BD for 3 days
starting day before pemetrexed + other
antiemetics as per section 3.
MitCE week only. No Dexamethasone as
antiemetic.
BO week only.
Day 1 & 6 only
7
R-MiniBEAM
Drug / Regimen
Haemato-onc
Tumour Site
B
Antiemetic
Category
(refer to
section 3)
R-PMitCEBO
Haemato-onc
C
R-PMitCEBO
Sorafenib
Stanford V
Haemato-onc
Renal
Haemato-onc
A
A
C
Stanford V
Haemato-onc
A
Sunitinib
Temozolamide
Thalidomide
Tioguanine
TIP
Renal
CNS
Haemato-onc
Haemato-onc
Germ cell
A
A
A
A
D
Topotecan
Trastuzumab
Trastuzumab / Docetaxel
Gynaecology
Breast
Breast
B
A
B
Trastuzumab / Paclitaxel
Breast
B
Trastuzumab / Vinorelbine
VAD
VAMP
VAPEC-B
Breast
Haemato-onc
Haemato-onc
Haemato-onc
A
C
C
C
VAPEC-B
Vemurafenib
Vinblastine
Vincristine
Vinorelbine
Vinorelbine / Carboplatin
Vinorelbine / Cisplatin
VIP
Z-DEX
Haemato-onc
Melanoma
Various
Various
Breast / lung
Lung
Lung
Germ cell
Haemato-onc
A
A
A
A
A
C
D
D
C
Day 2 – 5 only
Comments or special instructions
MitCE week only. No Dexamethasone as
antiemetic.
BO week only.
Week 1, 3, 5, 7, 9, 11 only. No
Dexamethasone as antiemetic.
Week 2, 4, 6, 8, 10, 12 only.
Thioguanine
Dexamethasone 20mg (19.8mg) IV pre 3
weekly paclitaxel (instead of 8mg) plus other
antiemetics as per section 3.
Dexamethasone 8mg PO BD for 3 days
starting day before docetaxel + domperidone
as per section 3.
Dexamethasone 20mg (19.8mg) IV pre 3
weekly paclitaxel (instead of 8mg) plus other
antiemetics as per section 3.
No dexamethasone as antiemetic
No dexamethasone as antiemetic
Week 1 & 3 only. No Dexamethasone as
antiemetic.
Week 2 & 4 only
No dexamethasone as antiemetic
8
Section 3: Antiemetic Regimen Categories (grouped according to emetogenic potential)
Category A: MINIMAL EMETOGENIC POTENTIAL
PRE CHEMOTHERAPY
POST CHEMOTHERAPY
No routine antiemetic indicated
DOMPERIDONE
20mg PO QDS PRN
Category B: LOW EMETOGENIC POTENTIAL
PRE CHEMOTHERAPY
POST CHEMOTHERAPY
DEXAMETHASONE 8mg PO
(IV only if nausea / vomiting /
dysphagia)
DEXAMETHASONE
4mg PO BD for 3 days
And
DOMPERIDONE
20mg PO QDS x 3 days, then
PRN
Category C: MODERATE EMETOGENIC CHEMOTHERAPY
PRE CHEMOTHERAPY
POST CHEMOTHERAPY
ONDANSETRON
8mg PO (8mg IV if
nausea/vomiting/dysphagia)
and
DEXAMETHASONE 8mg PO
(6.6mg IV only if nausea /
vomiting / dysphagia)
DEXAMETHASONE
4mg PO BD for 3 day
and
ONDANSETRON
8mg PO BD x 1 days
and
DOMPERIDONE
20mg PO QDS x 5 days then
PRN
Category D: HIGH EMETOGENIC CHEMOTHERAPY
PRE CHEMOTHERAPY
POST CHEMOTHERAPY
ANTIEMETIC FAILURE (see
definition – section 1)
 Recommend Domperidone postchemotherapy to be taken regularly.
 Commence on first line antiemetics
for breakthrough nausea and vomiting
(Section 4).
 Treat on subsequent courses of
chemotherapy as for low emetogenic
(Category B).
ANTIEMETIC FAILURE (see
definition – section 1)
 Ensure took antiemetics regularly post
chemotherapy (as prescribed).
 Commence on first line antiemetics for
breakthrough nausea and vomiting
(Section 4) or subsequent line if had
before with no benefit.
 Treat on subsequent courses of
chemotherapy as for moderate
emetogenic (Category C).
ANTIEMETIC FAILURE (see
definition – section 1)
 Ensure took antiemetics regularly post
chemotherapy (as prescribed).
 Commence on first line antiemetics
for breakthrough nausea and vomiting
(Section 4) or subsequent line if had
before with no benefit.
 Treat on subsequent courses of
chemotherapy as for high emetogenic
(Category D).
ANTIEMETIC FAILURE (see
definition – section 1)
9
 Ensure took antiemetics regularly post
chemotherapy (as prescribed) and
used suppositories if vomiting.
 Commence on first line antiemetics
for breakthrough nausea and vomiting
(Section 4) or subsequent line if had
and
before with no benefit.
DOMPERIDONE
 Consider treating on subsequent
20mg PO QDS x 5 days then
courses with:
PRN
Ondansetron 8mg PO BD for up to 5
Cisplatin >70mg / m2
Cisplatin >70mg / m2
days maximum
As above but also:
As above but also:
and/or
Regular antiemetic from
APREPITANT 125mg PO
APREPITANT 80mg PO OD
Section 4 in addition to the post
on days 2&3 post chemo
(Fosaprepitant 150mg IVI) Day
chemotherapy antiemetic regimen.
1 stat, only if nausea / vomiting /
(not needed if given IV

Consider
aprepitant for patients with
dysphagia)
Fosaprepitant)
grade 3 / 4 N&V if they are not already
receiving it
Note: TTA’s – For category D drugs/regimens, prescribe DOMPERIDONE suppositories 30mg PR QDS
prn if vomiting)
ONDANSETRON
8mg PO (8mg IV if
nausea/vomiting/dysphagia)
and
DEXAMETHASONE 8mg PO
(6.6mg IV only if nausea /
vomiting / dysphagia)
ONDANSETRON
8mg PO BD x 3 days
and
DEXAMETHASONE
4mg PO BD x 3 days
Section 4: Breakthrough nausea and vomiting
Antiemetic failure
If prolonged /distressing nausea occurs, or 2 or more episodes of vomiting in 24 hours occur after a
course of chemotherapy, move onto suggested antiemetic regimens for the next category level of
emetogenicity. Ensure patient has taken post chemotherapy antiemetic drugs regularly as prescribed,
otherwise add in drugs as below.
1st Line
2nd Line
3rd Line
DRUG AND SCHEDULE
COMMENTS
Cyclizine
 Prescribe regularly in addition to
50mg PO TDS
recommended post chemotherapy
Or
antiemetics
Ondansetron 8mg BD for 3-5
days if not given already
Prochlorperazine
 Prochlorperazine – replaces
5-10mg PO TDS or 25mg
Domperidone as post chemotherapy
PR TDS
antiemetic
or
Metoclopramide
 Metoclopramide – replaces
10mg PO TDS or 30mg PR
Domperidone as post chemotherapy
QDS (max 5 days)
antiemetic
Lorazepam
1mg PO/SL upto TDS
(2mg in patients > 100kg)


4th Line
Levomepromazine
12.5mg PO nocte – BD
Prescribe regularly in addition to
recommended post chemotherapy
antiemetics.
Consider adding first line if anxiety
component/anticipatory nausea

Levomepromazine – replaces
Metoclopramide as post chemotherapy
antiemetic

Consider instituting S/C infusion of
Cyclizine 1st or 2nd line if severe
or
Cyclizine
100-150mg continuous
10
subcutaneous infusion over
24 hours
vomiting occurs in inpatients.
Aprepitant
 Only in patients who have failed the
125mg PO prior to
category D antiemetic regimen and
chemotherapy, followed by
have CTC grade 3 / 4 Nausea and
80mg OD for 2 days after
Vomiting.
chemotherapy
Subsequent cycles of chemotherapy: If a patient has experienced significant breakthrough
nausea & vomiting on a category, then the category of antiemetic may be escalated
e.g. breakthrough N&V on carboplatin (category C) may be escalated to category D antiemetics for future cycles.
5th Line
RADIOTHERAPY GUIDELINES FOR PATIENTS AT MOUNT VERNON
CANCER CENTRE
Notes on Use of Guidelines
Major determinants of emetic risk include treatment field, dose of radiotherapy
administered per fraction, pattern of fractionation and previous chemotherapy.
RISK
AREA RECEIVING
RT
ANTIEMETIC REGIMEN
Low
Breast
Head and Neck
Extremities
Pelvis – small field
Thorax
No routine antiemetics – treat symptomatically
with
Upper abdominal
Abdominal
Whole Pelvis
Mantle
Cranium
Craniospinal
Before each fraction:
Dexamethasone 4-8mg PO
and either:
Domperidone 20mg PO
or
Ondansetron 4-8mg PO (or 4-8mg IV)
Moderate
Domperidone 20mg PO QDS prn
(and Domperidone 20mg PO QDS prn after
radiotherapy)
High
Hemibody Irradiation
TBI
Before each fraction
Dexamethasone 8mg PO/IV
and
11
Ondansetron 8mg PO (or 8mg IV)
(and 8mg PO BD for one day after)

Antiemetic failure: If patients suffer breakthrough nausea and vomiting while
receiving the above recommended antiemetics, additional therapy should be
commenced in accordance with the guidelines for breakthrough nausea and
vomiting for adult chemotherapy patients in Section 4.

Chemoradiation: Treat according to the highest emetogenic risk based on
radiotherapy treatment field or cytotoxic drug(s)/regime.
12