RESOURCE TYPE: Consensus-based guideline
PROCESS OF DEVELOPMENT: To change a guideline from the 2010 recommendation; a consensus of at least 67% of the expert panelists was needed. The panel considered changes of 10% or greater to be sufficient to warrant the change of a recommendation.
DATABASES USED: Not described in this publication; referenced the 2010 publication to describe the process; this process involved using MEDLINE with evaluation by 23 oncology professionals from various disciplines.
INCLUSION CRITERIA: Articles that described new agents identified from January 2009–June 2015
EXCLUSION CRITERIA: If the new agent was an oral agent, the study had to measure emetic risk for the entire course of therapy, not just for a single dose.
Forty-two new antineoplastic agents and 168 studies were identified since the 2010 guideline was updated. The emetogenicity of agents was also reviewed and updated as appropriate.
Low Emetic Agents
IV: Aflibercept, belinostat, blinatumomab, brentuximab, cabazitasel, carfilzomib, eribulin, ipilimumab, nab-paclitaxel, pegylated liposomal doxorubicin, pertuzumab, trastuzumab-emtansine, vinflunine
Oral: Afatinib, axatinib, dabrafenib, dastinib, ibrutinib, idelalisib, nilotinib, olaparib, pazopanib, ponatinib, regorafenib, vandetabin, and vorinostat
Moderate Emetic Agents
IV: Temozolomide, trabectedin, romidepsin, thiotepa
Oral: Bosutinib, crizotinib and ceritinib
Minimally Emetic Agents
IV: Nivolumab, ofatumumab, pembrolizumab, and pixantrone
Oral: Pomalidomide, ruxolitinib, vermurafenib, and vismodegib
A major update of the guideline was the inclusion of oral antineoplastic agents. Two new NK1 receptor antagnists—netupitant and rolapitant—were discussed for their role in acute and delayed chemotherapy-induced nausea and vomiting (CINV) induced by cisplatin, AC chemotherapy, or carboplatin in combination with a 5-HT3 plus dexamethasone. Two studies suggested that aprepitant and metoclopramide were equally effective in the prophylaxis of cisplatin-induced delayed nausea and vomiting, and that dexamethasone was as effective as aprepitant in women with breast cancer receiving an AC combination. A new classification of the emetogenic potential of radiotherapy according to irradiated sites was reported, as well as an update of recommended antiemetic treatments. Last, adding an NK1 receptor antagonist to a 5-HT3 receptor antagonist plus dexamethasone was addressed in multiple-day cisplatin-based chemotherapy and high-dose chemotherapy. If an NK1 receptor antagonist is not available for the prophylaxis of AC-induced CINV, palonsetron is the preferred 5-HT3 receptor antagonist.
Randomized clinical trials have not yet compared the new NK1s and NK1 receptor antagonist combinations. Oral medications have not yet been studied extensively, so they are not included in the guidelines. The authors recognized that nausea continues to be a problem, even with marked improvement in vomiting, and believe there should be a shift to the control of nausea. A review of the process requires readers to go back to the 2010 and 2004 publications.
This publication has important updates for the nurse regarding the inclusion of oral antineoplastics, radiation emetogenicity, and treatments, and the addition of two new NK1 receptor antagonists: netupitant and rolapitant. Both require further study before recommendations can be made. Although control of vomiting is markedly improved, nausea remains a challenge.