Recommendations for the prevention of nausea and vomiting after chemotherapy

When comparing the effectiveness of antiemetics, the "gold standard" is the 5-HT3 antagonist ondansetron. Unless otherwise indicated, anti-emetic regimens are used to prevent nausea and vomiting after a one-day chemotherapy with one of the cytostatics having this degree of emetogenicity. When using a combination of cytostatics, the emetogenicity of therapy is usually (if not specifically indicated) determined by the most emetogenic drug included in its composition, distinguish between high-, medium-, low-emetogenic and minimally emetogenic drugs.

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

Highly emetic chemotherapy

When performing highly emetic therapy, the risk of developing vomiting without adequate antiemetic therapy is> 90%. Drugs that have a highly emetic potential:

• preparations for intravenous administration of cisplatin, cyclophosphamide> 1500 mg / m ², carmustine, dacarbazine,
• preparations for oral administration of procarbazine (Natulan).

Algorithm for prescribing anti-emetic therapy when it is possible to use aprepitant (emend)

A drug	Prevention of acute vomiting (chemotherapy day)	Prevention of stitched vomiting
		Day + 1	Day + 2	Day + 3
Ondansetron *	8 mg iv drip 15 min before chemotherapy or 8 mg oral intake 1 h before chemotherapy and 8 mg oral administration after 12 h	- **	- **	- **
Dexamethasone	12 mg IV in struyno 15 minutes before chemotherapy	8 mg reception	8 mg oral administration	8 mg oral administration
Aprepitant	125 mg oral intake one hour before chemotherapy	80 mg oral administration in the morning	80 mg oral administration in the morning	-

• * Here and below, as an alternative, granisetron may be used at a dose of 3 mg IV for 2 mg if ingested, tropisetron 5 mg IV or ingestion.
• ** Here and further it is permissible to use, as an alternative, dexamethasone for its intolerance or the use of an additional dose, for example, in the case of nausea and / or vomiting.

Destination algorithm for the impossibility of applying aprepitant (emend *)

A drug	Prevention of acute vomiting (chemotherapy day)	Prevention of stitched vomiting
		Day + 1	Day + 2	Day + 3
Ondansetron *	8 mg iv drip 15 min before chemotherapy or 8 mg oral intake 1 h before chemotherapy and 8 mg oral administration after 12 h	- **	- **	- **
Dexamethasone	20 mg in / in struyno 15 minutes prior to chemotherapy	8 mg oral administration 2 times a day	8 mg oral administration 2 times a day	8 mg oral administration 2 times a day

*, ** - see the previous table.

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

A drug	Prevention of acute vomiting (chemotherapy day)	Prevention of stitched vomiting
		Day + 1	Day + 2	Day + 3
Ondansetron *	8 mg iv drip 15 min before chemotherapy or 8 mg oral intake 1 h before chemotherapy and 8 mg oral administration after 12 h	- **	- **	- **
Dexamethasone	20 mg in / in struyno 15 minutes prior to chemotherapy	8 mg oral administration 2 times a day	8 mg oral administration 2 times a day	4 mg oral administration 2 times a day

Medium emetic chemotherapy

The risk of vomiting during medium emetic chemotherapy without adequate antiemetic therapy is 30-90%.

Medicines with a moderate emetic effect

• preparations for intravenous administration of oxaliplatin, cytarabine> 1000 mg / m ², carboplatin, ifosfamide, cyclophosphamide <1500 mg / m ², doxorubicin, daunorubicin, epirubicin, idarubicin, irinotecan,
• preparations for ingestion of cyclophosphamide, etoposide, imatinib.

Algorithm for prescribing antiemetics during chemotherapy with the inclusion of anthracyclines and cyclophosphamide (for other types of moderate emetic chemotherapy - at the doctor's discretion)

A drug	Prevention of acute vomiting (chemotherapy day)	Prevention of stitched vomiting
		Day + 1	Day + 2
Ondansetron *	8 mg iv drip 15 min before chemotherapy or 8 mg oral intake 1 h before chemotherapy and 8 mg oral administration after 12 h	- **	- **
Dexamethasone	8-12 mg in / in struyno 15 minutes before chemotherapy or ingestion for 30 minutes	-	-
Aprepitant	125 mg oral intake for 1 h before chemotherapy	80 mg intake in the morning ***	80 mg intake in the morning ***

Algorithm for prescribing antiemetics in other types of moderate emetogenic chemotherapy

A drug	Prevention of acute vomiting (chemotherapy day)	Prophylaxis of delayed vomiting
		Don +1	Day +2
Ondansetron *	8 mg iv drip 15 min before chemotherapy or 8 mg oral intake 1 h before chemotherapy and 8 mg oral administration after 12 h	- **	- **
Dexamethasone	8-12 mg in / in struyno 15 minutes before chemotherapy or ingestion for 30 minutes	8 mg oral administration	8 mg oral administration

Low-emetic chemotherapy

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

Medications with low emetogenic effect:

• preparations for intravenous administration of paclitaxel, docetaxel, topotecan, etoposide, methotrexate, mitomycin, cytarabine <100 mg / m2, 5-fluorouracil, cetuximab, trastuzumab,
• preparations for ingestion of capecitabine, fludarabine.

Minimally emetogenic chemotherapy

When conducting minimally emetogenic chemotherapy, the risk of developing vomiting without antiemetic therapy is <10%. Preparations with a minimally emetogenic effect:

• preparations for intravenous administration of bleomycin, busulfan, fludarabine, vinblastine, vincristine, bevacizumab,
• preparations for ingestion of thioguanine, phenylalanine, methotrexate, gefitinib, erlotinib.

When taking these medications, routine antiemetic prophylaxis is not used. It should be noted that the given recommendations refer only to prevention in patients receiving the first course of chemotherapy with these drugs. In the event that a patient has nausea and vomiting in the presence of the recommended prophylaxis, nausea and vomiting should be used in subsequent courses, and antiemetic prophylaxis recommended for a higher level of emetogenicity should be used.