Written by: Kirollos S. Hanna, PharmD, BCPS, BCOP – University of Minnesota Medical Center & Mayo Clinic
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This PQI will discuss optimal prevention and control of CINV which has been associated with improved adherence to oncolytic therapy.

Background:

CINV remains one of the most debilitating toxicities associated with cancer therapy leading to poor compliance with further treatment, dehydration, metabolic imbalances, degeneration of self-care and functional inability, anorexia and decline in performance status1,6. The emetogenic potential of the regimen should be coupled with other risk factors such as age, sex, history of alcohol consumption, combined chemoradiation, previous tolerability of chemotherapy and anatomical location of tumor (i.e. head and neck) to select an optimal antiemetic regimen. As much as 80% of CINV can be prevented with appropriate administration of antiemetics6.

PQI Process: Upon receipt of an order for a chemotherapy regimen:

  • Assess the antiemetic potential of therapy, patient risk factors, and disease state
    • High emetogenicity: NK1R antagonists + 5-HT3 receptor antagonists + dexamethasone ± olanzapine
    • Moderate emetogenicity: 5-HT3 receptor antagonists + dexamethasone ± NK1R antagonists
    • Low emetogenicity: 5-HT3-receptor antagonist or dexamethasone or phenothiazine
  • Evaluate drug-drug and drug-patient interactions to minimize adverse drug reactions (i.e. benzodiazepine and phenothiazine dosing in elderly, olanzapine interactions [refer to Olanzapine Use in CINV PQI] dexamethasone dosing with fosaprepitant, etc.)
  • Ensure take home antiemetics have been prescribed and will be in possession of the patient once home (may require coordination with caretakers and dispensing pharmacy)
  • Provide education to patients and caretakers (refer to Patient Centered Activities)
  • Follow up with patients (who have moderate to high emetogenicity on day 2/3 of cycle 1) upon return for cycle 2 of chemotherapy and determine future plans as clinically appropriate:
    • Assess for adequate management and prophylaxis
    • Consider benzodiazepines for anticipatory nausea/vomiting
    • Determine the need to modify antiemetic regimen based on incidence of acute, delayed and breakthrough events

 Patient Centered Activities:

  • Provide antiemetic counseling to patients and caretakers with written or graphic visual aids to easily guide drug selection at home. This should include:
    • When to initiate take home 5-HT3 receptor antagonists if a long acting agent has been administered with chemotherapy
    • Prioritizing and sequencing different agents of the take home antiemetic regimen for adequate control of CINV
    • Ensure a clear understanding of scheduled antiemetics such as dexamethasone or olanzapine
  • Have patient verbalize how they plan to utilize their antiemetics at home
  • Review common side effects with the patient (sedation, headaches, constipations, extrapyramidal symptoms, etc.)
  • Inform patients to drink plenty of fluids and avoid/minimize alcoholic beverages
  • Ensure patients have contact information for the clinic and know when to contact the clinic

 Drug therapy*:

  • 5-HT3 receptor antagonists: ondansetron, granisetron, dolasetron, palonosetron
  • NK1R antagonists**: aprepitant, fosaprepitant, rolapitant
  • Glucocorticoids: dexamethasone
  • Benzodiazepines: lorazepam
  • Dopaminergic agents: prochlorperazine, olanzapine, chlorpromazine
  • Combinations: netupitant/palonosetron, fosnetupitant/palonosetron
  • Other: metoclopramide, scopolamine, promethazine, meclizine, dronabinol, olanzapine

*Most commonly utilized agents, not inclusive of all agents

**Additional agents available as combination product

References:

  1. National Comprehensive Cancer Network (NCCN). NCCN Clinical practice guidelines in oncology. https://www.nccn.org/professionals/physician_gls/pdf/antiemesis.pdf (Accessed on August 11, 2018).
  2. Hesketh PJ, Kris MG, Basch E, et al. Antiemetics: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol 2017; 35:3240.
  3. Roila F, Molassiotis A, Herrstedt J, et al. 2016 MASCC and ESMO guideline update for the prevention of chemotherapy- and radiotherapy-induced nausea and vomiting and of nausea and vomiting in advanced cancer patients. Ann Oncol 2016; 27:v119.
  4. Fujii H, Iihara H, Ishihara M, et al. Improvement of adherence to guidelines for antiemetic medication enhances emetic control in patients with colorectal cancer receiving chemotherapy of moderate emetic risk. Anticancer Res 2013;33:5549–56.
  5. Affronti ML, Schneider SM, Herndon JE 2nd., et al. Adherence to antiemetic guidelines in patients with malignant glioma: a quality improvement project to translate evidence into practice. Support Care Cancer 2014;22:1897–905.
  6. Tageja N, Groninger H. Chemotherapy-induced nausea and vomiting: an overview and comparison of three consensus guidelines. Postgrad Med J. 2016;92(1083):34-40.

Supplemental Information:

Select Therapies for Chemotherapy-Induced Nausea and Vomiting Prevention

Risk CategoryAgentDosing on Day 1Dosing on subsequent days
High emetic risk (>90%)NK1R antagonist (one of the following)
 Aprepitant125 mg PO80 mg PO Days 2 & 3
 Fosaprepitant150 mg IV
 Rolapitant*180 mg PO or 166.5 mg IV
PLUS
 5-HT3 antagonist (one of the following)
 Palonosetron0.5 mg PO or 0.25 mg IV
 Granisetron2 mg PO or 1 mg IV
 Ondansetron8 mg PO or IV
PLUS
 Dexamethasone12 – 20 mg PO or IV8 mg PO or IV daily Days 2 to 4 (chemotherapy dependent)
PLUS
 Olanzapine5 – 10 mg PO5 – 10 mg PO daily Days 2 to 4
OR
 Netupitant plus palonosetron or Fosnetupitant plus palonosetronOnce
PLUS
 Dexamethasone12 – 20 mg PO or IV8 mg PO or IV daily Days 2 to 4 (chemotherapy dependent)
PLUS
 Olanzapine5 – 10 mg PO5 – 10 mg PO daily Days 2 to 4

*The FDA has issued a safety alert that anaphylaxis, anaphylactic shock and other serious hypersensitivity reactions have been reported in the postmarketing setting, some requiring hospitalization with rolapitant.

Supplemental Information

Moderate emetic risk (10 to 30%)5-HT3 antagonist (one of the following from high risk)
PLUS
 Dexamethasone8 – 20 mg PO or IV8 mg PO or IV daily Days 2 to 4 (chemotherapy dependent)
MAY CONSIDER IF CARBOPLATIN-BASED OR HIGH-RISK POTENTIAL
 NK1R antagonist (one of the following from high risk)
 Olanzapine5 – 10 mg PO5 – 10 mg PO daily Days 2 to 4

 

Low emetic risk

(<10%)

Dexamethasone4 – 8 mg PO or IV
OR
 5-HT3 antagonist (one of the following from high risk)
OR
 Phenothiazine-type drug

All patients should have supportive antiemetic therapy at home. Select patients with minimal risk for chemotherapy-induced nausea/vomiting may not require any treatment.

Important notice: National Community Oncology Dispensing Association, Inc. (NCODA), has developed this Positive Quality Intervention platform. This platform represents a brief summary of medication uses and therapy options derived from information provided by the drug manufacturer and other resources. This platform is intended as an educational aid and does not provide individual medical advice and does not substitute for the advice of a qualified healthcare professional. This platform does not cover all existing information related to the possible uses, directions, doses, precautions, warning, interactions, adverse effects, or risks associated with the medication discussed in the platform and is not intended as a substitute for the advice of a qualified healthcare professional. The materials contained in this platform are for informational purposes only and do not constitute or imply endorsement, recommendation, or favoring of this medication by NCODA, which assumes no liability for and does not ensure the accuracy of the information presented. NCODA does not make any representations with respect to the medications whatsoever, and any and all decisions, with respect to such medications, are at the sole risk of the individual consuming the medication. All decisions related to taking this medication should be made with the guidance and under the direction of a qualified healthcare professional.
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