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Table 3. Antiemetic Recommendations by Emetic Risk Categoriesa

Emetic Risk Category ASCO Guidelines NCCN Guidelines 
High (>90%) riskThree-drug combination of a 5-HT3 receptor antagonist, dexamethasone, and aprepitant recommended prechemotherapy.Prechemotherapy, a 5-HT3 receptor antagonist (ondansetron, granisetron, dolasetron, or palonosetronb), dexamethasone (12 mg), and aprepitant (125 mg) recommended, with or without lorazepam.
For patients receiving cisplatin and all other agents of high emetic risk, the two-drug combination of dexamethasone and aprepitant recommended for prevention of delayed emesis.For prevention of delayed emesis, dexamethasone (8 mg) on days 2–4 plus aprepitant (80 mg) on days 2 and 3 recommended, with or without lorazepam on days 2–4.
Moderate (30%–90%) riskFor patients receiving an anthracycline and cyclophosphamide, the three-drug combination of a 5-HT3 receptor antagonist, dexamethasone, and aprepitant recommended prechemotherapy; single-agent aprepitant recommended on days 2 and 3 for prevention of delayed emesis.For patients receiving an anthracycline and cyclophosphamide and selected patients receiving other chemotherapies of moderate emetic risk (e.g., carboplatin, cisplatin, doxorubicin, epirubicin, ifosfamide, irinotecan, or methotrexate), a 5-HT3 receptor antagonist (ondansetron, granisetron, dolasetron, or palonosetronb), dexamethasone (12 mg), and aprepitant (125 mg) recommended, with or without lorazepam, prechemotherapy; for other patients, aprepitant is not recommended.
For patients receiving other chemotherapies of moderate emetic risk, the two-drug combination of a 5-HT3 receptor antagonist and dexamethasone recommended prechemotherapy; single-agent dexamethasone or a 5-HT3 receptor antagonist recommended on days 2 and 3 for prevention of delayed emesis.For prevention of delayed emesis, dexamethasone (8 mg) or a 5-HT3 receptor antagonist on days 2–4 or, if used on day 1, aprepitant (80 mg) on days 2 and 3, with or without dexamethasone (8 mg) on days 2–4, recommended, with or without lorazepam on days 2–4.
Low (10%–30%) riskDexamethasone (8 mg) recommended; no routine preventive use of antiemetics for delayed emesis recommended.Metoclopramide, with or without diphenhydramine; dexamethasone (12 mg); or prochlorperazine recommended, with or without lorazepam.
Minimal (<10%) riskNo antiemetic administered routinely pre- or postchemotherapy.No routine prophylaxis; consider using antiemetics listed under primary prophylaxis as treatment.

ASCO = American Society of Clinical Oncology; NCCN = National Comprehensive Cancer Network.
aAdapted from Navari.[138]
bOrder of listed antiemetics does not reflect preference.

References

  1. Navari RM: Overview of the updated antiemetic guidelines for chemotherapy-induced nausea and vomiting. Community Oncology 4 (4 Suppl 1): 3-11, 2007. Also available online. Last accessed September 3, 2014.