Chemotherapy-Inducted Nausea and Vomiting Guidelines for Adult ...

Emetogenicity of Chemotherapeutic Agents
Level 1 (60 mg/m 2 )
Epirubicin hydrochloride (≤90 mg/m 2 )
Mechlorethamine
Idarubicin
Pentostatin
Ifosfamide
Streptozocin
Methenamine (oral)
Methotrexate (250-1000 mg/m 2 )
Mitoxantrone (≤15 mg/m 2 )
*Intrathecal coadministration of methotrexate and cytarabine to pediatric patients increases the emetogenicity level to 3.
Calculating Emetogenic Potential of Multiple-Agent Regimens
Identify the agent with the highest emetogenic level, then determine the contribution of the remaining agents by using the
following rules:
Examples:
(1) Level 1 agents do not contribute to emetogenicity. Level 1+1=0 2+1=2 3+1=3 4+1=4
(2) Adding one or more level 2 agents increases the highest level by 1. Level 2+2=3 3+2=4 2+2+2=3 3+2+2=4
(3) Adding level 3 or 4 agents increases the highest level by 1 per agent. Level 3+3=4 3+3+3=5 4+3=5
PEDIATRIC GUIDELINES FOR CHEMOTHERAPY-INDUCED EMESIS
Prevention of Acute Emesis
Level 1
Level 2-5
Granisetron PO (patients able to take PO medications)
OR
Granisetron IV (patients who are not candidates for PO)
PLUS
Dexamethasone PO or IV
No preventative therapy necessary
2 mg 30 minutes prior to chemotherapy
10 mcg/kg IV 30 minutes prior to chemotherapy
10 mg/m 2 PO or IV in single or divided doses
Prevention of Acute Emesis – History of Refractory Emesis
Ondansetron IV 0.15 mg/kg 30 minutes prior to chemotherapy and q4h x 2
PLUS
Dexamethasone PO or IV
10 mcg/kg IV 30 minutes prior to chemotherapy
Treatment of Breakthrough Emesis
Dexamethasone
OR
Lorazepam (children >5 yrs only)
OR
Promethazine
5-10 mg/m 2 PO or IV q12h prn
0.05 mg/kg (max 2 mg) IV q12h prn
0.25-0.5 mg/kg (max 25 mg) IV q6-8h prn
Treatment of Refractory Emesis
• Increase dose of current agent (within recommended range), OR
• Add agent from different pharmacologic class, OR
• Use a combination of above approaches