Nausea and vomiting guideline 2011

MANAGEMENT OF CHEMOTHERAPY INDUCED NAUSEA AND VOMITING
ALDER HEY CHILDREN’S NHS FOUNDATION TRUST
Cytotoxic Drug
Cisplatin
High dose Melphalan
>16 yrs Osteosarcoma receiving
Cisplatin
Carboplatin
Carmustine
Cyclophosphamide ≥1g/m²
Cytarabine >1g/m²
Dacarbazine
Ifosfamide
High dose MTX ≥3g/m²
Actinomycin D
Amsacrine
Busulfan IV
Cyclophosphamide 500mg/m 2 < 1g/m²
Daunorubicin
Docetaxel
Doxorubicin
Epirubicin
Idarubicin
Irinotecan
Lomustine
Mitoxantrone
Temozolomide
Asparaginase
Bleomycin
Busulphan oral
Cladribine
Cytarabine 16yrs on Cisplatin if above regimen fails
in 1 st cycle
Aprepitant and regular Dexamethasone
(50% dose) and Ondansetron
1.Ondansetron and Levomepromazine
2. Dexamethasone* (Pre-chemotherapy
loading dose + prescribe PRN. In case of 1 st
line failure** can be given regularly)
3. Consider Levomepromazine infusion
1. Ondansetron
2. Levomepromazine PRN (in case of
failure** of 1 st line)
3. Dexamethasone*
Ondansetron PRN
Discharge
Anti-emetics
3 days of
required
anti-emetics
3 days of
required
anti-emetic
3 days of
required
anti-emetics
2 days of
Ondansetron
Approved by DTC: 2 nd August 2010 (v2)
Author(s): L Howell, F Heard
1 of 2

NOTES ON ANTI-EMETIC PRESCRIBING
*Avoid Dexamethasone in the following groups:
1. Brain tumour patients (cyclizine may be helpful)
2. Myeloid leukaemia patients
3. Treatment cycle includes steroid therapy
4. BMT and SCT patients
**Antiemetic treatment failure: >2 vomits in 24 hours or > 4 hours continuous persistent nausea. Document this
in the patient’s case notes and escalate to the next emetogenic risk category.
All drugs are written for IV and oral administration. Please check for other routes prior to administration to ensure
no accidental repeat dosing. Oral administration is preferred wherever possible.
Refractory Nausea and Vomiting: Consider levomepromazine infusion or lorazepam (discuss with consultant).
Delayed Nausea and Vomiting: (commonly seen with Cisplatin). Re-start anti-emetics required whilst on
chemotherapy and escalate if necessary as per high risk emetogenic category. Ensure adequate hydration.
Dexamethasone is particularly helpful.
Anticipatory Nausea and Vomiting: Consider home administration of ondansetron +/- levomepromazine upto 24
hours prior to chemotherapy; lorazepam > 12 years (discuss with consultant)
ANTIEMETIC DRUG DOSES
Drug Dose Preparation
Ondansetron
(5HT3 antagonist)
IV: 5mg/m² three times daily
Oral: every 8-12 hours
1.2m² 8mg
Maximum single dose 8mg
IV: 8mg/4mL
Oral liquid: 4mg/5mL
Tablets: 4mg, 8mg
Sub lingual melts: 4mg, 8mg
Dexamethasone
(Steroid)
Levopmepromazine
(Dopamine antagonist)
Aprepitant
(Neurokinin receptor
Antagonist)
Caution - Many drug
interactions
Check with Pharmacy
IV/oral loading dose 8mg/m 2 (max
single dose 12mg)
then:
IV/oral 5mg/m 2 three times daily (max
single dose 8mg)
IV short infusion: 0.1mg/kg twice daily
IV continuous infusion: 0.25-0.5mg/kg/24
hours
Oral: 0.2 mg/kg twice daily
Day 1: 125mg once daily
Day 2 & 3: 80mg once daily
IV: 8mg/2mL
Oral solution: 2mg/5mL
Tablets: 500 microgram, 2mg
IV: 25mg/mL
Oral suspension: 1mg/mL
Tablets: 25mg scored
Capsules: 80mg, 125mg
Approved by DTC: 2 nd August 2010 (v2)
Author(s): L Howell, F Heard
2 of 2