CINV

1. Acute - within the first 24 hours  5-HT3RA’s NOT palosetron

2. Delayed - 24 hours - several days (2-5) after  NK1RA, Dex, Palosetron
3. Anticipatory - before treatment  Benzos
4. Breakthrough - despite prophylactic treatment
5. Refractory - during subsequent cycles when prior prophylaxis or rescue failed

 5-HT3RA’s - block serotonin

 1st Gen: constipation, headache, & QT-prolong

 Ondansetron - oral dissolving film [ Zuplenz ]

- ODT, tablet, suspension [ Zofran ]

- transdermal patch [ Sancuso ]

 Granisetron  NOT for Delayed
- ER SQ [ Sustol ]
- tablet, IV [ Kytril ]

 dolasetron only PO - [ Anzemet ]

 2nd Gen: does NOT prolong QT!!!

 Palonosetron  Good for both acute and delayed

- IV [ Aloxi ]
- + netupitant [ Akynzeo ]

 Dexamethasone [also used for RA]  pretreatment can be used with 5-HT3RA’s & NK1RA’s

 NK1-RA’s good only for delayed, so only given in combo with a 5-HT3 RA and dex. ----CYP Inhibitors-----
except Rola

 Aprepitant PO [ Emend ] Day 1,2,3

IV emulsion [ Cinvanti ] 1

 Fosaprepitant IV [ Emend ] 1
 Rolapitant PO [ Varubi ] 1
 Netupitant/palo PO/IV [ Akynzeo ] 1

 Dopamine Antagonists  QT-prolong

 Metoclopramide [ Reglan ]
 prochlorperazine [ Compazine ]
 promethazine [ Phenergan ]

 Benzos Lorazepam  anticipatory

 Cannabinoids  refractory

1 hour B4 After days

HIGH
1. Olanz 5mg 1. Olanz 5mg 2,3,4

2. NK1-RA “–tant” 2. NK1-RA “–tant” 2,3

: “plat” cyclophosphamide “rubi”

MOD
: top1&2

LOW
: -mab “tax” MTX 5-FU

1. High emetic risk - (cisplatin, dacarbazine, cyclophosphamide, ifosfamide, anthracyclines, alkylators)

 3 or 4 drugs
o NK1-RA  1 hour before except Fosapre Emend IV 30 mins before & Aprepitant Emend oral take 2 more days
o 5HT3RA  before except transdermal patch granisetron sancuso start prior to day 1 of chemo
o Dex  30 min before and then for days 2-4
 12mg then 8mg for 3 more days

o 5ht3RA (Palo)
o Dex
o Olanzapine  day 1 then 3 more days max 20/day

o NK1-RA
o 5ht3RA (Palo)
o Dex
o Olanzapine
2. Moderate emetic risk - lower doses of cytotoxic chemotherapy, high-dose methotrexate, and topoisomerase inhibitors –tecan’s
 2 or 3 drugs
o NK1-RA
o 5HT3RA
o Dex

o Combo NK1RA & 5HT3RA: Netupitant/pano (Akynzeo)  1 hour before

o Dex

o Olanzapine
o Specific 5HT3RA: Palo  1 hour before
o Dex

o 5HT3RA
o Dex

3. Low emetic risk - monoclonal antibodies, taxanes, and antimetabolites (e.g., standard methotrexate, 5-fluorouracil, pemetrexed)
 Pretreat 1 drug --NOT NK1RA--
o Cannibinoids  before and after for 2 more days
o 5ht3RA
o Dex
o Dopamine Antags 
 Prochlor  10mg Q12
 Prometh  12.5-25mg Q6
 Meto  10-40 Q6 CRCL<40 give 50%

4. Minimal emetic risk - monoclonal antibodies, some classic cytotoxic agents such as the vinca alkaloids and bleomycin