Treatment Regimens for CINV (3)

Question 1

General principles for acute/delayed prophylaxis and breakthrough treatment

Answer 1

Acute prophylaxis - usually given prior to chemotherapy administration at the infusion center (Day 1)

Delayed prophylaxis - usually receive RX prescription for PO medications to take at home (rarely - IV can be used if they have a home nurse)

Breakthrough - RX for prn medication (with different MOA than agents used for prophylaxis)

Counseling patients is very important - delayed prophylaxis drugs must be taken as scheduled, whereas breakthrough medications are taken only as needed

Question 2

What is the general regimen combination for IV HIGHLY emetogenic chemotherapy (HEC) prophylaxis?

Answer 2

NK1 RA and/or olanzapine
5HT3 RA
Dexamethasone

So either 3 or 4 drugs (usually 4 unless olanzapine is contraindicated)
And given as a 4 day regimen (note - not all drugs are given for all 4 days)

Question 3

IV HEC prophylaxis regimen option 1

Answer 3

(this is first option, unless something cannot be used, then we consider other option)

NK1RA + 5HT3 RA + dexamethasone + olanzapine

NK1 RA
-Given on day 1
-if apripetant is given on day 1 - then continue for day 2 and 3 (only with aprepitant - if fosaprepitant or rolapitant only give on day 1)

5HT3 RA
-Given on day 1 only
(ondansetron, granisetron, dolasetron, or palonosetron)

Dexamethasone
-Given on days 1-4

Olanzapine
-Given on days 1-4 (PO)

Question 4

IV HEC prophylaxis regimen option 2 (combination drugs)

Answer 4

Same as option 1, but combination NK1 RA/5HT3 RA products are used

Combination NK1 RA/5HT3 RA + dexamethasone + olanzapine

Combination NK1 RA/5HT3 RA
-given on day 1 only
-fosnetupitant/palonosetron or netupitant/palonosetron

Dexamethasone
-given on days 1-4 (IV/PO)

Olanzapine
-given on days 1-4 (PO)

Question 5

IV HEC prophylaxis regimen option 3 (olanzapine contraindication)

Answer 5

NK1 RA + 5HT3 RA + dexamethasone
-same as option 1 just without olanzapine
-we can do this if olanzapine cannot be used, or can start like this and see if n/v is not controlled then add olanzapine to the next cycle

NK1 RA
-Given on day 1
-if apripetant is given on day 1 - then continue for day 2 and 3 (only with aprepitant - if fosaprepitant or rolapitant only give on day 1)

5HT3 RA
-Given on day 1 only
(ondansetron, granisetron, dolasetron, or palonosetron)

Dexamethasone
-Given on days 1-4 IV/PO

Question 6

IV HEC prophylaxis regimen option 4 (steroid sparing)

Answer 6

5HT3 RA + dexamethasone + olanzapine
-can be used for high risk patients (e.g. those with diabetes)
-dexamethasone is only given for 1 day
-NK1 RAs are NOT given (because they interact with dexamethasone (increase the levels) and with this since dexamethasone is only given for 1 day, we need to give a high dose of it on day 1)

5HT3 RA
-IV Palonosetron on day 1 (this drug needs to be used because of its long half life)

Dexamethasone
-on day 1 only IV/PO

Olanzapine
-given on days 1-4

Question 7

IV moderately emetogenic chemotherapy (MEC) general regimen combination

Answer 7

5HT3 RA
Dexamethasone
+/- NK1 RA OR olanzapine (not both)

So 2 or 3 drugs
For 3 days
(note - not all drugs are given for all 3 days)

Question 8

IV MEC prophylaxis option 1

Answer 8

5HT3 RA + dexamethasone + NK1 RA

5HT3 RA
-given on day 1 only
(ondansetron, granisetron, dolasetron, or palonosetron)

Dexamethasone
-given on days 1-3 IV/PO
-note - if using aprepitant PO on days 2-3, can consider only using dexamethasone on day 1

NK1 RA
-Given on day 1
-if apripetant is given on day 1 - then continue for day 2 and 3 (only with aprepitant - if fosaprepitant or rolapitant only give on day 1 and continue steroid for days 2 and 3)

Question 9

IV MEC prophylaxis option 2 (combination)

Answer 9

Same as option one, but combination product NK1 RA / 5HT3 …

NK1 RA/5HT3 RA + Dexamethasone

NK1 RA/5HT3 RA
-given on day 1
-Netupitant/palonosetron or fosnetupitant/palonosetron

Dexamethasone
-must be given on day 1 +/- days 2-3 (since palonosetron has a long half life) IV/PO

Question 10

IV MEC prophylaxis regimen option 3 (2 drug)

Answer 10

5HT3 RA + dexamethasone

5HT3 RA
-given on day 1 only
(any of 4)

Dexamethasone
-given on day 1-3 IV/PO

Question 11

IV MEC prophylaxis regimen option 4 (steroid sparing)

Answer 11

5HT3 + dexamethasone + olanzapine
-dexamethasone is only given on day 1 at higher dose, so cannot use NK1 RA, so add olanzapine instead

5HT3 RA
-Palonosetron IV on day 1

Dexamethasone
-given on day 1 only IV/PO

Olanzapine
-given on days 1-3

Question 12

IV low emetogenic chemotherapy prophylaxis general regimen

Answer 12

Just 1 drug given for just 1 day…
dexamethasone or 5HT3 RA or Dopamine RA

(if chemo is given on multiple days, repeated on those days)

Question 13

Which dopamine RAs are used for IV low emetogenic chemotherapy prophylaxis (2)

Answer 13

Prochlorperazine or metoclopramide
(haloperidol is more potent and has more side effects)

Question 14

IV minimal emetogenic chemotherapy prophylaxis consideration

Answer 14

Routine prophylaxis is NOT recommended
(can be considered if n/v occurred with previous cycle)

Question 15

ORAL high/moderate emetic regimen prophylaxis

Answer 15

5HT3 RA
-dolasetron PO
-ondansetron PO
-granisetron PO or patch
(can’t do IV because patient is receiving oral chemo so they will not be at infusion center)

Start before chemo, continue every day before chemo (on days that chemo is taken)

Question 16

ORAL low/minimal emetic regimen prophylaxis

Answer 16

5HT3 RA
-dolasetron PO
-ondansetron PO
-granisetron PO (NOT patch - longer acting therapy is not needed because of low risk)

or

Dopamine Antagonist (not preferred because of side effects)
-metoclopramide PO
-prochlorperazine PO

Start before chemo and continue daily on days taking chemo

Question 17

Which drugs can be used for anticipatory N/v prevention and how should they be taken?

Answer 17

Benzodiazepines
-Alprazolam (PO) or Lorazepam (PO, IV, SL)

Take the evening prior to chemotherapy and then again 1-2 hours prior to chemotherapy administration (usually in the clinic)

Question 18

Breakthrough n/v therapy

Answer 18

Pick an agent different from one already being used for prophylaxis
-often ends up being a dopamine antagonist (since we do not use these much in prophylaxis)
-or cannabinoids (dronabinol) if refractory

But in general, just see which mechanism is currently missing, and that will be the best option to add