New Antiemetic Guidelines Issued by ASCO

Nick Mulcahy

July 31, 2017

The American Society of Clinical Oncology (ASCO) has fully updated its antiemetic guideline for patients with cancer receiving chemotherapy and radiation therapy for the first time since 2015. The update is published online in the Journal of Clinical Oncology.

Most notably, the guideline provides new evidence-based information on the use of olanzapine (Zyprexa Relprevv, Eli Lilly) as well as neurokinin-1 (NK1) receptor antagonists and dexamethasone. The guidance discusses using medical marijuana to control nausea and vomiting.

The guide includes a table detailing the estimated prices (per dose and per treatment cycle) of the antiemetic agents (generic and branded).

Olanzapine, which is an antipsychotic medication, should be added to standard antiemetic regimens for adults who receive chemotherapy with a high risk for emesis or who experience breakthrough nausea and vomiting. High-risk regimens include those using cisplatin or the combination of cyclophosphamide and an anthracycline.

The evidence for olanzapine comes from a large double-blind, randomized, phase 3 study that compared the drug with placebo in patients who received the standard triple-drug antiemetic regimen of an NK1-receptor antagonist, a 5-HT3-receptor antagonist, and dexamethasone.

Last year, trial results were published online in the New England Journal of Medicine. "This drug made a difference, it really did," lead author, Rudolph M. Navari, MD, PhD, from the Indiana University School of Medicine–South Bend, told Medscape Medical News at that time.  "The study was strikingly positive and the drug was tolerable and showed no significant side effects."

Mark Kris, MD, from Memorial Sloan Kettering Cancer Center in New York City, called the results "amazing" last year in an online commentary. "What is even more amazing is that this drug is sitting in your pharmacy. It literally costs pennies," said Dr Kris, who is also co-chair of the ASCO expert panel that developed and authored the guideline update.

For olanzapine, the quality of evidence is high and the strength of recommendation is strong, according to the ASCO guideline authors, including the other co-chair, Paul Hesketh, MD, from the Lahey Clinic in Burlington, Massachusetts.

In another key update, the ASCO guideline authors recommend that an NK1 receptor antagonist should be added to the standard antiemetic regimen (the combination of 5-HT3 receptor antagonist and dexamethasone) for adults receiving carboplatin-based chemotherapy or high-dose chemotherapy, and children receiving chemotherapy with a high risk for nausea and vomiting.

NK1 receptor antagonists include aprepitant (Emend, Merck) and casopitant (Rezonic, GlaxoSmithKline) and rolapitant (Varubi, Tesaro).

This recommendation was actually issued last year in an abbreviated update from ASCO and is now included in the new full update.

The quality of evidence for the addition of an NK1 receptor antagonist is high and the strength of recommendation is strong, according to the guideline authors.

In another recommendation, the authors say that clinicians should administer dexamethasone only on day 1 for adults who receive anthracycline and cyclophosphamide chemotherapy.

Medical marijuana is not recommended in the new guidance, for either prevention or treatment of nausea and vomiting in patients with cancer receiving chemotherapy or radiation therapy. The evidence "remains insufficient," say the authors.

However, the authors point out that ASCO guidance continues to recommend the US Food and Drug Administration–approved cannabinoids dronabinol or nabilone to treat nausea and vomiting that are resistant to standard antiemetic therapies.

The guideline authors are a panel of experts from medical oncology, radiation oncology, nursing, pharmacy, and health services research, as well as a patient representative.

The team conducted a systematic review of the medical literature published between November 2009 and June 2016.

"Tremendous progress has been realized over the last 25 years in the prevention of chemotherapy-induced nausea and vomiting with the introduction of new classes of antiemetic agents," said Dr Kris in a press statement. "The full benefit of these treatment advances will only be realized, however, if evidence-based guidelines are fully implemented."

Dr Hesketh has financial ties to UpToDate. Dr Kris has ties to AstraZeneca, ARIAD, Genentech. and Puma Biotechnology. Multiple other authors have financial ties to industry.

J Clin Oncol. Published online July 31, 2017. Abstract 

Follow Medscape senior journalist Nick Mulcahy on Twitter: @MulcahyNick

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