Fosaprepitant and Aprepitant for Chemotherapy-Induced Nausea and Vomiting in Children

Marcia L. Buck, PharmD, FCCP, FPPAG, BCPPS


Pediatr Pharm. 2018;24(6) 

In This Article

Clinical Experience

In 2014, Shillingburg and Biondo published the first retrospective study to include use of fosaprepitant as well as aprepitant in children and adolescents.[9] The authors reviewed the cases of 26 patients who received a total of 287 doses over 114 chemotherapy cycles. The patients ranged in age from 11 months to 17 years of age (mean 10.1 years). Fosaprepitant was used in seven of the patients, ranging in age from 13 to 17 years of age, accounting for 18 of the doses given (6%). All doses were either 115 mg or 150 mg. Only eight patients (38%) required rescue antiemetic doses. No adverse reactions were reported.

Last year, Kusick and colleagues provided a preliminary report of safety data on fosaprepitant use in 20 children between 9 months and 16 years of age who received 87 doses for CINV prophylaxis.[10] Patients weighing less than 30 kg received weight-based dosing, while 14 others received the adult dose of 150 mg. One patient experienced an infusion-related reaction, but their symptoms resolved after discontinuation of the infusion. No other adverse reactions were noted.

Another single-center retrospective study was recently published on-line ahead of print in the Journal of Pediatric Hematology and Oncology that describes the use of fosaprepitant in 35 children.[11] The median age of the patients was 10 years, with a range of 10 months to 18 years. The majority (57%) had central nervous system tumors, followed by 20% with sarcomas and 14% with neuroblastoma. All but one patient was receiving HEC. Fifteen patients (60%) had a prior history of CINV with earlier chemotherapy cycles. Over half of the patients weighed less than 40 kg and were given doses of 4 mg/kg. The remaining patients received the standard adult dose of 150 mg. The median number of doses given was 4 (range 1–21). All patients received ondansetron. In addition, 24 (69%) were given dexamethasone, three received scopolamine, two received dronabinol, and one each received diphenhydramine and lorazepam. Forty percent of the patients had nausea and/or emesis, but only 20% had nausea and 11% had emesis during the acute phase (the first 24 hours after chemotherapy). Twenty-six patients (74%) required rescue therapy, with 43% of patients needing treatment during the acute phase and 69% during the delayed phase (hours 25–120).

Patients younger than 6 years of age were more likely to experience emesis, while the adolescents were more likely to report nausea. The median number of rescue doses needed was highest in the adolescents, with a median of 4 doses compared to 2 doses in the infants to 6-year-olds and 1 in the 7 to 12-year-olds. Adverse reactions possibly related to fosaprepitant were noted in sixteen patients (43%). Twelve patients had elevated serum transaminases; however, eight had received high-dose methotrexate which may have contributed to the rise in levels. All cases resolved without intervention. Three patients had headaches, but were also receiving ondansetron, another possible cause, and one patient had intractable hiccups which resolved with baclofen. Two additional patients who were identified as meeting the study criteria were not included in the analysis after they developed anaphylactoid reactions with their first dose.