HPE CINV Pocket Guide 2018 | Page 14

minimising variations in clinical practice, but also to decrease rising healthcare costs, solve clinical controversies and manage better the (often significant) amount of new information published in a particular field. Clinical practice guidelines are also used in some places for insurance reimbursement purposes. The keyword behind clinical practice guidelines is being evidence-based, that is, incorporating statements that are developed through a systematic and methodologically rigorous literature assessment of evidence. However, it is not unusual to see the development of consensus- based or expert-based guideline recommendations, where there is limited or no evidence through trials in a particular clinical situation. Such guidelines do have a place in the delivery of care, but they should be considered more cautiously. Hence, it is important to understand the grading and strength of each recommendation made in any given guideline. Also, while the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) working group (www.gradeworkinggroup. org) 2 emphasises the link between the quality of a body of evidence and the recommendations made, it is important to remember that other factors beyond the quality of evidence can contribute to the 14 | 2018 | hospitalpharmacyeurope.com strength of a recommendation, such as patient values and preferences. 3 Key issues One of the key issues in the development of CINV is the emetogenicity of the chemotherapy drugs. Not all chemotherapy drugs have the same level of emetogenicity. Antiemetic guidelines provide a guide for the clinician to understand the particular level of emetogenicity, dividing drugs into four distinct categories. These include highly emetogenic chemotherapy (HEC), where more than 90% of patients are likely to experience nausea and vomiting if left untreated; moderately emetogenic chemotherapy (MEC), where 30–90% of patients can develop nausea and vomiting; low emetogenic chemotherapy (LEC), where 10–30% of patients can develop nausea and vomiting, and minimally emetogenic chemotherapy (MiEC), where less than 10% of patients can develop nausea and vomiting. This classification is very important, as each level of drug emetogenicity is linked with specific treatment recommendations in the guidelines. Understanding of the levels of emetogenicity can assist in minimising variations among clinicians in the way they manage nausea and vomiting.