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.