was thought to be one of the
most effective single agents for
prevention of emesis in CINV.
Although it was part of former
international guidelines, its use
is no longer recommended for
prevention of acute CINV. Its use
is related to the risk of irreversible
tardive dyskinesia with higher
doses and long-term use and a
special alert due to its association
with extrapyramidal symptoms in
children. 56
Domperidone is a selective
peripheral dopamine (D 2 )
antagonist, less likely to cross the
blood–brain barrier than other
agents, and thus is less prone to,
but not free from, extrapyramidal
reactions. Administration of these
drugs to children and young
adolescents as first-line treatment
is not recommended. 1,3 Its use is
no longer mentioned in current
guidelines. 6–9
Alizapride has shown to be
inferior to metoclopramide
when given as monotherapy,
or in combination with a
corticosteroid or benzodiazepine
but might be effective in managing
breakthrough CINV in patients
already treated with a 5-HT 3 RA and
a corticosteroid. The most common
adverse effect is drowsiness and
extrapyramidal symptoms. 1,3,57
Phenothiazines act
predominantly by antagonising
dopaminergic receptors
(D 2 ) involved in emesis. All
phenothiazines (chlorpromazine,
perphenazine) have antiemetic
properties, although the relative
efficacy of these agents remains
unclear. Main adverse effects are
extrapyramidal reactions such as
dystonia and, with prolonged use,
tardive dyskinesia. 3
Butyrophenones (haloperidol,
droperidol) are major tranquilisers
that have an antiemetic effect
when used alone. In general, doses
used to obtain emesis control
are lower than thoseused as
for antipsychotic effects. 7 Side-
effects and antiemetic efficacies
appear to be similar to those
of phenothiazines. Intravenous
administration of haloperidol and
droperidol has a dose-dependent
risk of QT-prolongation and
torsades de pointes. Other side
effects include hypotension and
acute dystonia. 3,7
Olanzapine, an atypical
antipsychotic agent indicated
for treatment of schizophrenia
and bipolar disorder, has been
effective in preventing both acute
and delayed CINV (olanzapine is
used off-label as an anti-emetic).
Olanzapine shows activity at
multiple receptors, particularly
dopamine, 5-HT receptors, and
histamine receptors, involved in
nausea and emesis, suggesting
that it may have significant
antiemetic properties.1 ,3,58–64 A dose
of 5mg olanzapine per os has been
determined as the recommended
dose and an acceptable safety
profile. 63,64
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