regimens), olanzapine has been
added, after a long debate, to the
three-drug combination which
include an NK 1 RA (in NCCN and
ASCO guidelines for HEC/AC
prevention; MASCC/ESMO states
that olanzapine may be considered
with a 5-HT 3 RA + dexamethasone,
particularly when nausea is an
issue, and for breakthrough nausea
and vomiting). For MEC, MASCC/
ESMO and ASCO recommend
the three-drug combination in
MEC in the carboplatin setting
only (ASCO specifically only at
carboplatin exposire AUC ≥ 4mg
ml/min); and NCCN recommends
three options, one of which
is the one recommended by
MASCC/ESMO and ASCO. ASCO
recommends prophylaxis with
dexamethasone or 5-HT 3 RAs
in LEC whereas MASCC/ESMO
recommends a single antiemetic
agent such as dexamethasone
or 5-HT 3 RA or dopamine
receptor antagonist, while NCCN
recommends dexamethasone
or prochlorperazine or
metoclopramide or a 5-HT 3 RA.
Some of the principles of
an optimal CINV management
include:
1 The goal is prevention
2 Risk period for emesis for HEC
and MEC is considered to be at
least four days (but patients can
experience nausea and vomiting
beyond that time)
3 Oral and IV 5-HT 3 receptor
antagonists are considered to be
equally effective
4 Antiemetic prophylaxis is
based on emetic risk of the
chemotherapy
5 Antiemetic prophylaxis should
be used when the CINV risk is
greater than 10%
6 Guidelines only make
recommendations for the first
cycle of treatment.
Table 1 shows selective
recommendations of the key
guidelines regarding management
of acute and delayed CINV in the
four emetic risk categories of
chemotherapy drugs.
The latest guidelines across
societies (with NCCN and MASCC/
ESMO updates in 2019) highlight
more the role of olanzapine as
an effective antiemetic, although
sedation is also highlighted as
a problem for some patients.
Olanzapine is an atypical
antipsychotic and is used off-label
for CINV management. Its dose as
an antiemetic is still a contentious
issue, with NCCN suggesting
5–10mg. Furthermore, NCCN
recently added recommendations
for avoiding corticosteroid
antiemetic premedication with
immune checkpoint inhibitors,
CAR T-cell therapies and lympho-
depleting chemotherapy. ASCO
has also commented on the
inconclusive data on cannabinoids
as antiemetics, preventing a clear
recommendation to be made.
MASCC/ESMO have further
added new guidelines for
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