The lack of complete nausea
control is the greatest unmet
need in CINV. 65 International
guidelines recommend the use of
olanzapine in combination with
a three-drug antiemetic regimen
(dexamethasone, NK 1 RA, and
5-HT 3 RA) in patients with
cisplatin or cyclophosphamide–
anthracycline chemotherapy
(see dedicated chapter in this
pocket guide).
In the latest NCCN update,
olanzapine-containing three-drug
or four-drug regimens for both
HEC- and MEC-based regimens are
recommended. 7 For patients not
able to use glucocorticosteroids
(for example, diabetes patients)
olanzapine can be used as a
substitute for dexamethasone. 7
According to the MASCC/ESMO
guidelines, 9 olanzapine may be
considered with a 5-HT 3 receptor
antagonist plus dexamethasone,
particularly when nausea is an
issue. A major adverse event
is sedation, especially in older
patients and olanzapine may
increase the risk of prolongation
of the QT-interval when used
in combination with other
QT-prolongating agents. The
most recent ASCO guidelines
have added olanzapine in their
recommendations as a quadruplet-
based regimen in HEC/AC. 6
The use of intramuscular
olanzapine combined with
parenteral benzodiazepines
is contra-indicated as toxicity
64 | 2019 | hospitalpharmacyeurope.com
might occur. 7
Benzodiazepines have no
major place in current antiemetic
schedules, but can be useful as
an adjunct to other antiemetic
regimens in certain circumstances.
Benzodiazepine formulations that
are fast-acting and with relatively
short half-lives (lorazepam) are
used to treat anxiety and can
reduce the risk of anticipatory
CINV and in patients with
refractory and breakthrough
emesis. The most commonly used
agent is this class is lorazepam.
It should be used with caution in
patients taking opioids. 1,3,7
Alprazolam should be used with
caution due to the risk of rebound
effect of anxiety. 7
Cannabinoids
The antiemetic potential of
cannabinoids (nabilone and
dronabinol) was first observed in
patients using marijuana during
chemotherapy that showed
improved emesis control. 1,3
Cannabinoids possess weak
to modest antiemetic efficacy
combined with potential beneficial
side effects as sedation and
euphoria. 1,3,66,67
Dronabinol and nabilone have
been approved by the FDA for
nausea and vomiting associated
with cancer chemotherapy
in patients who have failed
to respond adequately to
conventional antiemetic
treatments. 3