Preventing Chemotherapy-Induced Nausea and Vomiting: Using Guidelines in Clinical Practice 2011?
Our institutional guidelines at Memorial Sloan-Kettering Cancer Center have used the same 4 emetic risk categories used by all the major guideline groups: high, moderate, low, and minimal.
For the high-emetic-risk chemotherapy programs, including the combination of an anthracycline and cyclophosphamide, we recommend using palonosetron, dexamethasone, and aprepitant. In our practice setting, the tablets of aprepitant are the most effective, and we also use tablets of dexamethasone, but again, that may vary depending on your practice setting. [For moderate emetic risk, the MSKCC guidelines recommend the use of palonosetron and dexamethasone.]
For low emetic risk, we recommend dexamethasone alone. For minimal emetic risk, no prophylactic antinausea medicines [are routinely given], but an as-needed prescription is given to make sure that the patient has access to an antiemetic. Whether they use it or not, it is very comforting to know that it is available to them. I would encourage you to always give a prescription, or even better, give the medication to the patient.
To summarize how to do the best job in preventing the number-1 side effect that concerns patients beginning cancer therapy, my first recommendation is to use palonosetron on the day of therapy [when a 5-HT3 antagonist is indicated]. It gives better control of nausea. It gives better control of vomiting than other 5-HT3 antagonists. For patients receiving moderate- or high-emetogenic-risk chemotherapy regimens, give aprepitant with [a 5-HT3 antagonist], or if it is the right fit for your practice setting, use fosaprepitant IV.
Last, we have many available guidelines on the Internet and in print. The American Society of Clinical Oncology, the National Comprehensive Cancer Network (NCCN), and the Multinational Association of Supportive Care in Cancer (MASCC) all have published guidelines in print and on the Internet for you to use.
Even more important, take those guidelines and make sure that the specific drugs, doses, and schedules work in your practice. It may be that intravenous dexamethasone is the best drug in your practice setting rather than oral dexamethasone. It may be that fosaprepitant is a better fit for your practice setting [than aprepitant]. But make a choice, and make sure that you apply it [consistently].
One of the great advantages of guidelines is that they take the best available treatments that we have and ensure that they are given to every patient [when appropriate] and that [providing appropriate therapy] is very easy to do. There are a lot of different choices within the guidelines, and I encourage you to sit down with your care team -- the pharmacy, nursing staff, and physicians -- to choose the best treatment for the common chemotherapy regimens in your practice setting and use the guidelines as the starting point.
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