Antiemetics for chemotherapy-induced nausea and vomiting
The drugs that stopped chemotherapy from meaning days of vomiting: 5-HT3 blockers (ondansetron, palonosetron), NK1 blockers (aprepitant), dexamethasone and olanzapine, given by the emetic risk of each regimen.
Before 1991, cisplatin caused vomiting in nearly all patients; ondansetron (1991), granisetron, palonosetron (2003, long-acting), aprepitant (2003, NK1 antagonist), fosaprepitant, netupitant-palonosetron (2014), rolapitant and olanzapine (Navari, NEJM 2016) built the modern regimen. Guidelines (MASCC/ESMO, ASCO, NCCN) classify regimens as high (cisplatin, AC), moderate, low or minimal emetic risk and prescribe three- or four-drug prophylaxis for high risk (NK1 + 5-HT3 + dexamethasone ± olanzapine). Breakthrough, anticipatory and radiation-induced nausea have separate algorithms. CINV remains under-treated in ~30% of patients, particularly delayed nausea; dexamethasone-sparing and lower-dose olanzapine (5 mg) are recent refinements.
How it works
Prophylaxis matched to emetogenic risk of the regimen and patient risk factors, blocking serotonin (acute), substance P/NK1 (delayed), and dopamine/multiple receptors (olanzapine), with corticosteroid.
- Complete response in ~70-80% even with cisplatin
- Generic, oral, inexpensive options
- Consensus guidelines from three bodies
- Delayed and anticipatory nausea still common
- Guideline non-adherence (under- and over-prescribing)
- Olanzapine sedation; dexamethasone and immunotherapy interactions
Latest papers
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