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Appendix B Supportive Care

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Appendix B Supportive Care APPENDIX B SUPPORTIVE CARE 1-4 ACUTE EMESIS PROPHYLAXIS o Dolasetron 100 mg and dexamethasone 20 mg given PO 30 minutes before Minimally Emetogenic Regimes (< 10%) chemotherapy • Prophylactic antiemetic therapy generally is not Palonosetron 0.25 mg IV (day 1 only) required. o and dexamethasone 20 mg PO given 30 • If the patient experiences nausea or vomiting, minutes before chemotherapy use prophylactic therapy prior to subsequent Patients who do not respond to a 2-drug treatments. • combination may benefit from the following: One of the following regimens is recommended: A corticosteroid, dopamine antagonist, and Dexamethasone 8 to 20 mg PO, given 30 serotonin antagonist regimen or minutes before chemotherapy Addition of a neurokinin antagonist to their Prochlorperazine 10 mg PO ± previous regimen. diphenhydramine 25 to 50 mg PO if needed, given 30 minutes before chemotherapy Metoclopramide 0.5 to 2 mg/kg PO ± Mildly Emetogenic Regimens (10% to 30%) diphenhydramine 25 to 50 mg PO if needed, • For most patients, prophylactic antiemetic therapy, given 30 minutes before chemotherapy particularly with a serotonin antagonist, generally is Promethazine 25 to 50 mg PO ± not required. diphenhydramine 25 to 50 mg PO if needed, • If needed, one of the following regimens may be given 30 minutes before chemotherapy given 30 minutes prior to therapy: • If patient still experiences significant nausea Dexamethasone 8 to 20 mg PO, given 30 or vomiting, add an agent from a different minutes before chemotherapy pharmacologic category to the previous Prochlorperazine 10 mg orally ± prophylactic antiemetic regimen. diphenhydramine 25 to 50 mg PO if needed, The following regimens are recommended: given 30 minutes before chemotherapy Patients who received a corticosteroid only: Metoclopramide 0.5 to 2 mg/kg PO ± Add a dopamine antagonist. diphenhydramine 25 to 50 mg PO if needed, Patients who received a dopamine given 30 minutes before chemotherapy antagonist only: Add a corticosteroid. Promethazine 25 to 50 mg PO ± Patients who received a corticosteroid and diphenhydramine 25 to 50 mg PO if needed, dopamine antagonist: Substitute a serotonin given 30 minutes before chemotherapy antagonist for the dopamine antagonist. • If patient still experiences significant nausea If a corticosteroid and dopamine antagonist or vomiting, add an agent from a different combination is not effective, a serotonin pharmacologic category to the previous antagonist and corticosteroid combination may prophylactic antiemetic regimen. be required. The following regimens are recommended: The following regimens are recommended: Patients who received a corticosteroid only: o Ondansetron 8 to 16 mg and Add a dopamine. dexamethasone 20 mg given PO 30 Patients who received a dopamine minutes before chemotherapy antagonist only: Add a corticosteroid. o Granisetron 1 to 2 mg and Patients who received a corticosteroid and dexamethasone 20 mg given PO 30 dopamine antagonist: Substitute a serotonin minutes before chemotherapy antagonist for the dopamine antagonist. 518 Appendix B 519 If a corticosteroid and dopamine antagonist mg PO, and aprepitant 125 mg given PO combination is not effective, a serotonin 30 minutes before chemotherapy antagonist and corticosteroid combination may o Palonosetron 0.25 mg IV (day 1 only), be required. dexamethasone 12 mg, and aprepitant The following regimens are recommended: 125 mg given PO 30 minutes before chemotherapy o Ondansetron 8 to 16 mg and dexamethasone 20 mg given PO 30 • Antiemetic therapy should continue for at least 3 minutes before chemotherapy days. Prolonged (more than 24 hours) use of o Granisetron 1 to 2 mg and dexamethasone 20 mg given PO 30 serotonin antagonists is NOT recommended.6 minutes before chemotherapy A corticosteroid or corticosteroid and dopamine antagonist combination is recommended for o Dolasetron 100 mg and dexamethasone 20 mg given PO 30 minutes before follow-up therapy.6 chemotherapy One of the following regimens is suggested: Dexamethasone 4 mg PO twice a day for 3 o Palonosetron 0.25 mg IV (day 1 only) and dexamethasone 20 mg PO given 30 days ± metoclopramide 0.5 to 2 mg/kg PO minutes before chemotherapy every 4 to 6 hours ± diphenhydramine 25 to • Patients who do not respond to a 2-drug 50 mg PO every 6 hours if needed, starting combination may benefit from the following: on day 2 of chemotherapy A corticosteroid, dopamine antagonist, and Dexamethasone 4 mg PO twice a day for 3 serotonin antagonist regimen or days ± prochlorperazine 10 mg PO every 4 Addition of a neurokinin antagonist to their to 6 hours ± diphenhydramine 25 to 50 mg previous regimen. PO every 6 hours if needed, starting on day 2 of chemotherapy Moderately Emetogenic Regimens (30% to 90%) Dexamethasone 4 mg PO twice a day for 3 • Prophylactic antiemetic therapy with a serotonin days ± promethazine 25 to 50 mg PO every antagonist is recommended but may not be 4 to 6 hours ± diphenhydramine 25 to 50 mg required in all patients. PO every 6 hours if needed, starting on day 2 • One of the following regimens may be given 30 of chemotherapy minutes prior to therapy: If a neurokinin antagonist is used, one of the Ondansetron 8 to 24 mg PO and following regimens are suggested: dexamethasone 20 mg PO, given 30 minutes Ondansetron 16 to 24 mg, dexamethasone before chemotherapy 12 mg, and aprepitant 125 mg given PO 30 Granisetron 1 to 2 mg PO and dexamethasone minutes before chemotherapy 20 mg PO, given 30 minutes before Granisetron 1 to 2 mg, dexamethasone 12 chemotherapy mg, and aprepitant 125 mg given PO 30 Dolasetron 100 mg PO and dexamethasone 20 minutes before chemotherapy mg PO, given 30 minutes before chemotherapy Dolasetron 100 mg, dexamethasone 12 mg, Palonosetron 0.25 mg IV and dexamethasone and aprepitant 125 mg given PO 30 minutes 20 mg PO, given 30 minutes before before chemotherapy chemotherapy on day 1 only Palonosetron 0.25 mg IV (day 1 only), Use of a neurokinin (NK1) antagonist is dexamethasone 12 mg, and aprepitant recommended for regimens that include both 125 mg given PO 30 minutes before doxorubicin and cyclophosphamide.2,3,5 chemotherapy The following regimens are suggested: Patients who experience significant nausea o Ondansetron 8 to 24 mg, dexamethasone or vomiting with one of these regimens 12 mg, and aprepitant 125 mg given PO should receive an agent from a different 30 minutes before chemotherapy pharmacologic category. o Granisetron 1 to 2 mg, dexamethasone Substituting granisetron for ondansetron 12 mg, and aprepitant 125 mg given PO in subsequent treatment cycles has not 30 minutes before chemotherapy been shown to be effective and is NOT 7-11 o Dolasetron 100 mg, dexamethasone 12 recommended. 520 A Guide to Combination Cancer Chemotherapy Regimens Highly Emetogenic Regimes (>90%) if needed, ± diphenhydramine 25 to 50 mg PO • Day 1 of each cycle every 6 hours if needed serotonin antagonist Prochlorperazine 25 mg rectally every 4 to 6 neurokinin (NK1) antagonist hours if needed, ± diphenhydramine 25 to 50 corticosteroid mg PO every 4 to 6 hours if needed • Days 2 and 3 of each cycle Promethazine 25 to 50 mg PO every 4 to 6 neurokinin antagonist hours if needed, ± diphenhydramine 25 to 50 corticosteroid mg PO every 4 to 6 hours if needed ± a dopamine or serotonin antagonist • Recommended regimens SPECIAL CONSIDERATIONS Day 1 Serotonin (5HT ) antagonists Aprepitant 125 mg, dexamethasone 12 mg, 3 • Meta-analysis recommends against use of these and ondansetron 16 to 24 mg PO 30 minutes agents after the first 24 hours.6 before chemotherapy • There is no benefit to using granisetron in patients Aprepitant 125 mg, dexamethasone 12 mg, who do not respond to ondansetron.7-11 and granisetron 2 mg PO 30 minutes before • High-dose granisetron (3 mg IV or 40 to 240 chemotherapy mcg/kg)7-11 for breakthrough nausea provides no Aprepitant 125 mg, dexamethasone 12 benefit.7-11 mg, and dolasetron 100 to 200 mg PO 30 minutes before chemotherapy Carboplatin Aprepitant 125 mg, dexamethasone 12 mg, • Causes delayed nausea or emesis similar to and palonosetron 0.5 mg PO 30 minutes cisplatin. before chemotherapy Mechanism of action and clinical course differ 12,13 Days 2 to 3 from cisplatin. A neurokinin antagonist and corticosteroid Urinary 5-hydroxyindole acetic acid (5-HIAA) or neurokinin antagonist, corticosteroid, and excretion indicates carboplatin causes dopamine antagonist combination is most A lower peak level. appropriate for follow-up therapy. One of the Prolonged release of serotonin. following regimens is recommended: • The clinical course of nausea or vomiting Reflects this pattern of serotonin release. o Aprepitant 80 mg PO and dexamethasone 8 mg PO ± one of the following: Usually begins 6 to 7 hours after drug . Metoclopramide 0.5 to 2 mg/kg PO administration. every 4 to 6 hours May persist for up to 120 hours. Prochlorperazine 10 mg PO every 4 to • Some clinicians divide the daily antiemetic dose into 6 hours 2 doses on days when carboplatin is administered. Promethazine 25 to 50 mg PO every 4 Cisplatin to 6 hours • Doses > 50 mg/m2 (single dose or cumulative over o Aprepitant 80 mg PO and dexamethasone consecutive days) causes delayed: 8 mg PO ± diphenhydramine 25 to 50 mg Nausea in 78% of patients. PO every 6 hours if needed Emesis in 61% of patients. Patients with significant nausea or vomiting May begin as soon as 16 hours after while receiving one of these regimens administration. should receive an agent from a different Peak severity occurs at 48 to 72 hours after pharmacologic category.1-4 administration. Breakthrough Nausea and Vomiting1-4 Usually abates between 96 to 168 hours after administration.14 • Patients should have an antiemetic for breakthrough nausea. Cyclophosphamide • Recommended regimens: • Emesis is often delayed for up to 12 hours after Metoclopramide 0.5 to 2 mg/kg PO every 4 to drug administration and may persist for up to 120 6 hours if needed, ± diphenhydramine 25 to 50 hours.12,15 mg PO every 6 hours if needed • Divide the daily antiemetic dose into 2 doses on Prochlorperazine 10 mg PO every 4 to 6 hours days when cyclophosphamide is administered.
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