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The National Comprehensive Cancer Network (NCCN) recently updated its guidelines for the prevention of emesis in patients receiving chemotherapy or radiation. The new guidelines serve as an update to the 2006 guidelines and are consensus based, with explicit review of the scientific evidence by a multidisciplinary panel of expert physicians and pharmacists.
Chemotherapy-induced nausea and vomiting (CINV) can negatively impact a patient's quality of life and often lead to poor compliance with future chemotherapy.
Chemotherapy-induced emesis is generally classified as acute, delayed, breakthrough, anticipatory, or refractory. "The management of delayed-onset emesis, which develops more than 24 hours after a treatment, has been a persistent clinical challenge for healthcare providers caring for patients with CINV," said Sally Yowell, Pharm.D., BCOP, clinical oncology pharmacist at Duke University's Duke Comprehensive Cancer Center in Durham, N.C., and a NCCN antiemesis panel member.
In the updated guidelines, metoclopramide and diphenhydramine are no longer recommended for prevention of delayed emesis in patients receiving moderate emetic risk chemotherapy. When moderately emetogenic chemotherapy is prescribed, aprepitant (Emend, Merck) may be given on days two and three if used on day one, with or without dexamethasone, or a 5-HT3 antagonist, such as ondansetron, may be administered. If the 5-HT3 antagonist palonosetron (Aloxi, MGI Pharma/Helsinn Healthcare) is given on day one of highly or moderately emetogenic regimens, no follow-up dosing is necessary, since it has a much longer serum half-life than other available 5-HT3 antagonists.
Research has shown that clinicians often underestimate the incidence of delayed CINV, mostly because chemotherapy is usually administered in the outpatient setting, and patients often do not contact their physician when episodes of emesis occur at home. Yowell believes that pharmacists can intervene in some ways to help tackle this issue. "Pharmacists must ensure that patients receive prescriptions for appropriate antiemetics and that they have the financial means to obtain their medications," she stated. Furthermore, "it is crucial that pharmacists educate patients about their antiemetic regimen and provide some tools to help them adhere to their regimen. "
The updated guidelines also include revised tables describing the emetogenic potential of different antineoplastic drugs. First, bortezomib (Velcade, Millennium) and trastuzumab (Herceptin, Genentech) have been moved from the low to the minimal emetic risk category. The NCCN antiemesis panel also added several agents, such as decitabine (Dacogen, MGI Pharma), dasatinib (Sprycel, Bristol-Myers Squibb), lenalidomide (Revlimid, Celgene), nelarabine (Arranon, GlaxoSmithKline), sunitinib (Sutent, Pfizer), and thalidomide (Thalomid, Celgene) to the minimal emetic risk category.
The guidelines also address the often difficult task of managing breakthrough emesis. The general principle of treatment is to give an additional agent as needed from a different drug class. The updated guidelines include nabilone (Cesamet, Valeant) for breakthrough treatment for CINV. Nabilone, a cannabinoid, was recently approved for nausea and vomiting in patients who have not responded to conventional antiemetics. Nabilone has complex effects on the central nervous system, and its antiemetic effects are believed to be caused by an interaction with the cannabinoid receptor system.
The next issue is incorporating the guideline recommendations into clinical practice, and this is where pharmacists can play a critical role. Yowell suggested implementing procedures whereby appropriate antiemetics are automatically ordered with the chemotherapy regimen, such as utilizing standardized order forms with antiemetic regimens linked to chemotherapy agents.
The NCCN antiemesis guidelines can be found at http://www.nccn.org/.
THE AUTHOR is a writer and hospital pharmacist in New Jersey.