Antiemetics: Richard Gralla

Thursday, January 31, 2019

In the first episode of Blood & Cancer, David Henry, MD (http://bit.ly/2MFDfzm), welcomes Richard J. Gralla, MD (http://bit.ly/2ShsxEv), of the Albert Einstein College of Medicine in New York. The topic today centers around antiemetics and ways to use them. And later, Ilana Yurkiewicz, MD (https://stanford.io/2RXPixR), debuts her segment Clinical Correlations all about hematology care.

Visit MDedge/hematology-oncology

Show Notes

By Emily Bryer, DO

  • Highly emetic chemotherapy regimens include cisplatin, dacarbazine, anthracycline, and cyclophosphamide combinations
    • Treatment should include an NK1 receptor antagonist, dexamethasone, and a 5HT3 antagonist
    • All 5HT3 antagonists should be given only once (no evidence that prn or delayed administration is helpful)
    • Olanzapine is an effective antiemetic, although its precise role and dose are undergoing investigation
    • An all-oral regimen for highly emetic could include Netupitant (NK1) and palonosetron (long-acting 5HT3) (NEPA) + Oral Dex + Olanzapine
  • Moderately emetic chemotherapy regimens include irinotecan and taxotere
    • Treatment should include 5HT3 antagonist and dexamethasone
  • Carboplatin causes more emesis than initially thought
    • Improvement with NK1 antagonist yields a 15% decreased risk of emesis
    • Guidelines now recommending NK1 with carboplatin
  • Low emetic chemotherapy regimens include gemcitabine, pemetrexed as single agent
    • Single drug: one dose of corticosteroid or one dose of 5HT3 antagonist
  • Minimal emetic chemotherapy regimens include vincristine or bleomycin
    • No drugs are recommended for acute or delayed nausea/emesis
  • 20 mg Dexamethasone IV (or 12 mg PO 12 mg) should be administered only on day 1 of chemotherapy. Dexamethasone can be spared after that unless cisplatin (would require 2 days of steroids)
  • Marijuana and THC have some antiemetic properties, but are about one quarter as effective as 5HT3 antagonists
  • Lorazepam may be used in anticipatory emesis started a few days prior to chemotherapy

References:

Ann Oncol. 2014 Jul;25(7):1333-9.

JCSO 2015;13(4):128-30.

JCSO 2016;4(1):11-20.

Contact information:

Contact us: podcasts@mdedge.com

MDedge on Twitter: @mdedgehemonc

Dr. Ilana Yurkiewicz on Twitter: @ilanayurkiewicz

Dr. Yurkiewicz on MDedge: http://bit.ly/2DItTAb

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David Henry, MD
David Henry, MD, FACP, is a clinical professor of medicine at the University of Pennsylvania and vice chairman of the department of medicine at Pennsylvania Hospital in Philadelphia. He received his bachelor’s degree from Princeton University and his MD from the University of Pennsylvania, then completed his internship, residency, and fellowship at the Hospital of the University of Pennsylvania. After 2 years as an attending in the U.S. Air Force, he was drawn to practicing as a hem-onc because of the close patient contact and interaction, and his belief that, win or lose with each patient, one can always make a difference in their care and lives. Follow Dr. Henry on Twitter: @davidhenrymd. Dr. Henry reported being on the advisory board for Amgen, AMAG Pharmaceuticals, and Pharmacosmos. He reported institutional funding from the National Institutes of Health and FibroGen.



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