Anti-emetics – pro

Zofran belongs to a class of medication, which includes dolasetron, granisetron, ondansetron, palonosetron, and tropisetron, has been the primary treatment for nausea and vomiting for many years. 5-HT3 serotonin receptor antagonists work by blocking serotonin release to the CTZ, alleviating emesis in most patients.

In early 2006, the American Society of Clinical Oncology (ASCO) set out to update their 1999 treatment guidelines regarding antiemetics in oncology.
The committee also reviewed the treatment guidelines discussed at the Antiemetic Consensus Conference, hosted by the Multinational Association of Supportive Care in Cancer (MASCC) in 2004. This international conference facilitated consensus statements and recommendations by representatives from nine oncology organizations, which would be published in whole or in part with their individual organization’s antiemetic guidelines. The ASCO Update Committee used the findings from this meeting to expand on their own recommendations and to aid in preparing their update document.

In terms of treating nausea and vomiting in patients who experience symptoms due to chemotherapy of high emetic risk (cisplatin and noncisplatin groups) within 24 hours after treatment, three agents are included in the 2006 guidelines. 5-HT 3 serotonin receptor antagonists, corticosteroids (dexamethasone), and aprepitant are all effective in the acute treatment of emetic symptoms related to chemotherapy. The addition of aprepitant to ASCO’s updated guidelines is the one major difference from their previous recommendations. The Update Committee, after analyzing numerous studies involving these three agents and cisplatin, states that all three agents improve the symptoms of cisplatin-induced emesis. The committee is able to generalize this claim to include other agents in the high-risk emesis category due to the universal incidence of emesis with cisplatin (>99%). The incidence is so great that if an antiemetic agent is effective against cisplatin, efficacy against other chemotherapy agents in this high-risk category is assumed.

Delayed Emesis (24 hours after chemotherapy): Recommendations for the prevention of delayed emesis in oncology patients receiving cisplatin and other agents of high emetic risk include the use of dexa­ methasone and aprepitant.1 This two-drug combination for the prevention of cisplatin and noncisplatin delayed emesis is a change from previous guidelines,  which advised the use of a corticosteroid alone or in combination with metoclopramide or a 5-HT3 antagonist.1 The combination of a 5-HT3 serotonin receptor antagonist with dexamethasone is no longer recommended by the Update Committee due to study results suggesting inferiority of the combination compared to dexamethasone alone. Furthermore, a trial published in 2005 found dexamethasone in combination with aprepitant superior to dexamethasone in combination with ondansetron, thus supporting ASCO’s most updated recommendation of dexamethasone and aprepitant.

FDA notified healthcare professionals in 2011 that a contraindication is being added to the prescribing information advising that the injection form of Anzemet (dolasetron mesylate) should no longer be used to prevent nausea and vomiting associated with cancer chemotherapy (CINV) in pediatric and adult patients. New data demonstrate that Anzemet injection can increase the risk of developing torsade de pointes, an abnormal heart rhythm, which in some cases can be fatal. Patients at particular risk are those with underlying heart conditions or those who have existing heart rate or rhythm problems. Anzemet causes a dose-dependant prolongation in the QT, PR, and QRS intervals on an electrocardiogram.

Kris MG, Hesketh PJ, et al. American Society of Clinical Oncology guideline for antiemetics in oncology: update 2006. J Clin Oncol. 2006;24:2932-2947.

Feinberg B, Gilmore J, Haislip S, Jackson J, Jain G, Balu S, Buchner D. Impact of initiating antiemetic prophylaxis with palonosetron versus ondansetron on risk of uncontrolled chemotherapy-induced nausea and vomiting in patients with lung cancer receiving multi-day chemotherapy.Support Care Cancer. 2012 Mar;20(3):615-23

Roila F. Prevention of cisplatin-induced delayed emesis: still unsatisfactory. Support Care Cancer. 2000;8:229-232.

NCCN.ORG, Supportive care

Armbruster, Wen-Jan Candy, Bayait, Frank, Papish, Steven Antiemetic guidelines for low and moderately low emetogenic potential chemotherapy Journal of Oncology Pharmacy Practice 1998 4: 212-213

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