Antiemetic administration in adults by radiation therapy risk category

Risk category	Dose	Schedule
High: Total body irradiation
5-HT₃ receptor antagonist*
Ondansetron	8 mg oral or 8 mg oral dissolving tablet, or 8 mg oral soluble film or 8 mg or 0.15 mg/kg IV	Use as prophylactic therapy: Once daily to twice daily on days of radiation therapy, with first dose administered before radiation therapy; once daily to twice daily on the day after each day of radiation therapy, if radiation therapy is not planned for that day
Granisetron	2 mg oral or 1 mg or 0.01 mg/kg IV	Use as prophylactic therapy: Once daily on days of radiation therapy, before radiation therapy; once daily on the day after each day of radiation therapy, if radiation therapy is not planned for that day
Corticosteroid
Dexamethasone	4 mg oral or IV	Use as prophylactic therapy: Once daily on days of radiation therapy, before radiation therapy; once daily on the day after each day of radiation therapy, if radiation therapy is not planned for that day
Moderate: Upper abdomen,^¶ craniospinal irradiation
5-HT₃ receptor antagonist^Δ
Ondansetron	8 mg oral or 8 mg oral dissolving tablet, or 8 mg oral soluble film or 8 mg or 0.15 mg/kg IV	Use as prophylactic therapy: Once daily to twice daily on days of radiation therapy, with the first dose administered before radiation therapy^◊
Granisetron	2 mg oral or 1 mg or 0.01 mg/kg IV	Use as prophylactic therapy: Once daily on days of radiation therapy, before radiation therapy^◊
Tropisetron	5 mg oral or IV	Use as prophylactic therapy: Once daily on days of radiation therapy, before radiation therapy^◊
Corticosteroid
Dexamethasone	4 mg oral or IV	Use as prophylactic therapy: Once daily on the days of first five radiation therapy fractions, before radiation therapy
Low: Brain, head and neck, thorax, pelvis^§
5-HT₃ receptor antagonist^¥
Ondansetron	8 mg oral or 8 mg oral dissolving tablet, or 8 mg oral soluble film or 8 mg or 0.15 mg/kg IV	Use as rescue therapy^‡
Granisetron	2 mg oral or 1 mg or 0.01 mg/kg IV	Use as rescue therapy^‡
Corticosteroid
Dexamethasone	For brain, if not already taking corticosteroid, 4 mg oral or IV; for other anatomic regions, 4 mg oral or IV	Use as rescue therapy: Titrate up as needed to a maximum of 16 mg oral or IV daily^‡
Dopamine receptor antagonist^†
Prochlorperazine	5 to 10 mg oral or IV	Use as rescue therapy: Titrate up as needed to maximum of 3 to 4 administrations daily^‡
Metoclopramide	5 to 20 mg oral or IV	Use as rescue therapy: Titrate up as needed to maximum of 3 to 4 administrations daily^‡
Minimal: Extremities, breast
5-HT₃ receptor antagonist**
Ondansetron	8 mg oral 8 mg oral dissolving tablet, or 8 mg oral soluble film or 8 mg or 0.15 mg/kg IV	Use as rescue therapy^¶¶
Granisetron	2 mg oral or 1 mg or 0.01 mg/kg IV	Use as rescue therapy^¶¶
Corticosteroid
Dexamethasone	4 mg oral or IV	Use as rescue therapy^¶¶
Dopamine receptor antagonist^†
Prochlorperazine	5 to 10 mg oral or IV	Use as rescue therapy^¶¶
Metoclopramide	5 to 20 mg oral or IV	Use as rescue therapy^¶¶

RT: radiation therapy; 5-HT₃: 5-hydroxytryptamine-3; IV: intravenous.
* Either 5-HT₃ receptor antagonist is appropriate. Palonosetron, dolasetron, and tropisetron have been removed from the 2017 guideline as data on their use in high-emetic-risk radiation therapy are lacking.
¶ Radiation therapy involving, at least in part, the anatomic region from the superior border of the 11th thoracic vertebra to the inferior border of the third lumbar vertebra.
Δ Ondansetron or granisetron preferred due to a larger body of evidence for these agents. Palonosetron and dolasetron have been removed from the 2017 guideline as sufficient data on their use in moderate-emetic-risk radiation therapy are lacking.
◊ Monitor patients during radiation therapy schedules that span multiple weeks to detect symptoms experienced during interspersed days when radiation therapy and prophylaxis are not administered, for example, weekends, and to balance benefits and toxicities of prolonged 5-HT₃ receptor antagonist therapy.
§ Corticosteroid is the preferred first agent for the brain. Any antiemetic class is appropriate for head and neck, thorax, and pelvis.
¥ Either 5-HT₃ receptor antagonist is appropriate. Palonosetron, dolasetron, and tropisetron have been removed from the 2017 guideline as sufficient data on their use in low-emetic-risk radiation therapy are lacking.
‡ Depending on the severity of symptoms and the remaining duration of radiation therapy, patients can receive subsequent rescue therapy as needed or begin receiving prophylactic therapy for the remainder of radiation therapy.
† Either dopamine receptor antagonist is appropriate.
** Either 5-HT₃ receptor antagonist is appropriate. Palonosetron, dolasetron, and tropisetron have been removed from the 2017 guideline as sufficient data on their use in minimal-emetic-risk radiation therapy are lacking.
¶¶ Patients can receive rescue therapy as needed. Alternative explanations for symptoms should be investigated to avoid the need for prophylactic therapy for the remainder of radiation therapy.

From: Hesketh PJ, Kris MG, Basch E, et al. Antiemetics: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol 2017; 35(28):3240-3261. Reprinted with permission. Copyright © 2017 American Society of Clinical Oncology. All rights reserved.

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