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Antiemetic dosing for adults by antineoplastic risk category[1,2]

Antiemetic dosing for adults by antineoplastic risk category[1,2]
Risk category Agent Dosing on day of chemotherapy Dosing on subsequent days

High emetic risk*
(>90%)

Option 1

NK1R antagonist (one of the following):
  • Aprepitant
125 mg oral 80 mg oral daily on days 2 and 3.
130 mg IV  
  • Fosaprepitant
150 mg IV  
  • Rolapitant
180 mg oral  
PLUS
5-HT3 antagonist (one of the following):
  • Granisetron
2 mg oral; 1 mg or 0.01 mg/kg IV; 1 transdermal patch; 10 mg subcutaneous  
  • Ondansetron
24 mg single oral dose, or 8 mg (or 0.15 mg/kg) single dose IV  
  • Palonosetron
0.5 mg oral; 0.25 mg IV  
  • Dolasetron
100 mg oral ONLY  
  • Tropisetron
5 mg oral; 5 mg IV  
  • Ramosetron
0.3 mg IV  
PLUS
Glucocorticoid:
  • Dexamethasone
12 mg oral or IV (20 mg orally if using rolapitant)

If aprepitant is used: 8 mg oral or IV daily on days 2 to 4.Δ

If fosaprepitant is used: 8 mg oral or IV on day 2; 8 mg oral or IV twice daily on days 3 to 4.Δ

If rolapitant is used: 8 mg oral or IV twice daily on days 2 to 4.Δ
PLUS
  • Olanzapine
5 to 10 mg 5 to 10 mg daily on days 2 to 4.

High emetic risk*
(>90%)

Option 2

NEPA (netupitant plus palonosetron, capsule) Once  
OR
Fosnetupitant plus palonosetron (injection) Once  
PLUS
Glucocorticoid:
  • Dexamethasone
12 mg oral or IV 8 mg oral once daily on days 2 to 4 (cisplatin only§).
PLUS
  • Olanzapine
5 to 10 mg 5 to 10 mg daily on days 2 to 4.

Moderate emetic risk¥
(30 to 90%)

Non-carboplatin

5-HT3 antagonist (one of the following):
  • Refer above for options for high emetic risk option 1.
  • If ondansetron is used, change dose to 8 mg oral twice daily.
PLUS
Glucocorticoid:
  • Dexamethasone
8 mg oral or IV 8 mg oral or IV daily on days 2 and 3.

Moderate emetic risk¥
(30 to 90%)

Carboplatin based

NK1R antagonist (one of the following):
  • Refer above for options for high emetic risk option 1.
  • If IV aprepitant is used, the dose should be 100 mg IV on day 1, with oral aprepitant 80 mg per day on days 2 and 3, or 130 mg IV on day 1 only.
PLUS
5-HT3 antagonist (one of the following):
  • Refer above for options for high emetic risk option 1.
  • If oral ondansetron is used, change dose to 8 mg oral twice daily.
PLUS
Glucocorticoid:
  • Dexamethasone
12 mg oral or IV (20 mg orally if using rolapitant)  
Low emetic risk
(10 to 30%)
Glucocorticoid:
  • Dexamethasone
4 to 8 mg oral or IV  
OR
5-HT3 antagonist (one of the following):
  • Refer above for options for high emetic risk option 1.
  • If oral ondansetron is used, change dose to 8 mg oral once daily.
OR
Phenothiazine-type drug (eg, prochlorperazine or levomepromazine)
Minimal emetic risk
(<10%)
None None None.
NK1R: neurokinin 1 receptor; IV: intravenous; 5-HT3: type 3 5-hydroxytryptamine.
* Includes the combination of an anthracycline and cyclophosphamide.
¶ Netupitant, aprepitant, and fosaprepitant all interfere with dexamethasone metabolism, leading to higher exposure for any specific dose. When given as a single dose on day 1, fosaprepitant impairs dexamethasone metabolism on days 1 and 2 only. If patients do not receive an NK1R antagonist, the dexamethasone dose should be adjusted to 20 mg on day 1 and 16 mg daily on days 2 to 4.
Δ For patients receiving anthracycline/cyclophosphamide for breast cancer or a carboplatin-containing regimen, delete days 2 to 4 of dexamethasone.
The 5 mg dose of olanzapine is preferred for most patients receiving a cisplatin-based highly emetogenic regimen because of the likely similar efficacy and less sedation than with a 10 mg dose. There is insufficient evidence to recommend the lower dose for those receiving an anthracycline plus cyclophosphamide.
§ When NEPA is used on day 1, multiday administration of glucocorticoids is only used in the delayed phase period with cisplatin. For anthracycline/cyclophosphamide combinations, administer glucocorticoids on day 1 only. If a first-generation 5-HT3 antagonist is used on day 1 rather than palonosetron, treatment with a first-generation 5-HT3 antagonist alone on days 2 and 3 is an acceptable alternative.
¥ Clinicians who choose to use an NK1R antagonist for a moderate-risk regimen should follow the recommendations for high-risk chemotherapy regimens. Importantly, a corticosteroid is only given on day 1; the dexamethasone dose is lower (12 mg) unless rolapitant is employed (20 mg).
‡ We would only add NK1R antagonist if carboplatin area under the curve dose is ≥4 mg/mL per min. This regimen is also appropriate for anthracycline/cyclophosphamide-containing chemotherapy in diseases other than breast cancer.
† If palonosetron is the 5-HT3 receptor antagonist used on day 1, no additional prophylaxis beyond day 1 is needed for most patients.
Originally from: Basch E, Prestrud AA, Hesketh PJ, et al. Antiemetics: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol 2011. Adapted and reprinted with permission. Copyright © 2011 American Society of Clinical Oncology. All rights reserved.
Updated with information from:
  1. ​Hesketh PJ, Kris MG, Basch E, et al. Antiemetics: ASCO Guideline Update. J Clin Oncol 2020; 38:JCO2001296.
  2. Hesketh P, Kris MG, Basch E, et al. Antiemetics: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol 2017; 35:3240.
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