Antiemetic efficacy and safety of a combination of palonosetron, aprepitant, and dexamethasone in patients with testicular germ cell tumor receiving 5-day cisplatin-based combination chemotherapy

Olanzapine combined with standard antiemetics for the prevention of nausea and vomiting in patients with germ cell tumor undergoing a 5-day cisplatin-based chemotherapy (NAVIGATE study)： A phase III crossover trial

Purpose Prophylactic use of olanzapine significantly improves chemotherapy-induced nausea and vomiting (CINV) in patients receiving single-day highly emetogenic chemotherapy and 3-day cisplatin-based chemotherapy. This phase III, double-blind, placebo-controlled crossover trial aimed to evaluate the efficacy and safety of olanzapine combined with triple antiemetic therapy for CINV in germ cell tumor (GCT) patients receiving 5-day cisplatin-based chemotherapy.Methods Eligible patients receiving at least two consecutive identical courses of 5-day cisplatin-based chemotherapy were randomly assigned to either olanzapine (5 mg) or its matching placebo during days 1-7 of the first chemotherapy cycle, then crossed over to the alternate group during the second cycle. The primary endpoint was complete response (CR) rate. Main secondary endpoints included CR rates in acute and delayed phases, no nausea rates, and toxicities. Results Between January 2022 and February 2024, 77 patients were enrolled, 40 were randomized to the olanzapine group, and 37 to the placebo group during the first course. The overall CR rate was 55.8 % (43/77) in the olanzapine group, compared with 36.3 % (28/77) in the placebo group (P = 0.03). The CR rates in the acute and delayed phases were 62.3 % (48/77) vs. 40.3 % (31/77), P = 0.01, and 79.2 % (61/77) vs. 53.2 % (41/77), P = 0.04, respectively. No nausea rates were also significantly higher in the olanzapine group than those in the placebo group: 36.4 % vs. 15.6 % in overall phase (P = 0.005), 39.0 % vs.16.9 % in acute phase (P = 0.004) and 72.7 % vs. 49.4 % in delayed phase (P = 0.005). Addition of olanzapine did not increase toxicities. Conclusion This trial provides the first high-level evidence supporting the olanzapine-based four-drug combination to prevent CINV in GCT patients undergoing 5-day cisplatin-based chemotherapy. Clinical Trial Registration: ClinicalTrials.gov, number NCT05198796.

Efficacy and safety of multi-day antiemetic treatment for patients undergoing multi-day chemotherapy: a systematic review of Clinical Practice Guidelines for Antiemesis 2023 from Japan Society of Clinical Oncology

BACKGROUND

A standardized multi-day antiemetic regimen for multi-day chemotherapy remains elusive. This systematic review evaluated the efficacy and safety of multi-day antiemetic regimens in patients undergoing multi-day intravenous chemotherapy.

METHODS

We conducted a comprehensive search of PubMed, Cochrane Library, and Ichushi-Web databases for relevant studies published from January 1990 to December 2020. We included studies comparing multi-day and single-day antiemetic regimens for preventing chemotherapy-induced nausea and vomiting.

RESULTS

No studies directly comparing multi-day versus single-day antiemetic regimens were found. Despite expanding control group criteria beyond "single-day antiemetic therapy" limited high-quality studies and variations in cancer types, chemotherapy regimens, and antiemetic treatments precluded meta-analysis. Among the included studies, some randomized controlled trials (RCTs) focused on complete response and vomiting rates. Two studies comparing two- and three-drug combinations reported higher complete response and no-vomiting rates with the three-drug regimen. Limited RCTs explored "nausea control" and "cost," and assessing "adverse events" proved challenging due to inconsistent reporting.

CONCLUSION

The research on multi-day antiemetic therapy is limited, necessitating further investigation. Nonetheless, our findings suggest that three-drug combination therapy, including aprepitant, may offer superior antiemetic efficacy compared to two-drug regimens. Multi-day antiemetic therapy is strongly recommended during multi-day intravenous administration of cytotoxic anticancer drugs.

Efficacy and safety of netupitant/palonosetron in preventing nausea and vomiting in diffuse large B cell lymphoma patients undergoing R-CHOP chemotherapy

Diffuse large B-cell lymphoma (DLBCL) is the most common type of non-Hodgkin's lymphoma, for which cyclophosphamide, doxorubicin, vincristine, and prednisone with rituximab(R-CHOP) is one of the standard regimens. Given that R-CHOP is highly emetogenic, chemotherapy-induced nausea and vomiting (CINV) prevention is clinically important. However, there is a paucity of studies focusing on these patients. This study aimed to ascertain the effectiveness of an oral fixed-dose combination of netupitant and palonosetron (NEPA) in preventing CINV in patients with DLBCL undergoing first-line R-CHOP chemotherapy. Seventy patients were enrolled in this single-center prospective non-comparative study conducted between November 2020 and May 2023 in South Korea. NEPA was administered 1 h prior to chemotherapy initiation on day 1. The primary endpoint of the study was the complete response rate (no emesis, and no rescue medication) during the acute, delayed, and overall phases, which were assessed over a period of 120 h post-chemotherapy. The complete response rates for NEPA were 90.0% [95% CI 80.5, 95.9] for the acute phase, 85.7% [95% CI 75.3, 92.9] for the delayed phase, and 84.3% [95% CI 73.6, 91.9] for the overall phase, with no-emesis rates (acute: 97.1% [95% CI 97.1, 99.7], delayed: 95.7% [95% CI 88.0, 99.1], overall: 92.9% [95% CI 84.1, 97.6]). NEPA was well tolerated with no severe treatment-emergent adverse events. NEPA exhibited substantial efficacy in mitigating CINV in DLBCL patients undergoing R-CHOP chemotherapy, demonstrating high CR and no-emesis rates, and favorable safety profiles.

A multicenter, randomized, double-blind, placebo-controlled, phase 3 trial of olanzapine plus triple antiemetic regimen for the prevention of multiday highly emetogenic chemotherapy-induced nausea and vomiting (OFFER study)

Background

Evidence supports prophylactic use of olanzapine for the treatment of chemotherapy-induced nausea and vomiting (CINV). However, most studies to date have focused on patients with single-day highly emetogenic chemotherapy (HEC). Currently, administration of antiemetic therapies for nausea and vomiting induced by multiday chemotherapy regimens remains a challenge. In this study, we evaluated the efficacy of olanzapine combined with triple antiemetic therapy for the prevention of CINV in patients receiving multiday chemotherapy.

Methods

We performed a randomized, double-blind, placebo-controlled phase 3 trial in 22 hospitals. Eligible patients were between 18 and 75 years old, were diagnosed with malignant solid tumors, and they had an Eastern Cooperative Oncology Group (ECOG) performance status of 0-2. All the study participants were scheduled to be treated with chemotherapy regimens containing 3-day cisplatin (3-day total dose ≥75 mg/m2). Randomization was computer generated and stratified by gender and chemotherapy treatment history. Allocation was done via an interactive web response system. Enrolled patients were randomly assigned 1:1 to receive either 5 mg olanzapine or placebo orally before bedtime for 5 days combined with intravenous fosaprepitant (150 mg) 1 h before the administration of cisplatin on day 1, ondansetron hydrochloride intravenously, and dexamethasone orally 30 min before cisplatin from days 1 to 3. Dexamethasone was also administered at the same time on days 4 and 5. The primary endpoint was the proportion of subjects with complete response (no vomiting and no rescue therapy) within the overall phase (days 1-8) after starting chemotherapy. Baseline plasma concentrations of P-substance and 5-HT were measured for exploratory analysis. This study was registered at ClinicalTrials.gov, number NCT04536558.

Findings

Between December 2020 and September 2021, 349 patients with malignant solid tumors were enrolled in the study, with 175 participants randomly assigned to receive olanzapine and 174 participants assigned to receive placebo. The proportion of patients who achieved a complete response in the overall phase was significantly higher in the olanzapine group than in the placebo group (69% vs. 58%, P = 0.031). A complete response benefit was observed in the olanzapine group versus the placebo group in almost all the subgroups. Four factors were considered significantly associated with complete response in multivariable analysis: treatment group, gender, baseline plasma concentration of 5-HT, and prior radiotherapy. All the reported adverse events associated with olanzapine administration were grades 1 and 2.

Interpretation

Olanzapine (5 mg) combined with fosaprepitant, ondansetron, and dexamethasone was better than triple antiemetic therapy alone for patients receiving multiday chemotherapy regimens. Based on these results, the four-drug combination should be recommended as the best antiemetic regimen given to patients receiving multiday cisplatin-based chemotherapy and baseline plasma concentration of 5-HT may be used to identify individuals who are prone to CINV. However, all these findings need to be further validated in future studies.

Funding

Jiangsu Hansoh Pharmaceutical Group Co., Ltd. provided research grant and study drugs for this investigator-initiated study.

Prolonged administration of aprepitant improves cisplatin-based chemotherapy-induced nausea and vomiting

Aims: To determine the antiemetic efficacy of a 6-day aprepitant schedule in patients receiving multiple-day cisplatin. Patients & methods: Patients diagnosed with lung cancer and who were chemotherapy naive were screened. The patients willing to use aprepitant were randomly divided into two groups: prolonged use of aprepitant (PA; 6-day aprepitant) and standard use of aprepitant (SA; 3-day aprepitant); the patients who rejected aprepitant were recruited into the control group (group C). Primary end points included the safety and the number of days without chemotherapy-induced nausea and vomiting. Results: There was no statistical difference in adverse events among the three groups. The average days without chemotherapy-induced nausea and vomiting of group PA (18.28 ± 3.35) was significantly longer than in groups SA and C. Furthermore, better life function scores were achieved in group PA according to the Functional Living Index - Emesis questionnaire. Conclusion: In this study 6-day aprepitant was safe and more effective than standard 3-day aprepitant in controlling chemotherapy-induced nausea and vomiting due to 3-day cisplatin regimens.

Palonosetron on Days 1 and 5 Versus Granisetron Daily (Days 1-5) in Germ Cell Tumour Therapy

BACKGROUND/AIM

The control of chemotherapy-induced nausea and vomiting during bleomycin, etoposide, and cisplatin (BEP) treatment is important for maintaining treatment intensity. The effects of palonosetron and granisetron were compared in BEP chemotherapy.

PATIENTS AND METHODS

The administration of palonosetron on days 1 and 5 (Pal method) and granisetron daily (days 1-5, Gra method) were compared in terms of their efficacy and cost-effectiveness.

RESULTS

Additional rescue antiemetic agents were used in 15 of 32 and 30 of 30 cycles in the Pal and Gra method groups, respectively (p<0.05). The complete response rate, defined as no vomiting and no rescue agent usage, in each cycle, was 50% and 0% in the Pal and Gra method groups, respectively (p<0.05). The average cost of antiemetic agents in a cycle was 50,759 and 54,555 yen in the Pal and Gra method groups, respectively (p<0.05).

CONCLUSION

The Pal method may be the standard method in BEP.

Cisplatin-Based Therapy and CINV: Optimal Antiemetics During Germ Cell Testicular Cancer Treatment

BACKGROUND

Cisplatin-based chemotherapy regimens are the backbone of chemotherapy for germ cell testicular cancer. Cisplatin is administered for five days, causing an overlap of acute and delayed chemotherapy-induced nausea and vomiting (CINV). Although CINV is widely researched, studies involving multiday chemotherapy regimens are limited.

OBJECTIVES

This article synthesizes the research in antiemetics used in multiday cisplatin-based chemotherapy regimens and provides recommendations to optimize antiemetic therapy.

METHODS

A literature review was conducted for articles examining antiemetics in multiday cisplatin-based chemotherapy regimens. Results were synthesized, and findings were applied to existing antiemetic strategies.

FINDINGS

Although an optimal regimen has not been identified, patients receiving multiday cisplatin chemotherapy should have an antiemetic administered on each day of chemotherapy and two to three days after chemotherapy. Antiemetics should include an NK1 antagonist, 5-HT3 receptor antagonist, and dexamethasone.

Phase II study of palonosetron, aprepitant and dexamethasone to prevent nausea and vomiting induced by multiple-day emetogenic chemotherapy

PURPOSE

This study aimed to determine the antiemetic efficacy and safety of palonosetron, aprepitant and dexamethasone in patients with testicular germ cell tumours (TGCTs) receiving 5-day cisplatin-based combination chemotherapy.

METHODS

In this open-label, single-arm, single-centre study, the antiemetic therapy consisted of palonosetron 0.75 mg on day 1, aprepitant 125 mg on day 1 and 80 mg on days 2-7 and dexamethasone 6.6 mg on days 1-7. The primary endpoint was complete response (CR; no vomiting/retching or rescue medication) in the overall period (0-240 h), and secondary endpoints included complete protection (CP; defined as CR and no more than mild nausea) and total control (TC; defined as CR and no nausea). The incidence and severity of nausea were assessed on the basis of the Common Terminology Criteria for Adverse Events v4.0 and a subjective rating scale completed by patients.

RESULTS

Twenty-five patients were enrolled and evaluated for safety, and 24 patients were evaluated for efficacy. CR was achieved in 62.5% of patients (95% confidence interval [CI] = 40.6-81.2, p = 0.043) in the overall period. CP and TC were achieved in 62.5% (95% CI = 40.6-81.2) and 25.0% of patients (95% CI = 9.8-46.7), respectively, in the overall period. The primary adverse drug reaction was hiccups (48.0%). The events were expected, and none was grade 3 or 4.

CONCLUSIONS

The examined combination antiemetic therapy was effective and well-tolerated in patients with TGCTs receiving 5-day cisplatin-based combination chemotherapy.

Antiemetics: American Society of Clinical Oncology Clinical Practice Guideline Update

Purpose

To update the ASCO guideline for antiemetics in oncology.

Methods

ASCO convened an Expert Panel and conducted a systematic review of the medical literature for the period of November 2009 to June 2016.

Results

Forty-one publications were included in this systematic review. A phase III randomized controlled trial demonstrated that adding olanzapine to antiemetic prophylaxis reduces the likelihood of nausea among adult patients who are treated with high emetic risk antineoplastic agents. Randomized controlled trials also support an expanded role for neurokinin 1 receptor antagonists in patients who are treated with chemotherapy.

Recommendation

Key updates include the addition of olanzapine to antiemetic regimens for adults who receive high-emetic-risk antineoplastic agents or who experience breakthrough nausea and vomiting; a recommendation to administer dexamethasone on day 1 only for adults who receive anthracycline and cyclophosphamide chemotherapy; and the addition of a neurokinin 1 receptor antagonist for adults who receive carboplatin area under the curve ≥ 4 mg/mL per minute or high-dose chemotherapy, and for pediatric patients who receive high-emetic-risk antineoplastic agents. For radiation-induced nausea and vomiting, adjustments were made to anatomic regions, risk levels, and antiemetic administration schedules. Rescue therapy alone is now recommended for low-emetic-risk radiation therapy. The Expert Panel reiterated the importance of using the most effective antiemetic regimens that are appropriate for antineoplastic agents or radiotherapy being administered. Such regimens should be used with initial treatment, rather than first assessing the patient’s emetic response with less-effective treatment. Additional information is available at www.asco.org/supportive-care-guidelines and www.asco.org/guidelineswiki .

Addition of 3-day aprepitant to ondansetron and dexamethasone for prophylaxis of chemotherapy-induced nausea and vomiting among patients with diffuse large B cell lymphoma receiving 5-day cisplatin-based chemotherapy

BACKGROUND

Neurokinin-1 receptor antagonists, such as aprepitant are currently emerging as powerful prophylactic agents for chemotherapy-induced nausea and vomiting (CINV). Therefore, it is important to adjust the anti-emetic regimens based on personal risk factors of the patient, duration of the chemotherapy regimen and cost-effectiveness.

PURPOSE

To determine the efficacy of the 3-day aprepitant along with ondansetron and dexamethasone in controlling CINV in patients with large B cell lymphoma receiving multiday-cisplatin regimen chemotherapy.

METHODS

This is a pilot prospective cross-over trial. Patients were allocated to either aprepitant 125mg on day 1 and 80mg on days 2 & 3 or placebo in the first 2 cycles, with crossover to the opposite treatment in the 3rd and 4th cycles. The primary end point was complete response (CR) of both acute (days 1-5) and delayed (days 6-8) CINV. CR means neither to develop emetic episodes nor to use rescue anti-emetics medication.

RESULTS

Twelve of the 15 patients recruited for the study were fully evaluable and completed 4 cycles of ESHAP regimen with a total of 48 cycles given. In the cycles with aprepitant and those without the CR were 83.3% and 0% respectively (p<0.05). Patients receiving aprepitant in the first 2 cycles recorded less nausea in subsequent cycles that were given without aprepitant. This was not statistically significant.

CONCLUSION

This triple anti-emetic regimen showed efficacy in controlling the multi-day cisplatin-induced nausea and vomiting. Further randomized controlled trials are needed to compare between 3-day and 7-day aprepitant for multi-day cisplatin regimens.

Gender Differences in Hiccup Patients: Analysis of Published Case Reports and Case-Control Studies

CONTEXT

Although sporadic male predominance in hiccup patients has been reported, the association between gender differences and triggering factors has rarely been evaluated in patients with hiccups.

OBJECTIVES

The aim of this study was to investigate whether gender differences exist in hiccup patients by analyzing all previously published hiccup literature containing gender and etiology information.

METHODS

Published literature on this topic was identified using a standardized search strategy in the PubMed, SCOPUS, and CINAHL electronic databases. The literature search included studies published from January 1990 to December 2013. Searches were limited to English-language publications. Of 476 identified studies, 318 studies were eligible including eight case-control studies that contained nonhiccup control groups. Triggering factors for hiccups were categorized into two types: central nervous system (CNS) and non-CNS causes. Odds ratios (ORs) were calculated for the eight case-control studies and event rates for the other studies by meta-analysis. In addition, gender differences and mean ages were analyzed for the case studies.

RESULTS

Pooled OR was 2.42 (95% confidence interval [CI] 1.40-4.17) with inclination for male predominance. Subgroup analysis by cause showed clear male predominance in the non-CNS type with OR of 11.72 (95% CI 3.16-43.50), whereas indistinct in the CNS type with OR of 1.74 (95% CI 0.95-3.16). Of the remaining 310 studies with 864 patients, previous findings were consistent. Male predominance was consistent in non-CNS (85.1%, 95% CI 78.2-90.2) and unknown origin (82.2%, 95% CI 75.8-87.2) patients, whereas mitigating the sex discrepancy in those with CNS origin (65.8%, 95% CI 53.1-76.5).

CONCLUSION

We demonstrated male predominance in hiccup patients. This gender difference for hiccups was more pronounced in patients with non-CNS causes, whereas indistinct in patients with CNS causes.

Management of Chemotherapy Induced Nausea and Vomiting in Patients on Multiday Cisplatin Based Combination Chemotherapy

Introduction of cisplatin based chemotherapy has revolutionized the treatment of germ cell tumors. A common side effect of multiday cisplatin chemotherapy is severe nausea and vomiting. Considerable progress has been made in the control of these side effects since the introduction of cisplatin based chemotherapy in the 1970s. Germ cell tumor which is a model for a curable neoplasm has also turned into an excellent testing ground to develop effective strategies to prevent chemotherapy induced nausea and vomiting (CINV) in multiday cisplatin based regimens. The use of combination of a 5-hydroxytryptamine (HT)3 receptor antagonist, a neurokinin-1 (NK1) antagonist, and dexamethasone has greatly improved our ability to prevent and control acute and delayed CINV. Mechanism and pattern of CINV with multiday chemotherapy may differ from those in single day chemotherapy and therefore efficacy of antiemetic drugs as observed in single day chemotherapy may not be applicable. There are only few randomized clinical trials with special emphasis on multiday chemotherapy. Further studies are essential to determine the efficacy, optimal dose, and duration of the newer agents and combinations in multiday cisplatin based chemotherapy.

Comparative evaluation of triplet antiemetic schedule versus doublet antiemetic schedule in chemotherapy-induced emesis in head and neck cancer patients

PURPOSE

To compare the antiemetic combination of palonosetron, dexamethasone, and aprepitant (PDA) with antiemetic combination of ondansetron and dexamethasone (OD) in head and neck cancer patients receiving docetaxel, carboplatin, and 5-FU based chemotherapy.

METHODS

Sixty previously untreated patients were randomly divided into two groups of thirty patients each. The PDA group received a combination of palonosetron 0.25 mg intravenously (IV), dexamethasone 12 mg IV, and capsule aprepitant per oral. OD group received ondansetron 16 mg IV, and dexamethasone 12 mg IV for emesis control. The primary objective was to compare the efficacy of two antiemetic schedules for preventing acute and delayed CINV (chemotherapy-induced nausea and vomiting). The primary efficacy end point was complete response (CR).

RESULTS

All the patients tolerated both schedules well. The antiemetic response for acute emesis (first 24 hours) in PDA versus OD group was: CR was 86.7 versus 60%. For delayed emesis (from day 2-5) in PDA versus OD group CR was 83.3 versus 53.3%. The intensity of acute nausea (first 24 hours) in PDA versus OD group was: no nausea-70 versus 46.6%. The intensity of delayed nausea (from day 2-5) in PDA versus OD was: no nausea-76.6 versus 43.3%. The CR to both acute and delayed emesis (no vomiting from day 1-5) in PDA versus OD group was 83.3 versus 53.3% (p < 0.05, significant). The CR to nausea (no nausea from day 1-5) in PDA versus OD group was 70 versus 43.3% (p < 0.05, significant).

CONCLUSION

Although both the schedules were tolerated well, the PDA schedule (palonosetron, aprepitant, and dexamethasone) was significantly better than the OD schedule (ondansetron and dexamethasone) in controlling cancer CINV in the acute as well as delayed phases.

Palonosetron for the treatment of chemotherapy-induced nausea and vomiting

INTRODUCTION

Chemotherapy-induced nausea and vomiting (CINV) is associated with a significant deterioration in quality of life. The emetogenicity of the chemotherapeutic agents, repeated chemotherapy cycles, and patient risk factors significantly influence CINV. The introduction of 5-hydroxytryptamine-3 (5-HT3) receptor antagonists has been a major factor in the improvement of the prevention of chemotherapy-induced acute and delayed emesis. Palonosetron , a second-generation 5-HT3 receptor antagonist with a different half-life, a different binding capacity, and a different mechanism of action than the first-generation 5-HT3 receptor antagonists appears to be the most effective agent in this drug class.

AREAS COVERED

Palonosetron's chemistry, pharmacodynamics, pharmacokinetics, metabolism, clinical efficacy, including comparison with other antiemetics, role in controlling nausea, potential role in multi-day chemotherapy and bone marrow transplantation, and overall safety are discussed.

EXPERT OPINION

The clinical data in the literature have established palonosetron as the 5-HT3 receptor antagonist of choice in terms of efficacy and safety for the prevention of CINV for patients receiving moderately or highly emetogenic chemotherapy. Three international guidelines have listed palonosetron as the preferred 5-HT3 receptor antagonist. Due to its higher efficacy, the use of palonosetron may be more cost effective compared to the generic first-generation 5-HT3 receptor antagonists. Clinical organizations' pharmacy and formulary committees should consider efficacy when making recommendations for agents for the prevention of CINV.

Palonosetron in the management of chemotherapy-induced nausea and vomiting in patients receiving multiple-day chemotherapy

Prevention of chemotherapy-induced nausea and vomiting (CINV) is a key component of treatment for patients with cancer. Guidelines are available to assist prescribers in the management of CINV associated with single-day chemotherapy regimens. However, currently there are no clear guidelines for management of CINV in patients receiving multiple-day chemotherapy regimens. Serotonin (5-HT₃) receptor antagonists are a mainstay in preventing CINV, and palonosetron, given its longer half-life and duration of action relative to other 5-HT₃ receptor antagonists, may be a useful option for managing CINV in multiple-day chemotherapy. Here we provide an overview of CINV and CINV treatment options, with a focus on palonosetron. We describe existing challenges in managing CINV, and discuss two patients receiving multiple-day chemotherapy, in whom CINV was managed successfully with palonosetron.