2023 updated MASCC/ESMO consensus recommendations: prevention of nausea and vomiting following multiple-day chemotherapy, high-dose chemotherapy, and breakthrough nausea and vomiting

Personalized Prophylactic Antiemetic Regimens for Control of Chemotherapy-Induced Nausea and Vomiting by Pharmacogenetic Analysis of Three Receptor Genes: HTR3A, HTR3B, TACR1

PURPOSE

Contemporary prophylactic antiemetic regimens have improved the control of chemotherapy-induced nausea and vomiting (CINV). However, over 50% of patients still suffer from nausea. This study aimed to correlate the genetic determinants of individual patients with the efficacy of three prophylactic antiemetic regimens.

METHODS

Patients with breast cancer in two previously reported prospective antiemetic studies consented for the present pharmacogenetic study. Before high-emetogenic doxorubicin and cyclophosphamide (AC) (neo)adjuvant chemotherapy, they received a combination of antiemetic prophylaxis: regimen A and regimen B were, respectively, aprepitant/ondansetron/dexamethasone with or without olanzapine; regimen C was netupitant/palonosetron/dexamethasone. The effectiveness of antiemetic regimens was mainly assessed by complete protection (CP) rates. Patients' genotypes in three genes, HTR3A, HTR3B and TACR1, were analyzed.

RESULTS

Patients who were homozygous TT (p.129Tyr) of a non-nonsynonymous variant in HTR3B rs1176744 and homozygous GG of TACR1 rs3821313 had better outcome with regimen B. Digenic interaction analysis further reveals interaction between rs1176744 and rs3821313. Homozygotes TT of rs1176744 and homozygotes GG of rs3821313 achieved the highest CP rate with regimen B (10/12 patients; 83%), in contrast to only 29% (7/24) with regimen A (P = .0027). Homozygotes GG in both HTR3A rs1176722 and TACR1 rs3821313 showed the poorest response to regimen A with a CP rate of 17% (2/12), whereas patients given regimen B had the highest CP rate (70%; 7/10; P = .0159). The findings were confirmed upon logistic regression adjusted for clinical factors.

CONCLUSION

The present study confirmed our hypothesis that among Chinese patients with breast cancer who received AC, the selection of optimal antiemetic prophylaxis may be aided by assessing an individual's pharmacogenetic profile. It also highlights a novel digenic interaction that has not been known before for pharmacogenetic analysis.

A prospective analysis of efficacy of dexamethasone-sparing antiemetic regimens in high and moderate emetogenic chemotherapy

ObjectivesMultiple moderate-to-severe side effects associated with dexamethasone (DEX) were observed by patients undergoing a multi-day DEX regimen for delayed chemotherapy-induced nausea and vomiting (CINV). Therefore, there is increasing demand in clinical practice to lower DEX doses in subsequent emetogenic treatment cycles. This study aimed to evaluate the efficacy of the DEX-sparing antiemetic regimens in high- and moderate- emetogenic chemotherapy (HEC, MEC respectively) and to explore its functional impact on health-related Quality of Life (QoL).Materials and methodsThis is a prospective, observational study that includes 91 patients who received HEC and MEC with DEX. We evaluated the percentage of complete response and complete control of CINV in acute phases (<24 h) and delayed phases (25-120 h). The Functional Living Index-Emesis (FLIE), a 5-day recall tool, was used to evaluate the functional impact of DEX-sparing regimens on health-related QoL. Nausea and vomiting were graded using the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0.Statistical analysisThe SPSS version 20.0 was used for the statistical analysis. In the descriptive analysis, the study's parameters were analyzed and their mean (±SD), percentage, and frequency were determined.ResultsIn terms of overall efficacy, the DEX sparing was 86.36% in complete control and 90.91% in complete response. In the CTCAE version 5.0 analyses, only 1.1% of cases were reported with a Grade 3, and none with a Grade 4 or Grade 5. The FLIE score was above 54 in each domain, indicating no impact of CINV on daily life.ConclusionThe use of DEX-sparing antiemetic regimens in clinical settings, which can be better tolerated by patients, is made clear by this study. Consequently, our findings guide clinicians to optimize the use of DEX to preserve anti-emetic efficacy throughout the scheduled cycles of emetogenic chemotherapy.

Efficacy of triplet antiemetic prophylaxis against chemotherapy-induced nausea and vomiting in patients with soft tissue sarcomas receiving consecutive-day doxorubicin and ifosfamide therapy

BACKGROUND

Doxorubicin and ifosfamide (AI) therapy for soft tissue sarcomas (STS) is given as a 5-day continuous-dose chemotherapy regimen, and classified as carrying high emetic risk. The purpose of this study was to evaluate the efficacy of triplet antiemetic prophylaxis, consisting of a 5-HT3 receptor antagonist, dexamethasone (DEX), and an NK1 receptor antagonist, against chemotherapy-induced nausea and vomiting (CINV) induced by AI therapy, and to determine the prophylactic antiemetic effect of the addition of olanzapine (OLZ) to this triplet antiemetic prophylaxis in cases of poor antiemesis.

PATIENTS AND METHODS

Patients who received AI therapy for STS between October 2011 and October 2022 were included in this retrospective study. Patients who did not receive the standard triplet antiemetic prophylaxis of granisetron, DEX, and aprepitant were excluded. Primary endpoint was the rate of complete response (CR) and secondary endpoint was the rate of significant nausea prevention during the acute (days 1-6), delayed (days 7-10), and overall (days 1-10) periods. In addition, CR rate and significant nausea prevention during the acute phase were compared before and after the addition of OLZ in patients who received OLZ as antiemetic prophylaxis in the subsequent cycle due to poor antiemetic control.

RESULTS

A total of 58 patients were analyzed. CR rate for all patients was 32.8% in the acute phase, 53.4% in the delayed phase, and 29.3% in the overall period. The significant nausea prevention rate was 19.0%, 43.1%, and 13.8%, respectively. Sixteen patients received additional OLZ as an antiemetic prophylaxis. Their CR rate before and after the addition of OLZ during the acute phase improved significantly, from 6.3 to 43.8% (P = 0.041). The rate of significant nausea prevention tended to improve, from 6.3 to 43.8% (P = 0.077).

CONCLUSION

Control of CINV with granisetron, DEX, and aprepitant was poor in patients with STS receiving AI therapy. Addition of OLZ to this standard triplet antiemetic prophylaxis may improve CINV control in the subsequent cycle in patients who experience inadequate CINV control during their first cycle of AI therapy.

Medication management: supportive care medications in older adults with cancer

PURPOSE OF REVIEW

This review raises awareness regarding the lack of data available for healthcare professionals caring for older adults with cancer when using supportive care medications.

RECENT FINDINGS

Guidelines for supportive cancer care lack concrete recommendations on the appropriate use of medications in older adults with cancer. Some guidelines, such as the National Comprehensive Cancer Network Older Adult Oncology guideline, contain vital information for prescribers to consider when choosing a supportive care medication. Information at present in most guidelines is generally vague, identifying areas where caution is required in older adults, without specific details.

SUMMARY

Research is needed to assess the efficacy and safety of supportive cancer care medications in older adults.

Health-Related Quality of Life and Economic Analysis of Olanzapine Versus Aprepitant in Preventing Chemotherapy-Induced Nausea and Vomiting in Patients Receiving Highly Emetogenic Chemotherapy in Malaysia

OBJECTIVES

Olanzapine has been shown to be effective in preventing chemotherapy-induced nausea and vomiting (CINV) after highly emetogenic chemotherapy (HEC); however, there is limited work on the impact of CINV on health-related quality of life (HRQoL) and the comparative cost-effectiveness of CINV prophylaxis in the Malaysian context. Therefore, this study was conducted to determine the HRQoL using EQ-5D-5L and the cost-effectiveness of olanzapine compared with aprepitant for CINV prophylaxis in Malaysia using data from a local study.

METHODS

Fifty-nine chemo-naive patients receiving either olanzapine or aprepitant were randomly recruited and completed the EQ-5D-5L before and day 5 after HEC. HRQoL utility scores were analyzed according to the Malaysian valuation set. The economic evaluation was conducted from a healthcare payer perspective with a 5-day time horizon. Quality-adjusted life days (QALD) and the rate of successfully treated patients were used to measure health effects. The incremental cost-effectiveness ratio is assessed as the mean difference between groups' costs per mean difference in health effects. A one-way sensitivity analysis was performed to assess variations that might affect outcomes.

RESULTS

Aprepitant and olanzapine arms' patients had comparable baseline mean HRQoL utility scores of 0.920 (SD = 0.097) and 0.930 (SD = 0.117), respectively; however, on day 5, a significant difference (P value = .006) was observed with mean score of 0.778 (SD = 0.168) for aprepitant and 0.889 (SD = 0.133) for olanzapine. The cost per successfully treated patient in the aprepitant arm was 60 times greater than in the olanzapine arm (Malaysian Ringgit [MYR] 927 vs MYR 14.83). Likewise, the cost per QALD gain in the aprepitant arm was 36 times higher than in the olanzapine arm (MYR 57.05 vs MYR 1.57). Incremental cost-effectiveness ratio of MYR -937.00 (USD -200.98) per successfully treated patient and MYR -391.84 (USD -85.43) per QALD gained for olanzapine compared with the aprepitant-based regimen.

CONCLUSIONS

An olanzapine-based regimen is a cost-effective therapeutic substitution in patients receiving HEC in Malaysia.

Antiemetic prophylaxis regimens in haematologic malignancies patients undergoing a hematopoietic stem cell transplantation. Which is the best standard of care? A systematic review

INTRODUCTION

This systematic review, adhering to PRISMA guidelines, aimed to evaluate the efficacy and safety of antiemetic prophylaxis in haematological patients undergoing high-dose chemotherapy as part of their hematopoietic stem cell transplantation (HSCT) conditioning regimens.

METHODS

We performed a comprehensive search in PubMed, EMBASE, ClinicalTrials.gov and the Cochrane database to identify randomised controlled trials (RCTs) and systematic reviews of antiemetic prophylaxis. Studies in English, French, Italian or Spanish were included. This review is registered with PROSPERO, ID CRD42023406380.

RESULTS

Eight RCTs were analysed. The antiemetic regimens evaluated ranged from monotherapy with 5-Hydroxytryptamine Receptor 3 antagonists (5-HT3RAs) to complex combinations including olanzapine, neurokinin-1 receptor antagonists, 5-HT3RAs and corticosteroids. Complete response rates for triplet or quadruple regimens varied between 23.5% and 81.9%. Although no significant adverse effects were observed, minor symptoms such as diarrhoea, constipation, sedation and headaches were reported.

CONCLUSION

Existing evidence on HSCT antiemetic therapy highlights its benefits but fails to provide clear clinical directions. The choice between triplet and quadruplet therapies for different patient scenarios is still uncertain. Until more detailed research is available, healthcare providers must rely on the latest guidelines and their judgement to customise antiemetic care for each patient's specific needs and risks.

Pharmacokinetics, pharmacodynamics, safety, and tolerability of dopamine-receptor antagonists for the prevention of chemotherapy-induced nausea and vomiting

INTRODUCTION

Dopamine (D)2,3-receptor antagonists (RAs) were the first antiemetics used in the prophylaxis of chemotherapy-induced nausea and vomiting (CINV).

AREAS COVERED

Eight D2,3-RAs, amisulpride, domperidone, droperidol, haloperidol, metoclopramide, metopimazine, olanzapine and prochlorperazine are reviewed focusing on pharmacokinetics, pharmacodynamics, antiemetic effect and side effects.

EXPERT OPINION

Since the introduction of D2,3-RAs, antiemetics such as corticosteroids, 5-hydroxytryptamine (5-HT)3-RAs and neurokinin (NK)1-RAs have been developed. The classical D2,3-RAs are recommended in the prophylaxis of CINV from low emetic risk chemotherapy, but not as a fixed component of an antiemetic regimen for moderately or highly (HEC) emetic risk chemotherapy. D2,3-RAs are also used in patients with breakthrough nausea and vomiting. It should be emphasized, that most of these drugs are not selective for dopamine receptors.The multi-receptor targeting agent, olanzapine, is recommended in the prophylaxis of HEC-induced CINV as part of a four-drug antiemetic regimen, including a 5-HT3-RA, dexamethasone and a NK1-RA. Olanzapine is the most effective agent to prevent chemotherapy-induced nausea.Side effects differ among various D2,3-RAs. Metopimazine and domperidone possess a low risk of extrapyramidal side effects. Domperidone and metoclopramide are prokinetics, whereas metopimazine delays gastric emptying and haloperidol does not influence gastric motility. Many D2,3-RAs increase the risk of prolonged QTc interval; other side effects include sedation and orthostatic hypotension.

2020 ASCO, 2023 NCCN, 2023 MASCC/ESMO, and 2019 CCO: a comparison of antiemetic guidelines for the treatment of chemotherapy-induced nausea and vomiting in cancer patients

Chemotherapy-induced nausea and vomiting (CINV) is a common toxicity that may impair the quality of life of patients with various malignancies ranging from early to end stages. In light of frequent changes to the guidelines for optimal management of CINV, we undertook this narrative review to compare the most recent guidelines published by ASCO (2020), NCCN (2023), MASCC/ESMO (2023), and CCO (2019). The processes undertaken by each organization to evaluate existing literature were also described. Although ASCO, NCCN, MASCC/ESMO, and CCO guidelines for the treatment and prevention of CINV share many fundamental similarities, the literature surrounding low and minimal emetic risk regimens is lacking. Current data regarding adherence to these guidelines is poor and warrants further investigation to improve care.