Important developments addressed by current international guidelinesrr are summarised below:
1. Antiemetic efficacy of olanzapine
- ASCO and NCCNrr now include olanzapine in their guidelines; with ASCO recommending its use with high emetic risk chemotherapy drugs (HEC) and NCCN for HEC and moderate risk emetic chemotherapy drugs (MEC),r even listing it as the preferred option for HEC. MASCC/ESMO have added olanzapine to their 2019 update, noting it can be considered particularly if nausea is a concern for HEC. Evidence has also confirmed that the use of olanzapine as a rescue for breakthrough emesis is superior to metoclopramider for patients receiving HEC.
- Although the olanzapine dose used in studies has mainly been 10 mg, data suggests that a 5 mg dose is efficaciousr and reflects current clinical practice. The 5 mg dose should be considered as the preferred starting dose, especially for elderly patients and for patients with concerns regarding excessive sedation.
- It is recommended that olanzapine is added to the antiemetic regimen for patients treated with high dose cytotoxic therapy and blood or marrow transplantation.
eviQ acknowledges there is a mismatch between the Australian indication for olanzapine and international guideline recommendations. The clinical data supporting olanzapine in the management of anti-cancer therapy induced nausea and vomiting, was not explored at the time of its initial TGA registration.* For this reason, olanzapine will not be included in the eviQ protocol treatment schedules, until registration recognises olanzapine has an established place in the management of anti-cancer therapy induced nausea and vomiting.
*via personal communication from initial sponsor September 2020
2. Dexamethasone use in breast anthracycline and cyclophosphamide (AC) regimens
In its latest AINV guidelines, ASCO no longer recommends the administration of dexamethasone on days 2 to 4 following AC anti-cancer therapy, whereas NCCN (which does not distinguish between AC vs. non-AC HEC regimens) and ESMO/MASCC states that administration may be considered. This was based on limited data supporting dexamethasone beyond day 1 when an NK1 receptor antagonist (NK1 RA) is used with AC.rr
eviQ will continue to add dexamethasone for delayed emesis in the breast AC protocols, with the note stating that dexamethasone may not be required and may be reduced or omitted at the clinician’s discretion
3. Antiemetic prophylaxis in patients treated with immune checkpoint inhibitors
- The addition of an immune checkpoint inhibitor to anti-cancer therapy does not change the emetogenic classification or antiemetic regimen used.r
- All immune checkpoint inhibitors administered either alone or in combination with other immune checkpoint inhibitors are minimally emetogenic and do not require the use of a prophylactic antiemetic.
4. Low emetic risk anti-cancer drugs
The option of a single dose of a 5HT3 receptor antagonist (5HT3 RA) or a single dose of dexamethasone, for the prevention of acute nausea and vomiting associated with low emetic risk anti-cancer drugs is now included in all guidelines.rrr However, it is important to note that the quality of the evidence to support these recommendations is low, guided by expert opinion and informal consensus. Both NCCN and MASCC include alternatives; MASCC a dopamine receptor antagonist e.g. metoclopramide; and NCCN metoclopramide or prochlorperazine. There is no evidence at this time to recommend superiority of one option over another.
5. Changes to the display of emetogenic risk for oral anti-cancer drugs
As emetic risk information for oral anti-cancer drugs is limited and varies, eviQ has now aligned with both ASCO and NCCN to display two categories of emetogenicity for oral anti-cancer drugs: minimal to low and moderate to high.
Changes across eviQ single oral anti-cancer drug protocols to be addressed.