Herrstedt, J., Roila, F., & ESMO Guidelines Working Group (2009). Chemotherapy-induced nausea and vomiting: ESMO clinical recommendations for prophylaxis. Annals of Oncology, 20(Suppl. 4), 156–158.

To provide guidance to clinicians for the prevention and management of chemotherapy-induced nausea and vomiting in patients receiving cancer chemotherapy of varying emetogenic potential

The evidence-based process was not fully described. Specific research was not stated. Literature cited were the antiemetic resource center at www.mascc.org and the Antiemetic Subcommittee of the Multinational Association of Supportive Care in Cancer 2004 consensus conference, cited in Annals of Oncology 2006, 17, 20–28.

Levels of evidence and grades of recommendation as used by the American Society of Clinical Oncology (ASCO) were applied to specific recommendations and considered by the authors and European Society for Medical Oncology (ESMO) faculty. This was approved by the ESMO guidelines working group.

This reference provides definitions of nausea and vomiting; relative emetogenic potential of oral and IV drugs; recommended drugs, dosing, and schedules for antiemetic drugs; and recommendations for management of nausea and vomiting based on emetogenic potential.

Specific regimens are outlined below. Stated level (I–V) and grade of evidence assessed are shown in parentheses.

• Acute nausea and vomiting
  • High-emetogenic potential: Serotonin antagonists + corticosteroid + aprepitant (I, A)
  • Anthracycline + cyclophosphamide: Serotonin antagonist + dexamethasone + aprepitant (II, A)
  • Moderate potential: Serotonin antagonist + corticosteroid (I, A)
  • Low potential: Single agent such as corticosteroid (III, IV, D)
  • Minimal potential: No prophylaxis (V, D)

• Delayed nausea and vomiting
  • High-emetogenic potential: Corticosteroid + aprepitant (II, A)
  • Anthracycline +cyclophosphamide: Dexamethasone or aprepitant (II, A)
  • Moderate potential: Corticosteroid (I, A) or serotonin antagonist (II, B)
  • Low potential: No routine prophylaxis
  • Minimal potential: No routine prophylaxis

• Specific issue recommendations
  • Multiple-day chemotherapy: As for acute on chemotherapy days and as delayed 1–2 days after chemotherapy
  • Refractory nausea and vomiting: Consider aprepitant if not already used or add dopamine antagonists to serotonin antagonists and corticosteroids (V, D)
  • Anticipatory nausea and vomiting: Lorazepam or similar drugs, behavioral techniques (V, D)
  • High-dose chemotherapy: Corticosteroids, serotonin and dopamine antagonists in full doses (III, C)

• The principal author performed ad hoc advisory board activity for multiple pharmaceutical companies and was conducting research sponsored by Merck.
• The secondary author was a member of advisory boards on palonosetron and aprepitant, had been a sponsored speaker, and had conducted research on casopitant and fosaprepitant.
• Recommended timing of interventions for delayed nausea and vomiting prophylaxis was unclear.
• The authors were not clear if the recommendation was to use these medications prophylactically interventionally for delayed symptoms.
• No discussion was provided regarding dosage titration approaches to individualize management.

• This guideline provides a good reference for classification of chemotherapeutic agents according to emetogenic potential and a good reference for initial dosing of medications used.
• The recommendations are based on patients who are chemotherapy-naïve.
• The recommendations focus on pharmaceutical management, except for consideration of behavioral techniques for anticipatory nausea and vomiting.