Wickham, R. (2010). Best practice management of CINV in oncology patients: II. Antiemetic guidelines and rationale for use. Journal of Supportive Oncology, 8(2, Suppl. 1), 10–15.

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This article discussed underlying shared principles in chemotherapy-induced nausea and vomiting (CINV) guidelines from the American Society of Clinical Oncology (ASCO), the Multinational Association for Supportive Care in Cancer (MASCC), and the National Comprehensive Cancer Network (NCCN).

• Common goals among these guidelines are to prevent CINV and to identify the risk period for CINV asscociated with at least four days of moderate- and high-intensity emetogenic treatments.
• The guidelines report that oral and IV formulations of 5-HT₃ receptor antagonists are equally effective.
• Selection of an antiemetic regimen should be based on the emetic risk of the chemotherapy being used as well as patient factors and experience.
• Prophylactic antiemetics should be used when the risk of CINV is 10% or more.
• A table of chemotherapeutic medications by emetogenic risk was provided. The author noted that such risk assignment does not provide for moving up the CINV risk ladder according to differing patient experience. Current guidelines are similar in terms of antiemetic regimens but only outline this for the first course of chemotherapy.
• The article provided a brief review of current specific antiemetic recommendations provided in guidelines. Substantial differences exist between physician and nursing assignment of patient risk for delayed CINV, and limited evidence exists regarding the best approaches for breakthrough CINV.

Currently recommended agents for breakthrough CINV are prochlorperazine, metoclopramide with or without diphenhydramine, haloperidol, dexamethasone, dronabinol nabilone, lorazepam, alternating 5-HT₃ receptor antagonists, olanzapine, and promethazine. The author noted that guidelines are useful, but guideline adherence can only go to a certain extent in preventing CINV, particularly with delayed symptoms, multiple-day chemotherapeutic regimens, high-dose chemotherapy, breakthrough CINV, and refractory CINV.

CINV guidelines are a good clinical tool to help clinicians implement evidence-based practice; however, their use needs to be accompanied by accurate patient assessments throughout the period of CINV risk. A standard guideline may not fit the needs of all patients and recommendations need to be viewed as a starting point for individualized patient care. More study and attention needs to be given to issues of delayed, breakthrough, and refractory CINV. This article is expert opinion-based and does not provide evidence for all information provided.