| Anti-emetic |
MOA |
Parenteral dose |
Oral dose |
Prescribing notes |
|
Akynzeo®
(netupitant 300mg & palonosetron 0.5mg)
|
Neurokinin inhibitor plus 5HT3 Antagonist |
N/A |
1 capsule single dose
(300mg/0.5mg)
|
Administer 1 hour before cisplatin-containing SACT.
Multiple drug interactions - check Stockley’s or other interaction checker.
Concomitant use with steroids: increases Dexamethasone exposure approx 2-fold. Reduce Dex doses by ~50% when given with Akynzeo.
Caution in moderate / severe hepatic impairment
Do NOT use in patients with SABO, switch to aprepitant and metoclopramide.
|
| Aprepitant |
Neurokinin inhibitor |
N/A |
125mg D1
80mg OD D2&3
|
For high risk emesis SACT - Administer 1 hour prechemo, and on days 2+3
Caution in mod / severe hepatic impairment
Multiple drug interactions - check Stockley’s or other interaction checker.
Concomitant use with steroids: increases Dexamethasone exposure approx 2-fold. Reduce Dex doses by ~50% when given with Aprepitant. (see table 4 high-risk SACT). Similar effect with Methylprednisolone (reduce IV Methylpred dose by 25% or oral dose by 50%). No interaction with Prednisolone.
|
| Cyclizine |
Central acting antihistamine
|
50mg 8 hourly IV/IM
150mg CSCI pump over 24 hours
|
50mg TDS
|
Antimuscarinic side effects (dry mouth, blurred vision, constipation, hypotension and confusion.
Slows peristalsis in GI tract.
Caution in epilepsy, cardiac failure and angle-closure glaucoma.
Very painful to give as intramuscular injection.
|
| Dexamethasone |
Steroid |
8-20mg IV pre-SACT |
8-20mg pre-SACT
2-4mg BD post-SACT
|
Where prescribed intravenously, dexamethasone should be administered slowly - bolus over several minutes or infused over 15 – 30 minutes, as may cause perineal discomfort.
May induce / unmask/ destabilise diabetes – advise patients of symptoms of thirst / increased dieresis; increase BM monitoring in patients with diabetes as per ECC guidelines.
May cause dyspepsia when used at high dose for prolonged course - consider PPI prophylaxis as per ECC policy.
If nausea/malaise in 24-48hrs after stopping Dexamethasone, consider a weaning regimen. For example – if 4mg BD for days 2-4, add 2mg BD 2/7, 2mg od 2/7, then stop.
Prolonged or high dose courses may cause hypoadrenalism.
|
| Fosaprepitant |
Neurokinin inhibitor
|
150mg IV
IV infusion over 20-30 mins.
Give at 30 minutes pre-chemo.
|
N/A
|
For patients unable to swallow oral NKI (akynzeo or aprepitant)
Drug prepared on ward and administered as a 1mg/ml solution using following method:
1. Inject 5 ml sodium chloride (NaCl 0.9 %) into the vial assuring that this is added along the vial wall in order to prevent foaming. Swirl vial gently and avoid shaking.
2. Removing 105 ml of NaCl 0.9 % solution from a 250 ml NaCl 0.9% infusion bag, leaving 145mls.
3. Withdraw the entire volume (5ml) from the vial and transfer it into an infusion bag containing 145 ml of sodium chloride (0.9 %) to yield a total volume of 150 ml (1mg/ml). Gently invert the bag 2-3 times and administer over 20-30 minutes.
|
|
Granisetron
|
5HT3 Antagonist
|
1-2mg IV infusion (over 15 mins)
|
1-2mg OD
Can be used BD if OD dosing is inadequate
Sancuso® patch (3.1mg over 7 days).
1 patch applied 24 – 48 hours prior to SACT and to remain in place for a max of 7 days.
|
May reduce lower bowel motility leading to constipation - consider aperients. Patients with signs of sub-acute bowel obstruction (SABO) should be monitored following administration.
Caution in patients with history of migraines
Note that concurrent administration of steroids can enhance the efficacy of 5HT3 antagonists.
May cause QTc prolongation. See Table 7.
Consider Granisetron patch for patients on multi-drug regimens where patients have swallowing difficulties. For any other indication MMC approval is required. Apply patch to a dry hairless area on the outer part of the upper arm. Patch could also be applied to the abdomen if arm is not possible. Patches should not be cut into pieces. Showering / bathing is permitted with the patch but patients should avoid direct heat / saunas. The patch should be covered by clothing and protected from direct natural or artificial sunlight for duration of wear and area protected for or up to 10- days after removal.
|
|
Levomepromazine
|
Central acting
|
2.5mg SC injection 8-12hrly PRN or
5 – 25mg CSCI over 24 hours
|
6mg tablets (very limited availability) 12hrly
|
S/C administration can be used for patients admitted with N&V.
Use low doses in first instance to avoid sedation and hypotension. Doses can be increased if tolerated.
Avoid in liver dysfunction.
Risk of QT prolongation – see Table 7.
|
|
Lorazepam
|
Central acting, Anxiolytic
|
0.5 – 1mg IV up to TDS
|
0.5 – 1mg up to TDS (sublingual)
|
Useful for patients who are anxious or who experience anticipatory nausea and vomiting
Caution in patients with long-term nausea, as risk of dependence
|
|
Metoclopramide
|
Prokinetic
|
10mg by slow IV injection 6- 8 hourly (max 30mg in 24 hours).
If < 60kg, consider 500mcg/kg/24h in 3 divided doses.
30mg over 24h in subcutaneous syringe driver
|
10mg TDS or 6 hourly prn
Max of 3 doses in 24hrs
(oral liquid available)
Max daily dose is 0.5mg/kg body weight
|
The EMEA issued advice on use of metoclopramide in 2013 (ECC metoclopramide statement) restricting the dose and duration of use of the medicine to minimise the known risks of potentially serious neurological SE’s.
Metoclopramide is associated with agitation and extra-pyramidal symptoms particularly in young females; in addition prolonged use may lead to neurological side effects in elderly patients. Caution is advised in patients with Parkinson’s disease and taking concurrent neuroleptics.
The max duration of regular treatment is 5 days, after which it can be taken as required. Regular use for longer than 5 days can be considered in patients whose nausea remains poorly controlled and are without risk factors at the prescriber’s discretion.
Bowel transit time can be reduced, exacerbating diarrhoea and it is contra-indicated in GI obstruction.
|
|
Ondansetron
|
5HT3 Antagonist
|
8-16 mg IV infusion (infuse over a minimum of 15 mins) or IM
Max dose IV = 16mg; (in patients over 75 yrs, max dose IV = 8mg)
|
8mg BD (usual dose)
Dose range 4-8mg up to TDS
16mg OD per rectum
|
May cause QTc prolongation. See Table 7.
Ondansetron is known to increase large bowel transit time, patients with signs of sub-acute bowel obstruction (SABO) should be monitored following administration. Consider aperients to treat/prevent constipation.
Repeat IV doses should not be given less than 4 hrs apart.
Melts formulation available for patients unable to swallow tablets.
|
|
Olanzapine
|
Central acting
|
N/A
|
2.5-10mg once daily (usually at night).
Consider 2.5mg at night for a starter dose. If tolerated, can increase to twice daily
Tablets or orodispersible
|
Adults who experience nausea or vomiting despite optimal prophylaxis should be offered olanzapine in addition to continuing the standard antiemetic regimen.
5-10mg pre-SACT then 5-10mg at night for 3 days following SACT.
Causes drowsiness – caution with driving.
May increase QTc interval – see table 7.
May be pro-epileptogenic so should be used with caution with patients with difficult to control seizures.
May have benefit for appetite and general wellbeing.
|
|
Palonosetron
|
5HT3 Antagonist, steroid sparing
|
250mcg single dose IV
(no additional 5HT3 given)
|
N/A
|
Only for patients in whom steroids are contraindicated or compliance is in doubt. For other indications MMC approval is required.
Risk of QTc prolongation – see table 7.
May increase large bowel transit time - therefore monitor in patients with constipation or potential SABO.
Capsules contain sorbitol and lecithin derived from soya; therefore patients with known sensitivity to soya or peanuts should be monitored closely for hypersensitivity reactions.
Palonosetron may be superior to ondansetron or granisetron during period of 24 – 120 hours post-SACT but non-significant difference in first 24 hours. Therefore good if delayed emesis is a particular problem
|
|
Prochlorperazine
|
Central acting
|
Deep IM 12.5mg if required (one dose only)
|
5-10mg 2-3 times daily oral
3-6mg BD buccal
|
May cause drowsiness.
Avoid in liver or renal dysfunction, parkinsons disease, cardiac failure and hypothyroidism.
Buccal preparation (Buccastem®) useful for the vomiting patient as absorbed from oral mucosa. Place tablet between upper lip and gum, leave to dissolve slowly.
|
Acute Oncology Guidelines
