Guidelines and Patient Factors Impact on Treatment of CINV

A review of the guidelines and patient factors to determine the therapeutic agents used for prophylactic care for chemotherapy-induced nausea and vomiting.

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Bhavesh Shah, RPh, BCOP: The next question is, what is the standard-of-care prophylaxis for acute and delayed CINV [chemotherapy-induced nausea and vomiting] at your institutions?

Katherine Lin, PharmD, BCOP: For the standard-of-care prophylaxis, you’re going to want to go back to the guidelines. There are several guidelines that exist, and what the guidelines do are just that. They’re kind of guidelines to give you a basic idea of where to start, and then you tailor your therapy as your patient has specific risk factors.

What we do is we take a look at different guidelines. There are 3 major guidelines that talk about how to handle CINV. There’s NCCN [National Comprehensive Cancer Network], there’s ASCO [American Society of Clinical Oncology], and there’s MASCC [Multinational Association of Supportive Care in Cancer].

I think it depends on which institution you practice at. My institution was an NCCN-designated center, so we tended to follow NCCN Clinical Practice Guidelines. What you do is you take a look at your agent, or agents, that you’re receiving. Based on that, the agents are classified in a risk table of how likely they are, as you had said in the beginning, to cause emesis if patients are not given any prophylaxis.

Those 4 categories are highly emetogenic, so that would affect greater than 90% of patients. There’s moderate emetogenicity, just 30% to 90% of patients. There’s a low, which is 10% to 30%. And then there’s minimal, which is less than 10%. Based on where patients fall into those, we start that as our starting board and what we should be thinking about, what we should be providing.

But it’s also really important to take a look at the individual patient when you’re trying to come up and follow these guidelines. We take a look at patient risk factors, which are also written into the guidelines—patient risk factors that would make someone more likely to experience CINV. Things like a younger age, female sex, if patients had prior history of nausea and vomiting; ie, they get motion sickness, they had hyperemesis in pregnancy. They had maybe nausea and vomiting with prior chemotherapy cycles.

We take a look at all those factors, then we consolidate that based on the guidelines, and and we go from there. If we’re looking at acute nausea and vomiting, we kind of talked about the pathophysiology of this before, so we know that there’s really that serotonin surge that kind of tends to play into the acute nausea and vomiting. We do use 5-HT3 or serotonin receptor antagonists as the backbone for the management of acute nausea and vomiting.

And then delayed CINV. We know that we talked about really what we think, and what the data tend to show is that it’s probably mediated by neurotransmitters other than serotonin. So we look at things like substance-P—should we be adding a neurokinin antagonist or substance-P inhibitor? Corticosteroids are also very effective and can be very effective in managing delayed nausea and vomiting. You had mentioned olanzapine. So those other neurotransmitters that we think are coming into play.

How do we decide on those different agents? It’s all based on the guidelines. We had talked about how the guidelines have kind of changed recently. So if you’re looking at highly emetogenic chemotherapy, you really now have 3 options. What you can do for a backbone is you can use triplet therapy. So we use 5-HT receptor antagonists. You can use a corticosteroid. And you could use a neurokinin receptor antagonist.

Another option that’s come out now is that you can use 4 agents, and we would just add olanzapine to that. And the other change in the guideline, too, is if you don’t want to add an NK-1 receptor antagonist, maybe the insurance company won’t pay for it. Maybe the patient is not a good candidate for it. You could do something like, it actually says: Your 5-HT should be Aloxi, or palonosetron, because it actually has a longer half-life, dexamethasone, and then olanzapine. Do you want to cover maybe the moderate?

Bhavesh Shah, RPh, BCOP: Yes. I was going to actually highlight the fact that the ASCO Guidelines had a little bit of difference with NCCN. It’s interesting. You had mentioned you have 3 options NCCN. But ASCO Guidelines actually recommend, if you’re highly emetogenic, just a 4-drug regimen. So it’s really amazing that you have the 2 differences in practice. So thank you for sharing that. And this is why there are a lot of variations in practice and things that we see with CINV.

And then also talking about the palonosetron versus the 5-HT receptor. What I’ve seen is that in terms of the NCCN Clinical Practice Guidelines, when it comes to highly emetogenic regimen, they say you can use any 5-HT3 if you’re using it with an NK-1. But if you’re using just a 5-HT3, then palonosetron is preferred. It’s interesting, but for moderate they definitely recommend you can do a palonosetron backbone as a standard for moderately emetogenic chemotherapy regimens.

And it’s really interesting how there are 3 levels that you have with ASCO Guidelines, but then you have 4 levels with NCCN’s. But I think it’s very helpful because a lot of payers actually look at that when they’re making decisions in treatment and approvals. As you had mentioned, sometimes NK-1 receptor may be not appropriate. Or maybe it’s cost prohibitive for a patient where palonosetron is covered.

So it’s definitely nice to have that option for patients.