no recommendations for treating
patients in subsequent cycles,
particularly if patients in the
first cycle have failed ‘optimal’
treatment. The strength of
evidence in antiemetic guidelines
is weak in several areas of nausea/
vomiting management, including
breakthrough nausea/vomiting,
multiple day chemotherapy
(including in the haematology
setting), radiotherapy, and in
LEC/MEC. Finally, guidelines can
also become out of date quickly,
particularly in a rapidly evolving
field such as CINV management,
and these need to have
mechanisms to bring new data
into the existing recommendations
and be updated regularly. Finally,
a new tool to help clinicians make
appropriate clinical decisions is
underway (www.riskcinv.org) based
on work assessing risk predictors
for CINV using a large sample size 10
(for further information, please
see the dedicated chapter on risk
factors in this pocket guide).
International antiemetic
guidelines
Several international societies have
been developing and disseminating
antiemetic guidelines related
to cancer treatments since the
late 1990s. Among them, the
most prominent ones are the
antiemetic guidelines produced
by the Multinational Association
of Supportive Care in Cancer
(MASCC; www.mascc.org), the
European Society of Medical
Oncology (ESMO; www.esmo.org);
with MASCC and ESMO working
together in developing antiemetic
guidelines and publishing the
second combined update in
2016 11 )), the American Society
of Clinical Oncology (ASCO) 12
(www.asco.org), and the National
Comprehensive Cancer Network
(NCCN) in the USA (www.nccn.
org). 13 The key recommendations
are almost the same across these
guidelines, although there are
subtle differences between them.
For HEC (including anthracycline
plus cyclophosphamide (AC)-based
regimens), a triple antiemetic
combination of 5-HT3 RA,
NK1 RA and dexamethasone
is recommended by MASCC/
ESMO and NCCN (one option of
three), while ASCO recommends
a four-drug combination, adding
olanzapine to the previous
three-drug regimen for acute
prevention of CINV. MASCC/ESMO
and ASCO recommend the three-
drug combination in MEC in the
carboplatin setting only; and NCCN
recommends three options, one of
which is recommended by MASCC/
ESMO and ASCO.
ASCO recommends prophylaxis
with dexamethasone or 5-HT3
RAs in low emetogenic risk
chemotherapy whereas MASCC/
ESMO recommends a single
antiemetic agent such as
dexamethasone or 5-HT3 RA or
dopamine RA, etc. In LEC, NCCN
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