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Aogi, Kenjiro, Hideki Takeuchi, Toshiaki Saeki, et al. "Optimizing antiemetic treatment for chemotherapy-induced nausea and vomiting in Japan: Update summary of the 2015 Japan Society of Clinical Oncology Clinical Practice Guidelines for Antiemesis." International Journal of Clinical Oncology 26, no. 1 (2020): 1–17. http://dx.doi.org/10.1007/s10147-020-01818-3.
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AbstractPatients with cancer should appropriately receive antiemetic therapies against chemotherapy-induced nausea and vomiting (CINV). Antiemetic guidelines play an important role in managing CINV. Accordingly, the first Japanese antiemetic guideline published in 2010 by the Japan Society of Clinical Oncology (JSCO) has considerably aided Japanese medical staff in providing antiemetic therapies across chemotherapy clinics. With the yearly advancements in antiemetic therapies, the Japanese antiemetic guidelines require revisions according to published evidence regarding antiemetic management worldwide. A revised version of the first antiemetic guideline that considered several upcoming evidences had been published online in 2014 (version 1.2), in which several updated descriptions were included. The 2015 JSCO clinical practice guideline for antiemesis (version 2.0) (in Japanese) has addressed clinical antiemetic concerns and includes four major revisions regarding (1) changes in emetogenic risk categorization for anti-cancer agents, (2) olanzapine usage as an antiemetic drug, (3) the steroid-sparing method, and (4) adverse drug reactions of antiemetic agents. We herein present an English update summary for the 2015 JSCO clinical practice guideline for antiemesis (version 2.0).
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Kadakia, Kunal C., Alexis D. Leal, Drew K. Seisler, et al. "Antiemetic prescribing practices using a computerized physician order entry system." Journal of Clinical Oncology 31, no. 15_suppl (2013): e17538-e17538. http://dx.doi.org/10.1200/jco.2013.31.15_suppl.e17538.
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e17538 Background: Adherence to guideline-consistent chemotherapy-induced nausea and vomiting (CINV) prophylaxis is suboptimal. The primary aim of this study was to evaluate the magnitude of compliance to institutional guideline-directed antiemetic prophylaxis using a computerized physician order entry system at a single tertiary care institution. A nurse survey was also performed to evaluate how oncology practices, within a cooperative group, manage clinician orders for the prevention of CINV. Methods: The electronic medical records of 100 consecutive patients were evaluated. The primary endpoint was the incidence of compliance to provide all aspects of institutional guideline-directed antiemetic prophylaxis for acute (Day 1) and delayed (Days 2-4) CINV for patients receiving high, moderate, low, and minimally-emetogenic chemotherapy (HEC/MEC/LEC/MinEC). Noncompliance was declared if a recommended antiemetic was not prescribed per the guidelines or if additional antiemetics were prescribed. Descriptive analyses were performed on the convenience sample. Logistic regression was applied to determine the association of potential factors with noncompliance. Results: The incidence of compliance on Days 1-4 was 94%. Half of the noncompliant events occurred on Day 1 alone and involved the omission of pre-chemotherapy prochlorperazine in patients receiving LEC (3 of 6, 50%). There was a high-degree of compliance to institutional guidelines for delayed CINV (97%). Patients receiving doxorubicin/cyclophosphamide were numerically less likely to receive institutional guideline-directed antiemetic prophylaxis, compared to patients receiving other chemotherapy regimens (OR: 0.24 (0.04, 1.36), p-value: 0.05). No other factors were significantly predictive for compliance. The nurse survey demonstrated significant variability amongst the involved institutions, with regards to antiemetic prescribing practices. Conclusions: Computerized physician order entry is associated with impressive adherence to clinician prescribing practices, according to institutional guideline-directed antiemetic prophylaxis, for preventing acute and delayed CINV.
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Basch, Ethan, Paul J. Hesketh, Mark G. Kris, Ann Alexis Prestrud, Sarah Temin, and Gary H. Lyman. "Antiemetics: American Society of Clinical Oncology Clinical Practice Guideline Update." Journal of Oncology Practice 7, no. 6 (2011): 395–98. http://dx.doi.org/10.1200/jop.2011.000397.
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Hesketh, Paul J., Mark G. Kris, Ethan Basch, et al. "Antiemetics: ASCO Guideline Update." Journal of Clinical Oncology 38, no. 24 (2020): 2782–97. http://dx.doi.org/10.1200/jco.20.01296.
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PURPOSE To update the guideline to include new anticancer agents, antiemetics, and antiemetic regimens and to provide recommendations on the use of dexamethasone as a prophylactic antiemetic in patients receiving checkpoint inhibitors (CPIs). METHODS ASCO convened an Expert Panel and updated the systematic review to include randomized controlled trials (RCTs) and meta-analyses of RCTs published between June 1, 2016, and January 24, 2020. To address the dexamethasone and CPI question, we conducted a systematic review of RCTs that evaluated the addition of a CPI to chemotherapy. RESULTS The systematic reviews included 3 publications from the updated search and 10 publications on CPIs. Two phase III trials in adult patients with non–small-cell lung cancers evaluating a platinum-based doublet with or without the programmed death 1 (PD-1) inhibitor pembrolizumab recommended that all patients receive dexamethasone as a component of the prophylactic antiemetic regimen. In both studies, superior outcomes were noted in the PD-1 inhibitor–containing arms. Other important findings address olanzapine in adults and fosaprepitant in pediatric patients. RECOMMENDATIONS Recommendations for adults are unchanged with the exception of the option of adding olanzapine in the setting of hematopoietic stem cell transplantation. Dosing information now includes the option of a 5-mg dose of olanzapine in adults and intravenous formulations of aprepitant and netupitant-palonosetron. The option of fosaprepitant is added to pediatric recommendations. There is no clinical evidence to warrant omission of dexamethasone from guideline-compliant prophylactic antiemetic regimens when CPIs are administered to adults in combination with chemotherapy. CPIs administered alone or in combination with another CPI do not require the routine use of a prophylactic antiemetic. Additional information is available at www.asco.org/supportive-care-guidelines .
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Childs, Daniel, and Aminah Jatoi. "Adherence to anti-emetic guidelines with a newly approved chemotherapy agent, trifluridine/tipiracil (TAS-102): A single-institution study." Journal of Clinical Oncology 34, no. 26_suppl (2016): 221. http://dx.doi.org/10.1200/jco.2016.34.26_suppl.221.
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221 Background: To our knowledge, no study has examined adherence to antiemetic guidelines with soon-to-be-approved or newly approved chemotherapy agents. In 2015, the Food and Drug Administration approved 18 cancer drugs, underscoring the timeliness of this topic. Here, we hypothesize that patients prescribed new drugs are at risk for poor guideline adherence, and we report on antiemetic prescribing practices and outcomes with TAS-102, a recently approved drug for metastatic colorectal cancer. Methods: This study focused on all patients prescribed TAS-102 in 2015 at the Mayo Clinic in Rochester, MN for compassionate use or routine care within 3 months of FDA approval. First-cycle antiemetic prophylaxis was examined for adherence to National Comprehensive Cancer Network Guidelines, version 1.2015, for chemotherapy of low emetogenic potential based on TAS-102 phase 3 data. Results: Among 44 patients, 28 (64%) had nausea and vomiting with prior chemotherapy. With the first cycle of TAS-102, 25 (57%) were prescribed antiemetics in a guideline-adherent manner; 15 (34%) in a non-guideline-adherent/more aggressive manner; and 4 (9%) in a non-guideline-adherent/less aggressive manner. In guideline-adherent patients, rates of nausea and vomiting were 52% and 24%, respectively, with one patient requiring an unscheduled clinic visit and another an emergency department visit and hospital admission - all for nausea and vomiting. In non-guideline-adherent/more aggressive patients (who received more prophylaxis than called for), these rates were 33% and 27%, respectively, with one patient requiring a clinic visit and emergency department visit and another an emergency department visit. In non-guideline-adherent/less aggressive patients, no nausea or vomiting was reported. Conclusions: Poor adherence to antiemetic guidelines occurred often. However, because adherence was not associated with better control of nausea and vomiting, clinical judgment should complement guidelines in patients about to receive new cancer drugs, particularly with drugs of low emetogenic potential and also in patients with a history of chemotherapy-induced nausea and vomiting.
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Copher, Ronda, Russell L. Knoth, Glenn Magee, Soamnauth Misir, and Ali McBride. "Chemotherapy induced nausea and vomiting in breast cancer treated with antiemetic prophylaxis as recommended by the ASCO antiemesis guidelines." Journal of Clinical Oncology 35, no. 15_suppl (2017): 10109. http://dx.doi.org/10.1200/jco.2017.35.15_suppl.10109.
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10109 Background: Current ASCO Antiemesis Guidelines recommend triple antiemetic therapy (a 5HT3RA, an NK1, and dexamethasone) to prevent chemotherapy (CT) induced nausea and vomiting (CINV) in patients undergoing highly emetogenic chemotherapy (HEC). This study evaluated whether this regimen resulted in reduced rates of CINV in patients diagnosed with breast cancer (BC) and initiated on HEC. The primary outcomes of interest were rates of acute and delayed CINV in patients whose antiemesis prophylaxis was or was not in accordance with the ASCO guideline (i.e., Per-guideline vs. Non-Guideline). Costs of treating CINV were also calculated. Methods: Patients were identified in the Premier Healthcare database, a complete geographically diverse census of inpatients and hospital-based outpatients. Adults treated for BC with HEC during the years 2012-14 were identified and stratified based on their antiemesis prophylaxis. Rates of acute (day of CT) and delayed CINV (days 2-7 post CT) were calculated following initiation of HEC. CINV was defined by ICD9 codes for nausea and vomiting or volume depletion/dehydration or use of a rescue antiemetic. Rates of CINV and health care costs were then compared between the two cohorts. Results: A total of 8,388 patients were included in the analysis. Of these, 5,447 (65%) had treatment Per-Guideline and 2,941 (35%) were Non-Guideline. For acute CINV, Per-Guideline patients had a significantly lower rate of CINV when compared to Non-Guideline patients (1.7% vs. 3.2%, respectively, p < .001). Similarly, in delayed CINV Per-Guideline patients had significantly lower rates of CINV when compared to Non-Guideline patients (15.4% vs. 19.1%, p < .001). Patients who experienced CINV also had significantly greater total health care costs versus those without CINV ($32,199 vs. $20,163, respectively, p < .001). Conclusions: The results showed adherence to the ASCO Antiemesis Guidelines led to lower rates of CINV and lower costs. Although defining CINV by claims may tell an incomplete story, this study suggests that following the ASCO Antiemesis Guidelines may help both patients and payers of health care costs.
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Hesketh, Paul J., Matti Aapro, Karin Jordan, Lee Schwartzberg, Snezana Bosnjak, and Hope Rugo. "A Review of NEPA, a Novel Fixed Antiemetic Combination with the Potential for Enhancing Guideline Adherence and Improving Control of Chemotherapy-Induced Nausea and Vomiting." BioMed Research International 2015 (2015): 1–12. http://dx.doi.org/10.1155/2015/651879.
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Combination antiemetic regimens targeting multiple molecular pathways associated with emesis have become the standard of care for prevention of chemotherapy-induced nausea and vomiting (CINV) related to highly and moderately emetogenic chemotherapies. Antiemetic consensus guidelines from several professional societies are widely available and updated regularly as new data emerges. Unfortunately, despite substantial research supporting the notion that guideline conformity improves CINV control, adherence to antiemetic guidelines is unsatisfactory. While studies are needed to identify specific barriers to guideline use and explore measures to enhance adherence, a novel approach has been taken to improve clinician adherence and patient compliance, with the development of a new combination antiemetic. NEPA is an oral fixed combination of a new highly selective NK1receptor antagonist (RA), netupitant, and the pharmacologically and clinically distinct 5-HT3RA, palonosetron. This convenient antiemetic combination offers guideline-consistent prophylaxis by targeting two critical pathways associated with CINV in a single oral dose administered only once per cycle. This paper will review and discuss the NEPA data in the context of how this first combination antiemetic may overcome some of the barriers interfering with adherence to antiemetic guidelines, enhance patient compliance, and offer a possible advance in the prevention of CINV for patients.
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Patil, Vijay M., Vanita Noronha, Amit Joshi, et al. "Adherence to and Implementation of ASCO Antiemetic Guidelines in Routine Practice in a Tertiary Cancer Center in India." Journal of Oncology Practice 13, no. 6 (2017): e574-e581. http://dx.doi.org/10.1200/jop.2016.019448.
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Background: Nonadherence of antiemetic prescriptions to evidence-based antiemetic guidelines is associated with an increased proportion of chemotherapy-induced nausea and vomiting. The current project was carried out to improve the quality of antiemetic prescriptions at our institute. Methods: We initially performed a retrospective analysis of 1,211 consecutive antiemetic prescription records of adult patients with solid tumors who received outpatient chemotherapy regimens. The antiemetic prescription records were classified as either ASCO-guideline adherent or nonadherent, and the impact on emesis was studied. These data were used to educate clinicians regarding the importance of adherence to guidelines. We then revised our antiemetic prescription policies and made their use mandatory. In addition, a double-check system was introduced to ensure implementation. A reaudit was performed to study the impact of these interventions. Results: ASCO-guideline–adherent prescriptions in the initial part of our study were associated with a lower rate of vomiting (6.6% v 21.9%; P < .001), emergency visits (2.6% v 5.8%; P = .006), and hospitalization for emesis (0.9% v 4.9%; P < .001). The proportion of prescriptions classified as ASCO-guideline adherent in the initial audit and the reaudit were 63.6% and 98.5%, respectively ( P < .001). The proportion of patients for whom antiemetic prescriptions were overused was significantly lower on the reaudit (41.3% v 68.3% before the interventions; P = .001). Conclusion: Mandatory, semirigid corrective steps as carried out in this audit led to an improvement in antiemetic-guideline adherence rate.
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Bosnjak, Snezana, Ana Zilic, and Bishal Gyawali. "Disparities in the availability of and access to antiemetics recommended by the international antiemetic guidelines in Serbia, Japan, and Nepal." Journal of Clinical Oncology 34, no. 26_suppl (2016): 117. http://dx.doi.org/10.1200/jco.2016.34.26_suppl.117.
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117 Background: Guideline-consistent antiemetic therapy requires 4 classes of antiemetics (AEs) to be available and accessible for the optimal prevention of chemotherapy induced nausea and vomiting (CINV): serotonin3 receptor antagonists (5HT3RAs), neurokinin 1 receptor antagonists (NK1RAs), dopamine receptor antagonists (DOPRAs) and dexamethasone. To evaluate disparities in the availability and accessibility of AEs recommended by the international antiemetic guidelines for the prevention of CINV inpatients treated in governmental hospitals in Nepal (low), Serbia (upper-middle) and Japan (high-income). Methods: Availability was evaluated by the formulary availability and marketing authorization (MA) in Serbia (RS), Japan (JP) and Nepal (NP). Accessibility was assessed by the National Health Insurance Fund (NHIF) coverage in Serbia and Japan and by the affordability in Nepal. Off-label use of medications is not legitimate in Serbia and Japan. Results: Barriers are presented in Table. Serbia has no access to NK1RAs and palonosetron for the prevention of CINV after HEC-AC and carboplatin. There are no barriers in Japan to provide all 4 classes of AEs. In Nepal all AEs are payed out of pocket and the guideline implementation completely depends on the affordability. Olanzapine is accessible in Nepal, but not in Japan and Serbia due to restricted off-label use of medications. Conclusions: The real life implementation of antiemetic guidelines for the prevention of CINV in various countries depends on the availability of and access to AEs recommended by the guideline. Identified barriers in Serbia and Nepal preclude physicians from providing optimal supportive care. [Table: see text]
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Hesketh, Paul J., Mark G. Kris, Ethan Basch, et al. "Antiemetics: American Society of Clinical Oncology Clinical Practice Guideline Update." Journal of Clinical Oncology 35, no. 28 (2017): 3240–61. http://dx.doi.org/10.1200/jco.2017.74.4789.
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Purpose To update the ASCO guideline for antiemetics in oncology. Methods ASCO convened an Expert Panel and conducted a systematic review of the medical literature for the period of November 2009 to June 2016. Results Forty-one publications were included in this systematic review. A phase III randomized controlled trial demonstrated that adding olanzapine to antiemetic prophylaxis reduces the likelihood of nausea among adult patients who are treated with high emetic risk antineoplastic agents. Randomized controlled trials also support an expanded role for neurokinin 1 receptor antagonists in patients who are treated with chemotherapy. Recommendation Key updates include the addition of olanzapine to antiemetic regimens for adults who receive high-emetic-risk antineoplastic agents or who experience breakthrough nausea and vomiting; a recommendation to administer dexamethasone on day 1 only for adults who receive anthracycline and cyclophosphamide chemotherapy; and the addition of a neurokinin 1 receptor antagonist for adults who receive carboplatin area under the curve ≥ 4 mg/mL per minute or high-dose chemotherapy, and for pediatric patients who receive high-emetic-risk antineoplastic agents. For radiation-induced nausea and vomiting, adjustments were made to anatomic regions, risk levels, and antiemetic administration schedules. Rescue therapy alone is now recommended for low-emetic-risk radiation therapy. The Expert Panel reiterated the importance of using the most effective antiemetic regimens that are appropriate for antineoplastic agents or radiotherapy being administered. Such regimens should be used with initial treatment, rather than first assessing the patient’s emetic response with less-effective treatment. Additional information is available at www.asco.org/supportive-care-guidelines and www.asco.org/guidelineswiki .
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Wilfong, Lalan S., Carla Portnoy, J. Russell Hoverman, et al. "Enhanced compliance with appropriate antiemetic prescribing guidelines by utilizing a medically integrated pharmacy antiemetic therapeutic interchange protocol." Journal of Clinical Oncology 36, no. 30_suppl (2018): 55. http://dx.doi.org/10.1200/jco.2018.36.30_suppl.55.
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55 Background: Appropriate antiemetic prescribing remains an unmet need in patients receiving emetogenic chemotherapy. Non-compliance with standard antiemetic guidelines is well reported, and a focus of the American Society of Clinical Oncology Choosing Wisely campaign. Using our medically integrated pharmacies, a community oncology practice sought to maximize compliance with national guidelines by minimizing the use of NK1 inhibitors for low and minimally emetogenic regimens and optimizing medications for highly emetogenic regimens per NCCN guidelines. Methods: A retrospective review of a medically integrated pharmacy antiemetic therapeutic interchange policy. Trained oncology pharmacists imbedded within 2 cancer centers evaluated all new chemotherapy orders to determine the level of emetogenicity per NCCN guidelines. Pharmacists then used a guideline compliant prespecified therapeutic interchange protocol to adjust the antiemetic medications. Patient education to enhance medication compliance was performed by the pharmacists, nurses, and in one on one treatment review sessions with an advance practice provider. Results: Of 271 low to minimally emetogenic regimens, 99% did not receive an NK1 inhibitor on the first cycle. Of 367 highly emetogenic regimens, 97% appropriately received guideline based therapy. Additionally, the use of olanzapine was non-existent in the practice prior to this protocol and increased to 55% of patients with highly emetogenic regimens. Conclusions: We demonstrated that a therapeutic interchange policy with a medically integrated pharmacist shows enhanced compliance with guideline based antiemetic medication usage. This system also allows rapid uptake of changes in supportive care guidelines such as rapid adoption of olanzapine. Efficacy results of this protocol will be reported separately.
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Navari, Rudolph M. "Treatment of Breakthrough and Refractory Chemotherapy-Induced Nausea and Vomiting." BioMed Research International 2015 (2015): 1–6. http://dx.doi.org/10.1155/2015/595894.
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Despite significant progress in the prevention of chemotherapy-induced nausea and vomiting (CINV) with the introduction of new antiemetic agents, 30–50% of patients receiving moderately or highly emetogenic chemotherapy (MEC or HEC) and guideline directed prophylactic antiemetics develop breakthrough CINV. International guidelines recommend the treatment of breakthrough CINV with an agent from a drug class that was not used in the prophylactic antiemetic regimen and recommend using the breakthrough medication continuously rather than using it on an as needed basis. There have been very few studies on the treatment of breakthrough CINV. A recent double-blind, randomized, phase III study suggested that olanzapine may be an effective agent for the treatment of breakthrough CINV. Refractory CINV occurs when patients develop CINV during subsequent cycles of chemotherapy when antiemetic prophylaxis has not been successful in controlling CINV in earlier cycles. Patients who develop refractory CINV should be considered for a change in their prophylactic antiemetic regimen. If significant anxiety exists, a benzodiazepine may be added to the prophylactic regimen. If a refractory patient is receiving HEC, olanzapine may be added to the prophylactic regimen. If the patient is receiving MEC, olanzapine or an NK-1 receptor antagonist may be added to the prophylactic regimen.
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Roeland, Eric, Kathryn Jean Ruddy, Thomas William LeBlanc, et al. "What the HEC? Physician variation and attainable compliance targets in antiemetic prophylaxis." Journal of Clinical Oncology 36, no. 34_suppl (2018): 74. http://dx.doi.org/10.1200/jco.2018.36.34_suppl.74.
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74 Background: U.S. National Antiemetic Guidelines recommend upfront triple prophylaxis (NK1 receptor antagonist (RA) + 5HT3 RA + dexamethasone) for patients receiving highly emetogenic chemotherapy (HEC), including carboplatin AUC ≥ 4 per 2017 guidelines. While existing data show gaps in guideline compliance, variation between individual physicians is less studied, and a realistic target compliance rate remains unknown. Methods: In a large electronic health record database (IBM Explorys), we identified HEC courses of therapy initiated from 2012 to 2017. Guideline compliance was defined as triple prophylaxis at chemotherapy initiation. Patient courses for ≥ 7 day cycles of cisplatin or anthracycline + cyclophosphamide (AC), or carboplatin (≥ 14 day cycles as a proxy for AUC ≥ 4) were ascribed to oncologists based on encounter frequency. We then ranked physicians treating ≥ 5 HEC courses and evaluated guideline compliance and individual physician variation. Results: In total, 10,074 HEC courses were identified and attributed to 451 unique physicians. Overall antiemetic guideline compliance with cisplatin and AC averaged 68% and 81% respectively. When ranked by compliance, the top 20% of physicians were 2.5 - 1.5 times as compliant as the bottom 20% (cisplatin 100% vs 40%; AC 100% vs 67%). For cisplatin, 32% of physicians had > 90% compliance; the remaining 68% were evenly distributed from 0 - 90%. For AC, 56% of physicians had > 90% compliance, and another 14% had 80 - 90%; the remaining 30% were evenly distributed. For carboplatin, 62% of physicians had ≤ 10% compliance, and another 17% had 11 - 20%; however, the majority of these data preceded guideline inclusion of carboplatin AUC ≥ 4 as HEC. Rates were independent of course volume per physician. Conclusions: Considerable physician-level variation exists in triple antiemetic prophylaxis guideline adherence for HEC. Hundreds of physicians had > 90% compliance with guidelines, suggesting 90% is a realistic target. However, the majority exhibited substantial gaps in NK1 RA use in HEC, placing patients unnecessarily at risk for CINV. Interventions are needed to bolster triple antiemetic prophylaxis in HEC, perhaps especially for carboplatin.
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Molassiotis, A., M. Aapro, J. Herrstedt, R. Gralla, and F. Roila. "MASCC/ESMO Antiemetic Guidelines: Introduction to the 2016 guideline update." Supportive Care in Cancer 25, no. 1 (2016): 267–69. http://dx.doi.org/10.1007/s00520-016-3324-x.
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Roeland, Eric J., Kathryn J. Ruddy, Thomas W. LeBlanc, et al. "What the HEC? Clinician Adherence to Evidence-Based Antiemetic Prophylaxis for Highly Emetogenic Chemotherapy." Journal of the National Comprehensive Cancer Network 18, no. 6 (2020): 676–81. http://dx.doi.org/10.6004/jnccn.2019.7526.
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Background: Clinician adherence to antiemetic guidelines for preventing chemotherapy-induced nausea and vomiting (CINV) caused by highly emetogenic chemotherapy (HEC) remains poorly characterized. The primary aim of this study was to evaluate individual clinician adherence to HEC antiemetic guidelines. Patients and Methods: A retrospective analysis of patients receiving HEC was conducted using the IBM Watson Explorys Electronic Health Record Database (2012–2018). HEC antiemetic guideline adherence was defined as prescription of triple prophylaxis (neurokinin-1 receptor antagonist [NK1 RA], serotonin type-3 receptor antagonist, dexamethasone) at initiation of cisplatin or anthracycline + cyclophosphamide (AC). Clinicians who prescribed ≥5 HEC courses were included and individual guideline adherence was assessed, noting the number of prescribing clinicians with >90% adherence. Results: A total of 217 clinicians were identified who prescribed 2,543 cisplatin and 1,490 AC courses. Patients (N=4,033) were primarily women (63.3%) and chemotherapy-naïve (92%) with a mean age of 58.6 years. Breast (36%) and thoracic (19%) cancers were the most common tumor types. Guideline adherence rates of >90% were achieved by 35% and 58% of clinicians using cisplatin or AC, respectively. Omission of an NK1 RA was the most common practice of nonadherence. Variation in prophylaxis guideline adherence was considerable for cisplatin (mean, 71%; SD, 29%; coefficient of variation [CV], 0.40) and AC (mean, 84%; SD, 26%; CV, 0.31). Conclusions: Findings showed substantial gaps in clinician adherence to HEC CINV guidelines, including a high variability across clinicians. Clinicians should review their individual clinical practices and ensure adherence to evidence-based CINV guidelines to optimize patient care.
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Basch, Ethan, Ann Alexis Prestrud, Paul J. Hesketh, Mark G. Kris, Mark R. Somerfield, and Gary H. Lyman. "Antiemetic Use in Oncology: Updated Guideline Recommendations from ASCO." American Society of Clinical Oncology Educational Book, no. 32 (June 2012): 532–40. http://dx.doi.org/10.14694/edbook_am.2012.32.230.
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Overview: In 2011, ASCO updated its guideline for the use of antiemetics in oncology, informed by a systematic review of the medical literature. This is an abbreviated version of that guideline, which is available in full at www.asco.org/guidelines/antiemetics . Key changes from the prior update in 2006 include the following: Combined anthracycline and cyclophosphamide regimens were reclassified as highly emetic. Patients who receive this combination or any highly emetic agents should receive a 5-HT3 receptor antagonist, dexamethasone, and an NK1 receptor antagonist. A large trial validated the equivalency of fosaprepitant, a single-day intravenous formulation, with aprepitant; either therapy is appropriate. Preferential use of palonosetron is recommended for moderate emetic risk regimens, combined with dexamethasone. For low-risk agents, patients can be offered dexamethasone before the first dose of chemotherapy. Patients undergoing high emetic risk radiation therapy should receive a 5-HT3 receptor antagonist before each fraction and for 24 hours following treatment and may receive a 5-day course of dexamethasone during fractions 1 to 5. Continued symptom monitoring throughout therapy is recommended. Clinicians often underestimate the incidence of nausea, which is not as well controlled as vomiting. Detailed information about the development of the guideline as well as practice tools are available at www.asco.org/guidelines/antiemetics .
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Grunberg, Steven M. "Obstacles to the Implementation of Antiemetic Guidelines." Journal of the National Comprehensive Cancer Network 7, no. 5 (2009): 601–5. http://dx.doi.org/10.6004/jnccn.2009.0040.
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Although guidelines help physicians deliver high quality clinical care, they will have minimal impact unless familiarity and adherence are achieved. Although nausea and vomiting are highly feared toxicities of chemotherapy that markedly decrease patient quality of life, modifications in physician behavior and improvements in standards of care, particularly in terms of preventing delayed emesis, have been slow. Variations in format, goals, physician education, and institutional education may all affect guideline implementation and state-of-the-art care. The relationship between these factors and the scientific basis of antiemetic guidelines must be considered to achieve optimal results and compliance.
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Mersiades, Antony J., Annette Tognela, Paul S. Haber, et al. "Oral cannabinoid-rich THC/CBD cannabis extract for secondary prevention of chemotherapy-induced nausea and vomiting: a study protocol for a pilot and definitive randomised double-blind placebo-controlled trial (CannabisCINV)." BMJ Open 8, no. 9 (2018): e020745. http://dx.doi.org/10.1136/bmjopen-2017-020745.
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IntroductionChemotherapy-induced nausea and vomiting (CINV) remains an important issue for patients receiving chemotherapy despite guideline-consistent antiemetic therapy. Trials using delta-9-tetrahydrocannabinol-rich (THC) products demonstrate limited antiemetic effect, significant adverse events and flawed study design. Trials using cannabidiol-rich (CBD) products demonstrate improved efficacy and psychological adverse event profile. No definitive trials have been conducted to support the use of cannabinoids for this indication, nor has the potential economic impact of incorporating such regimens into the Australian healthcare system been established. CannabisCINV aims to assess the efficacy, safety and cost-effectiveness of adding TN-TC11M, an oral THC/CBD extract to guideline-consistent antiemetics in the secondary prevention of CINV.Methods and analysisThe current multicentre, 1:1 randomised cross-over, placebo-controlled pilot study will recruit 80 adult patients with any malignancy, experiencing CINV during moderate to highly emetogenic chemotherapy despite guideline-consistent antiemetics. Patients receive oral TN-TC11M (THC 2.5mg/CBD 2.5 mg) capsules or placebo capsules three times a day on day −1 to day 5 of cycle A of chemotherapy, followed by the alternative drug regimen during cycle B of chemotherapy and the preferred drug regimen during cycle C. The primary endpoint is the proportion of subjects attaining a complete response to CINV. Secondary and tertiary endpoints include regimen tolerability, impact on quality of life and health system resource use. The primary assessment tool is patient diaries, which are filled from day −1 to day 5. A subsequent randomised placebo-controlled parallel phase III trial will recruit a further 250 patients.Ethics and disseminationThe protocol was approved by ethics review committees for all participating sites. Results will be disseminated in peer-reviewed journals and at scientific conferences.Drug supplyTilray.Protocol version2.0, 9 June 2017.Trial registration numberANZCTR12616001036404; Pre-results.
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Navari, Rudolph M., Kathryn J. Ruddy, Thomas W. LeBlanc, et al. "Impact of Addition of Carboplatin AUC ≥ 4 to Antiemetic Guidelines for Triple Antiemetic Prophylaxis: A Gap in Quality of Care, Guideline Adoption, and Avoiding Acute Care." JCO Oncology Practice 16, no. 2 (2020): e132-e138. http://dx.doi.org/10.1200/jop.19.00457.
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PURPOSE: After ASCO and National Comprehensive Cancer Network guideline recommendations for triple antiemetic prophylaxis for carboplatin area under the curve (AUC) ≥ 4, and the publication of studies documenting avoidable acute care after chemotherapy involving nausea and vomiting (NV) and other toxicities, we studied clinician adherence to the guideline change and assessed avoidable acute-care use. METHODS: Using a large electronic health record database, we evaluated antiemetic prophylaxis as recommended in the guidelines and post-chemotherapy avoidable acute-care use (defined as involving any of NV or 8 other toxicities) for patients initiating carboplatin or other chemotherapy from October 2012 to August 2018. RESULTS: We identified 11,554 carboplatin courses. After the guideline change adding neurokinin-1 receptor antagonists (RAs) for carboplatin AUC ≥ 4, its use rose to 20% of courses from the prior average of 16%; virtually all courses also included a 5-HT3 RA plus dexamethasone. We found avoidable acute care in 23% of courses; one quarter of these events were associated with NV. Acute care rates after carboplatin mirrored those after other highly emetogenic chemotherapy or oxaliplatin and exceeded those after other chemotherapy regimens. The > 80% shortfall in adherence may have been caused by low awareness or acceptance of the guideline change and/or by poor awareness of avoidable acute-care use after carboplatin. CONCLUSION: Neurokinin-1 RA prophylaxis for carboplatin AUC ≥ 4 remains low and largely unchanged despite National Comprehensive Cancer Network and ASCO 2017 recommendations for inclusion. NV and avoidable acute care involving NV seen after carboplatin were consistent with other highly emetogenic chemotherapy. Clinician action is required to remediate incomplete prophylaxis and to no longer place patient outcomes, resources for cancer treatment, and clinician reimbursement at risk.
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Gralla, Richard J., and Harry Raftopoulos. "Progress in the Control of Chemotherapy-Induced Emesis: New Agents and New Studies." Journal of Oncology Practice 5, no. 3 (2009): 130–33. http://dx.doi.org/10.1200/jop.0938502.
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New agents and studies have demonstrated benefit in improving antiemetic therapy. Incorporating evidence-based guideline recommendations and appropriate emesis assessments are key components to achieving the best practice.
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Aapro, Matti S., Marika Chrápavá, Razvan-Ovidiu D. Curca, et al. "Assessing the impact of antiemetic guideline compliance on prevention of chemotherapy-induced nausea and vomiting (CINV): Results of the Nausea/Emesis Registry in Oncology (NERO)." Journal of Clinical Oncology 38, no. 15_suppl (2020): 12083. http://dx.doi.org/10.1200/jco.2020.38.15_suppl.12083.
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12083 Background: Evidence-based antiemetic guidelines offer predominantly consistent recommendations for CINV prophylaxis. However, studies and surveys suggest that adherence to these recommendations is suboptimal. We explored potential inconsistencies between clinical practice and guideline-recommended treatment with a registry evaluating the effect of guideline-consistent CINV prophylaxis (GCCP) on patient outcomes. Methods: This was a prospective, non-interventional, observational, multicenter study designed to assess overall (0-120 h) complete response (CR: no emesis/no rescue use) rates in patients who received GCCP or guideline inconsistent CINV prophylaxis (GICP) using diaries for 5 days following chemotherapy. Cycle 1 results are presented in patients who received either 1) anthracycline/cyclosphosphamide (AC) highly emetogenic chemotherapy (HEC), non-AC HEC or carboplatin, with GCCP for all these groups consisting of prophylaxis with an NK1 receptor antagonist (RA), 5-HT3RA, and dexamethasone (DEX) prior to chemotherapy or 2) moderately emetogenic chemotherapy (MEC), with GCCP consisting of a 5-HT3RA and DEX prior to chemotherapy as per MASCC 2016 guidelines. CR rates for cohorts deemed to be GCCP and GICP were compared using a chi-square test. Results: A total of 1,089 patients were part of the cycle 1 efficacy evaluation. Overall GCCP was 23% for all patients. CR rates were significantly higher in patients receiving GCCP versus GICP (Table). Conclusions: Consistent with prior studies, GCCP was very low. The primary endpoint of the study was achieved as there was a significant benefit of almost 10% improved prevention of CINV when administering GCCP. As per MASCC/ESMO guidelines such an absolute difference should be practice changing. Comprehensive multifaceted strategies are needed to achieve better adherence to antiemetic guidelines. [Table: see text]
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Okita, Kenji, and Koichi Hirata. "A Validation Study of Japanese Antiemetic Guideline Using Quality Indicators." Annals of Oncology 25 (October 2014): v43. http://dx.doi.org/10.1093/annonc/mdu434.1.
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Cong, Luo, Mingge Shang, Lei Chen, et al. "A cross-sectional study on effectiveness of antiemetic regimens for chemotherapy-induced nausea and vomiting: A single-center retrospect study of 1,000 patients." Journal of Clinical Oncology 39, no. 15_suppl (2021): e24100-e24100. http://dx.doi.org/10.1200/jco.2021.39.15_suppl.e24100.
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e24100 Background: Chemotherapy-induced nausea and vomiting (CINV) is a common symptom in patients who undergoing chemotherapy, it is very important to control CINV to maintain dose intensity and patients' quality of life. To analyse the current situation of CINV for the tumor patients who undergoing chemotherapy, we used a cross-sectional survey to assess CINV status in those patients, and whether the drugs used by doctors in each department met the guidelines, and compared the efficacy of different antiemetic regimens on acute and delayed CINV overall post-chemotherapy periods. Methods: 1,000 patients were randomly selected from 5,468 patients with chemotherapy discharged from different departments of Zhejiang cancer hospital in China between April 1 and April 30, 2019, and there were 87 responses totally. Medical records were collected on patient’s department (internal medicine, surgery, radiotherapy, interventional), chemotherapy regimens, anti-vomiting program, etc. Patients' feedbacks were recorded by CTCAE4.03 standard using MASCC antiemetic tool (Mat). Participants reported the frequency, severity, and impact on daily life of CINV from the day of chemotherapy administration up to 5 days thereafter and nausea and vomiting, as well as pharmacologic and chemotherapy used. Results: A total of 66 antineoplastic drugs were investigated, of which 52 were given intravenously and 14 orally.There were 9, 7, 50 drugs with high, moderate and low emetic risk respectively.The most prescribed prophylactic regimens for the management of CINV were aprepitant, 5-HT3R, H1-RA and dexamethasone and metoclopramide. The overall incidence of CINV were 44.34%, 24.57% and 39.66% patients reported nausea or vomiting in the acute and delayed phases. 19.89% patients had both acute and delayed CINV. The consistency rate of antiemetic with guideline was 63.19% in internal medicine department, 61.41% in surgery department and 52.91% in radiotherapy department, which showed a significant gap between the actual use of drugs and the recommended guidelines(P = 0.001). In 875 patients, 518 patients received guideline recommended antiemetic regimen, the CINV rates of complete response (CR), defined as no vomiting with no rescue medication, were 61.58%. While the CR rates in other 357 patients were 47.06%(P < 0.001). Nausea was more frequent across the overall observation period (43.77% VS 18.86%). However, vomiting was more sever and had a greater impact on life than nausea. Conclusions: Overall, adherence to the guideline recommendations in different departments were poor with varying degrees. Future studies should set hard outcomes, such as the absence of any symptoms, as a primary end point. The standardized management of CINV in patients need to be further strengthened and doctors need to use drugs more regularly to reduce the occurrence of CINV in patients.
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Cong, Luo, Mingge Shang, Lei Chen, et al. "A cross-sectional study on the effectiveness of antiemetic regimens for chemotherapy-induced nausea and vomiting: A single center retrospect study of 1,000 patients." Journal of Clinical Oncology 39, no. 15_suppl (2021): e24055-e24055. http://dx.doi.org/10.1200/jco.2021.39.15_suppl.e24055.
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e24055 Background: Chemotherapy-induced nausea and vomiting (CINV) is a common symptom in patients who undergoing chemotherapy, it is very important to control CINV to maintain dose intensity and patients' quality of life. To analyse the current situation of CINV for the tumor patients who undergoing chemotherapy, we used a cross-sectional survey to assess CINV status in those patients, and whether the drugs used by doctors in each department met the guidelines, and compared the efficacy of different antiemetic regimens on acute and delayed CINV overall post-chemotherapy periods. Methods: 1,000 patients were randomly selected from 5,468 patients with chemotherapy discharged from different departments of Zhejiang cancer hospital in China between April 1 and April 30, 2019, and there were 87 responses totally. Medical records were collected on patient’s department (internal medicine, surgery, radiotherapy, interventional) , chemotherapy regimens, anti-vomiting program, etc. Patients' feedbacks were recorded by CTCAE4.03 standard using MASCC antiemetic tool (Mat). Participants reported the frequency, severity, and impact on daily life of CINV from the day of chemotherapy administration up to 5 days thereafter and nausea and vomiting, as well as pharmacologic and chemotherapy used. Results: A total of 66 antineoplastic drugs were investigated, of which 52 were given intravenously and 14 orally.There were 9, 7, 50 drugs with high, moderate and low emetic risk respectively.The most prescribed prophylactic regimens for the management of CINV were aprepitant, 5-HT3R, H1-RA and dexamethasone and metoclopramide. The overall incidence of CINV were 44.34%, 24.57% and 39.66% patients reported nausea or vomiting in the acute and delayed phases. 19.89% patients had both acute and delayed CINV. The consistency rate of antiemetic with guideline was 63.19% in internal medicine department, 61.41% in surgery department and 52.91% in radiotherapy department, which showed a significant gap between the actual use of drugs and the recommended guidelines(P = 0.001). In 875 patients, 518 patients received guideline recommended antiemetic regimen, the CINV rates of complete response (CR), defined as no vomiting with no rescue medication, were 61.58%. While the CR rates in other 357 patients were 47.06%(P < 0.001). Nausea was more frequent across the overall observation period(43.77% VS 18.86%). However, vomiting was more sever and had a greater impact on life than nausea. Conclusions: Overall, adherence to the guideline recommendations in different departments were poor with varying degrees. Future studies should set hard outcomes, such as the absence of any symptoms, as a primary end point.The standardized management of CINV in patients needs to be further strengthened and doctors need to use drugs more regularly to reduce the occurrence of CINV in patients.
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Patil, Vijay Maruti, Amit Joshi, Vanita Noronha, et al. "Survey of implementation of antiemetic prescription standards in Indian oncology practices and adherence to ASCO's antiemetic clinical guideline." Journal of Clinical Oncology 34, no. 15_suppl (2016): e18230-e18230. http://dx.doi.org/10.1200/jco.2016.34.15_suppl.e18230.
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Gilmore, James W., Nancy W. Peacock, Anna Gu, et al. "Antiemetic Guideline Consistency and Incidence of Chemotherapy-Induced Nausea and Vomiting in US Community Oncology Practice: INSPIRE Study." Journal of Oncology Practice 10, no. 1 (2014): 68–74. http://dx.doi.org/10.1200/jop.2012.000816.
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Gralla, Richard J., Fausto Roila, and Maurizio Tonato. "The 2004 Perugia Antiemetic Consensus Guideline process: methods, procedures, and participants." Supportive Care in Cancer 13, no. 2 (2004): 77–79. http://dx.doi.org/10.1007/s00520-004-0756-5.
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Hesketh, Paul J., Kari Bohlke, Gary H. Lyman, et al. "Antiemetics: American Society of Clinical Oncology Focused Guideline Update." Journal of Clinical Oncology 34, no. 4 (2016): 381–86. http://dx.doi.org/10.1200/jco.2015.64.3635.
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Purpose To update a key recommendation of the American Society of Clinical Oncology antiemetic guideline. This update addresses the use of the oral combination of netupitant (a neurokinin 1 [NK1] receptor antagonist) and palonosetron (a 5-hydroxytryptamine-3 [5-HT3] receptor antagonist) for the prevention of acute and delayed nausea and vomiting in patients receiving chemotherapy. Methods An update committee conducted a targeted systematic literature review and identified two phase III clinical trials and a randomized phase II dose-ranging study. Results In one phase III trial, the oral combination of netupitant and palonosetron was associated with higher complete response rates (no emesis and no rescue medications) compared with palonosetron alone in patients treated with anthracycline plus cyclophosphamide chemotherapy (74% v 67% overall; P = .001). In another phase III trial, the oral combination of netupitant and palonosetron was safe and effective across multiple cycles of moderately or highly emetogenic chemotherapies. In the phase II dose-ranging study, each dose of netupitant (coadministered with palonosetron 0.50 mg) produced higher complete response rates than palonosetron alone among patients receiving cisplatin-based chemotherapy. The highest dose of netupitant (ie, 300 mg) was most effective. Recommendations All patients who receive highly emetogenic chemotherapy regimens (including anthracycline plus cyclophosphamide) should be offered a three-drug combination of an NK1 receptor antagonist, a 5-HT3 receptor antagonist, and dexamethasone. The oral combination of netupitant and palonosetron plus dexamethasone is an additional treatment option in this setting. The remaining recommendations from the 2011 ASCO guideline are unchanged pending a full update. Additional information is available at www.asco.org/guidelines/antiemetics and www.asco.org/guidelineswiki .
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Roeland, Eric, Kathryn Jean Ruddy, Thomas William LeBlanc, et al. "Ondansetron versus palonosetron as a marker of non-adherence to antiemetic prophylaxis guidelines in highly emetogenic chemotherapy." Journal of Clinical Oncology 37, no. 15_suppl (2019): e23108-e23108. http://dx.doi.org/10.1200/jco.2019.37.15_suppl.e23108.
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e23108 Background: ASCO antiemetic guidelines recommend upfront triple prophylaxis (NK1 receptor antagonist (RA) + 5HT3 RA + dexamethasone) for patients receiving highly emetogenic chemotherapy (HEC). Physicians exhibit high variation in HEC guideline adherence, principally involving inclusion of NK1 RA. Whether adherence is associated with selection of the specific 5HT3 RA agent remains inadequately studied. Methods: In the IBM Explorys electronic health record database, we used procedure and diagnosis codes to identify HEC courses and related nausea/vomiting (NV) from 2012 to 2018. We defined HEC guideline adherence as triple prophylaxis at chemotherapy initiation. We assigned HEC courses for ≥ 7 day cycles of cisplatin or anthracycline + cyclophosphamide (AC), or carboplatin (≥ 14 day cycles as a proxy for AUC ≥ 4) to prescribing oncologists based on encounter frequency. We categorized 5HT3 RA use of each physician treating ≥ 5 HEC courses based on their most commonly used 5HT3 and performed descriptive statistics. Results: Of 12,262 HEC courses, 57% involved physicians having greater use of ondansetron (OND) (mean OND to palonosetron (PALO) ratio of 3.9:1). These courses had lower guideline adherence (due to NK1 RA omission) and higher rates of NV for combined HEC, AC, and carboplatin. NV rates for cisplatin did not vary by 5HT3 agent used. Courses involving physicians with greater PALO use (mean OND:PALO ratio of 0.2:1) had superior adherence and NV rates, despite involving a slightly higher risk population (younger and/or female). Conclusions: According to HEC antiemetic guidelines, NK1 RA use should occur independent of 5HT3 RA agent selection. However, we observed less NK1 RA use where OND was preferred, which may have caused the observed higher rates of NV with OND. Further evaluation should assess whether pharmacy cost minimization is a driver of both OND preference and NK1 omission in HEC. [Table: see text]
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Patil, Vijay, Vanita Noronha, Amit Joshi, et al. "Survey of Implementation of Antiemetic Prescription Standards in Indian Oncology Practices and Its Adherence to the American Society of Clinical Oncology Antiemetic Clinical Guideline." Journal of Global Oncology 3, no. 4 (2017): 346–59. http://dx.doi.org/10.1200/jgo.2016.006023.
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Purpose Adherence to international antiemetic prophylaxis guidelines like those of ASCO can result in better control of chemotherapy-induced nausea and vomiting; however, the extent of implementation of such guidelines in India is unknown. Therefore, this survey was planned. Methods This study was an anonymized cross-sectional survey approved by the ethics committee. Survey items were generated from the clinical questions given in the ASCO guidelines. The survey was disseminated through personal contacts at an oncology conference and via e-mail to various community oncology centers across India. The B1, B2, and B3 domains included questions regarding the optimal antiemetic prophylaxis for high, moderate, and low-minimal emetogenic regimens. Results Sixty-six (62.9%) of 105 responded and 65 centers (98.5%) were aware of the published guidelines. The partial, full, and no implementation scores were 92.5%, 4.5%, and 3.0%, respectively. Full implementation was better for the low-minimal emetogenic regimens (34.8%) than the highly emetogenic regimens (6.1%). The three most frequent reasons for hampered implementation of ASCO guidelines in routine chemotherapy practice cited by centers were a lack of sensitization (26 centers; 39.4%), lack of national guidelines (12 centers; 18.2%), and lack of administrative support (10 centers; 15.2%). Conclusion Awareness regarding ASCO antiemetic guidelines is satisfactory in Indian oncology practices; however, there is a need for sensitization of oncologists toward complete implementation of these guidelines in their clinical practice.
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Martin, I., V. Montheil, S. Ropert, J. Alexandre, F. Goldwasser, and J. P. Durand. "Incidence of chemotherapy-induced nausea and vomiting in 2008." Journal of Clinical Oncology 27, no. 15_suppl (2009): e20660-e20660. http://dx.doi.org/10.1200/jco.2009.27.15_suppl.e20660.
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e20660 Background: The authors determined the incidence of acute and delayed chemotherapy-induced nausea and vomiting (CINV) among new patients (pts) receiving chemotherapy with modern antiemetic prophylaxis in 2008. Methods: A prospective observational study of adult cancer pts receiving, for the first time, moderately or highly emetogenic chemotherapy (MEC or HEC) was performed. Study participants were called on day 2 and day 8, after first and second cycle, to evaluate acute and delayed emesis according a 10-item questionnaire. All patients received, before and after their chemotherapy, the optimal antiemetic prophylaxis according to the 2006 Update of ASCO Guideline for Antiemetics. Results: 131 consecutive pts were enrolled between January and June 2008. At cycle 1, on 124 assessable pts for acute emesis: 68 pts received MEC and 18, HEC. 5.6% developed acute vomiting (5.9% for MEC and 5.6% for HEC) and 33.1%, acute nausea (39.7% for MEC and 44.4% for HEC). At cycle 1, on 101 assessable pts for delayed emesis: 5% experienced delayed vomiting (5.1% for MEC and 6.3% for HEC) and 17.8%, delayed nausea (18.6% for MEC and 31.3% for HEC). At cycle 2, on 121 assessable pts for acute emesis: 62 pts received MEC and 18, HEC. 8.3% developed acute vomiting (6.5% for MEC and 16.3% for HEC) and 31.4%, acute nausea (35.5% for MEC and 44.4% for HEC). At cycle 2, on 96 assessable pts for delayed emesis: 5.2% experienced delayed vomiting (3.3% for MEC and 9.1% for HEC) and 19.8%, delayed nausea (23% for MEC and 27.3% for HEC). Conclusions: Though the application of the last antiemetic recommendations, CINV, especially nausea, remained a substantial toxicity for patients receiving chemotherapy, pointing out the need for improved therapeutic intervention. [Table: see text]
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Navari, Rudolph M., Kathryn Jean Ruddy, Thomas William LeBlanc, et al. "Physician concordance with update to ASCO guidelines for antiemetic use with carboplatin AUC ≥ 4." Journal of Clinical Oncology 37, no. 15_suppl (2019): 11595. http://dx.doi.org/10.1200/jco.2019.37.15_suppl.11595.
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11595 Background: In 2017, NCCN (2/2017) and ASCO (8/2017) each amended antiemetic guidelines to classify carboplatin AUC ≥4 as highly emetogenic chemotherapy (HEC), recommending upfront triple prophylaxis with an NK1 receptor antagonist (RA) + 5HT3 RA + dexamethasone. Physician concordance with the new recommendations, and the consequences for avoidable post-chemotherapy acute care, merit study. Methods: In a large electronic health record database (IBM Explorys), we identified carboplatin courses of therapy (≥14-day cycles as a proxy for AUC ≥4) and courses with ≥7-day cycles of other HEC and non-HEC therapy from 4Q 2012 through August 2018. Guideline concordance, defined as triple prophylaxis at HEC initiation, was evaluated. We also assessed 30-day post-chemotherapy acute care (inpatient or emergency department) associated with nausea or vomiting (NV) or eight other toxicities deemed avoidable in the US Centers for Medicare & Medicaid’s new oncology outcome measure OP-35. Results: 11,554 carboplatin courses were identified. Before the guideline change, rates of upfront triple prophylaxis grew from 14% in 2013 to 16% in mid-2017. Rates then rose to 26% by 1Q 2018 before dropping to 21% by 3Q 2018; quarterly rates averaged 20% (range 15%-26%) following the guideline change. In 31% of carboplatin courses we noted 30-day acute care use, of which 75% involved ≥1 of the ten OP-35 toxicities. NV (with or without acute care use) was reported in 24% of courses, and 27% of total OP-35 acute care events involved NV. Rates for NV, and for OP-35-related and NV-related acute care after carboplatin, were similar to rates after other HEC chemotherapy, and higher than rates after other non-HEC IV chemotherapy or oral HEC/MEC agents. Conclusions: Use of upfront triple antiemetic prophylaxis has increased only marginally for carboplatin AUC ≥ 4 since its 2017 re-classification as HEC in national guidelines, perhaps due to low awareness of the change. Patients receiving carboplatin had similar rates of NV and related 30-day acute care events as seen for other HEC, confirming that the new HEC definition fits clinical experience. More triple prophylaxis use is needed to reduce NV and NV-related avoidable acute care seen with carboplatin AUC ≥ 4.
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França, Monique Sedlmaier, Pedro Luiz Serrano Usón Junior, Yuri Philippe Pimentel Vieira Antunes, et al. "Assessment of adherence to the guidelines for the management of nausea and vomiting induced by chemotherapy." Einstein (São Paulo) 13, no. 2 (2015): 221–25. http://dx.doi.org/10.1590/s1679-45082015ao3097.
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ABSTRACT Objective: To assess adherence of the prescribing physicians in a private cancer care center to the American Society of Clinical Oncology guideline for antiemetic prophylaxis, in the first cycle of antineoplastic chemotherapy. Methods: A total of 139 chemotherapy regimens, of 105 patients, were evaluated retrospectively from 2011 to 2013. Results: We observed 78% of non-adherence to the guideline rate. The main disagreements with the directive were the prescription of higher doses of dexamethasone and excessive use of 5-HT3 antagonist for low risk emetogenic chemotherapy regimens. On univariate analysis, hematological malignancies (p=0.005), the use of two or more chemotherapy (p=0.05) and high emetogenic risk regimes (p=0.012) were factors statistically associated with greater adherence to guidelines. Treatment based on paclitaxel was the only significant risk factor for non-adherence (p=0.02). By multivariate analysis, the chemotherapy of high emetogenic risk most correlated with adherence to guideline (p=0.05). Conclusion: We concluded that the adherence to guidelines is greater if the chemotherapy regime has high emetogenic risk. Educational efforts should focus more intensely on the management of chemotherapy regimens with low and moderate emetogenic potential. Perhaps the development of a computer generated reminder may improve the adherence to guidelines.
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Mertens, Wilson C., Donald J. Higby, David Brown, et al. "Improving the Care of Patients With Regard to Chemotherapy-Induced Nausea and Emesis: The Effect of Feedback to Clinicians on Adherence to Antiemetic Prescribing Guidelines." Journal of Clinical Oncology 21, no. 7 (2003): 1373–78. http://dx.doi.org/10.1200/jco.2003.08.118.
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Purpose: To evaluate the effect of performance and outcomes feedback on adherence to clinical practice guidelines regarding chemotherapy-induced nausea and emesis (CINE). Methods: Institutional CINE clinical practice guidelines were developed based on American Society of Clinical Oncology guidelines. Consecutive administrations of moderately/highly emetogenic chemotherapy were assessed for errors. Baseline statistical process control (SPC) charts were created and mean errors per administration were calculated. Prospective SPC charts were used to measure the effect of guideline development and distribution, a visiting lecturer, and ongoing feedback regarding compliance with guidelines employing SPC charts. Patients were surveyed regarding the extent and severity of CINE for 5 days postadministration. These outcomes were then shared with physicians. Results: Baseline compliance was poor (mean, 0.87 omissions per chemotherapy administration), largely because of inadequate adherence to recommendations for delayed CINE management. Most patients experienced delayed nausea, particularly on day 3 postchemotherapy. Physician prescribing performance did not undergo sustained improvement despite guideline development or distribution, a lecture by a visiting expert, or sharing of adherence data with clinicians. Once patient outcomes were shared, physicians accepted the need for compliance and instituted nurse practitioner antiemetic prescribing, with almost complete compliance and concurrent measurable reduction in day 3 nausea. SPC charts documented improvements in both outcomes. Conclusions: SPC charts effectively monitor ongoing compliance and patient symptoms and represent appropriate outcome measurement and change facilitation tools. However, physician participation in guideline development and evidence of poor compliance alone did not improve prescribing performance. Only evidence of patient CINE experience coupled with noncompliance improved results.
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Lesser, M., R. Gralla, B. Napolitano, et al. "Determining the preferred dose of the serotonin antagonist (5-HT3) palonosetron: Results of an individual patient data meta-analysis (MA) of 1,947 patients in all randomized double blinded (RDB) trials." Journal of Clinical Oncology 27, no. 15_suppl (2009): e20512-e20512. http://dx.doi.org/10.1200/jco.2009.27.15_suppl.e20512.
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e20512 Background: Progress in antiemetic therapy has had a major impact on the administration of cancer chemotherapy (chemo). 5-HT3 agents are among the most used drugs in oncology and are considered the primary agents in guideline-recommended combination antiemetic regimens. Randomized trials have demonstrated advantages for palonosetron (palo) when compared with other 5-HT3 drugs in single agent trials (Ann Oncol 2003, Ann Oncol 2004) and recently in a combination trial with dexamethasone (Yoshizawa, ESMO 2008). With different doses of palo in use, we undertook this MA to determine if efficacy differs for palo doses of 0.75 mg or 0.25 mg. This has an impact on clinical dosing and on guideline recommendations as to whether there should be a preferred palo dose and a preferred 5-HT3 antiemetic. Methods: After a literature search and colleague inquiry, we identified 8 RDB trials; 4 in highly emetic (HEC) and 4 in moderately emetic (MEC) chemo that included treatment arms with 0.25 mg and 0.75 mg of palo; 6 IV and 2 PO trials. Primary endpoint: Complete Response (CR - no vomiting, no rescue) over days 1–5 after chemo. Secondary endpoints: Complete Control (CC - no vomiting, days 1–5); Acute emesis (day 1); Delayed emesis (days 2 - 5); by chemo (HEC / MEC); by other prognostic factors; by side-effects. Logistic regression, stratifying for protocol and including a treatment x protocol interaction term, was first used to test for heterogeneity (Het) of odds ratios (OR). In the absence of significant Het, the protocols were “pooled” in a protocol-stratified analysis. OR>1 favors palo 0.75 mg. Results: Individual patient data were obtained for the 1947 subjects. Half were randomized to palo 0.25. No significant heterogeneity was found for CR or CC. For CR, the pooled OR = 1.00 (95% CI: 0.83–1.20); for CC, OR = 0.99 (95% CI: 0.83–1.89). Similar ORs for CR and CC were found for HEC and MEC, with no Het. Conclusions: We conclude that trials using 0.25 mg or 0.75 mg palonosetron doses yield similar efficacy for CR and CC so that reports with either dose can be used clinically or in guideline considerations. Findings are true for HEC and MEC regimens as well. [Table: see text]
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Pym, A., and E. Ben-Menachem. "The Effect of a Multifaceted Postoperative Nausea and Vomiting Reduction Strategy on Prophylaxis Administration Amongst Higher-Risk Adult Surgical Patients." Anaesthesia and Intensive Care 46, no. 2 (2018): 185–89. http://dx.doi.org/10.1177/0310057x1804600207.
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Postoperative nausea and vomiting (PONV) is a common and distressing problem for patients and increases the burden of care in post-anaesthesia care units (PACU). As such it has been a recent focus for quality improvement. Evidence-based guidelines have demonstrated the benefit of PONV risk stratification and prophylaxis, but may be underutilised in clinical practice. This prospective pre-/post-intervention study was conducted at an adult tertiary hospital in non-cardiac adult surgical patients at higher risk of PONV. The intervention included promotion of an evidence-based PONV guideline, and provision of individualised prescribing and patient outcome data to anaesthetists. Six hundred and twenty-eight patients with ≥2 risk factors for PONV following general anaesthesia for non-cardiac surgery were included (333 pre-intervention and 295 post-intervention). Prior to the intervention, 9.0% (30/333) of moderate- and high-risk patients received antiemetic prophylaxis consistent with our guideline. Post-intervention, the rate of guideline adherence was 19.3% (57/295). In the high-risk PONV group, the time in PACU was significantly reduced post-intervention, 66 minutes versus 83 minutes (P=0.032). This institution-specific PONV reduction strategy had a modest but significant effect on improving prophylaxis administration. However, our findings indicate that further efforts would be required to ensure fuller compliance with the current extensive evidence base for PONV management in higher-risk patients.
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Young, Garrett, Stephen Matthew Schleicher, Edward Arrowsmith, et al. "Use of antiemetic prophylaxis and oral breakthrough medication for highly emetogenic chemotherapy (HEC) in a large community oncology network." Journal of Clinical Oncology 38, no. 29_suppl (2020): 253. http://dx.doi.org/10.1200/jco.2020.38.29_suppl.253.
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253 Background: Prophylaxis for highly emetogenic chemotherapy (HEC) is well established in clinical guidelines, but real-world treatment patterns are unclear. Today, consistent use of prophylaxis is more easily accomplished due to the incorporation of ordering premeds into the workflow prior to administration of intravenous chemotherapy. However, prescription of oral agents for treatment of breakthrough chemotherapy induced nausea and vomiting (CINV) is less consistent and standardized and has a scant evidence base. In an effort to standardize utilization, we evaluated the use of prophylaxis and oral breakthrough medications in a large national community oncology network. Methods: Data from electronic medical records at five practices comprising over 100 clinic sites was analyzed to examine the frequency of guideline-recommended triplet 5-HT3 receptor antagonist, NK-1 receptor antagonist, and corticosteroid use for prophylaxis prior to the administration of HEC agents. Oral breakthrough medication use and preference was also analyzed. Data was collected and analyzed at the practice level. Results: We identified 2645 patients that received HEC between 1/1/2019 and 5/8/2020. We found consistently high utilization of guideline-concordant triplet prophylaxis regimens for patients receiving HEC, ranging from 90-100% at each of the five practices. In addition, most patients (mean 83%, range 67% - 94%) received a prescription for at least one oral breakthrough medication, but the agent(s) utilized varied widely across practices (Table). Ondansetron was the most commonly prescribed oral breakthrough medication (mean 68%, range 53% - 88%), while olanzapine use for either prophylaxis or breakthrough CINV across practices ranged from 1% - 4%. Conclusions: In this national community oncology network, standard recommended triplet agent prophylaxis for HEC was delivered successfully. However, opportunity exists to increase appropriate use of olanzapine and reduce variation of oral breakthrough antiemetic medications in order to optimize clinical care. [Table: see text]
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Wertli, Maria M. "Opioid Prescription in Switzerland: Appropriate Comedication use in Cancer and Noncancer Pain." November 2019 6, no. 22;6 (2019): 537–48. http://dx.doi.org/10.36076/ppj/2019.22.537.
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Background: In Europe, limited information on the use of opioids is available. Objectives: To assess how guideline recommendations to manage opioid-related adverse events were followed in cancer- and noncancer-related opioid use. Study Design: Analysis of health insurance data of one of the major health insurers in Switzerland. Setting: All opioid claims between 2006 and 2014. Methods: Opioid episodes were cancer-related when cancer treatments were used within ± 3 months of the first opioid claim. Recurrent strong episodes were defined as ≥ 2 opioid claims with at least one strong opioid claim. Episode duration were acute (< 90 days), subacute, or chronic (≥ 120 days/≥ 90 days + ≥ 10 claims). Results: Out of 591,633 opioid episodes 76,968 (13%) were recurrent episodes: 94% were noncancer related (83% in recurrent episodes) and 6% cancer related (17% recurrent). Chronic opioid use was observed in 55% (noncancer) and 58% (cancer) recurrent episodes. Recommended laxatives were used in 50% noncancer and in 67% cancer episodes. Antiemetic drugs were used in 54% noncancer and in 83% cancer episodes. Not recommended coprescription of benzodiazepines was observed in 34% recurrent noncancer and 46% cancer episodes. Limitations: No clinical information was available to assess the indication for opioid use. Conclusions: In this study, opioids were primarily used outside the context of cancer-related treatment. In noncancer-related opioid use, we found a substantial higher proportion without recommended laxative and antiemetic medications. Coprescription of benzodiazepines may increase the risk for opioid overdose and was present in one-third of the noncancer episodes and in almost every second cancer episode. Key words: Pain medications, opioids, nonopioids, benzodiazepines, health insurance claims data, cancer pain, noncancer pain, chronic opioid use, adverse events prevention, guideline recommendations
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Gilmore, James W., Nancy Walker Peacock, Anna Gu, et al. "Antiemetic guideline consistency and incidence of chemotherapy-induced nausea and vomiting (CINV) in U.S. community oncology practice: INSPIRE study." Journal of Clinical Oncology 30, no. 34_suppl (2012): 167. http://dx.doi.org/10.1200/jco.2012.30.34_suppl.167.
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167 Background: Electronic Health Records (EHRs) are a valuable source to evaluate the quality of oncology care, particularly when combined with patient outcomes data. Our objective was to evaluate the impact of guideline consistent/inconsistent chemotherapy prophylaxis (GCCP, GICP) on the incidence of no CINV after cycle 1 of highly or moderately emetogenic chemotherapy (HEC or MEC). Methods: INSPIRE (Impact of NCCN Antiemesis Guideline Usage on Patient Reported Emesis) was a prospective observational, multicenter study that enrolled chemotherapy-naive adults initiating single-day HEC or MEC. Results from the MASCC Antiemesis Tool, administered 5 to 8 days after HEC/MEC, were merged with EHR data. The primary endpoint, no CINV (no emesis and no clinically significant nausea), was compared between groups using logistic regression. Results: 1,295 patients (mean age=59.3, 30.0% male, 35.5% HEC) were enrolled from Georgia Cancer Specialists (53.0%), Tennessee Oncology (38.1%), Florida Cancer Specialists (5.7%), and Cancer Specialists of N. Florida (3.2%). The prevalence of GCCP was 57.3% (28.7% HEC; 73.1% MEC). If corticosteroids were prescribed to all HEC patients on days 2-4, GCCP for HEC would increase from 28.7% to 89.8%. If NK1-receptor antagonists (NK1-RA) were prescribed to all MEC patients, GCCP for MEC would increase from 73.1% to 97.8%. GCCP and GICP-treated patients differed by age, (p=0.010), HEC/MEC (p<0.0001), primary cancer site (p<0.0001), practice site (p<0.0001). The percent with no CINV, no emesis, and no clinically significant nausea was significantly higher for GCCP patients. Conclusions: Increased GCCP could significantly reduce CINV after HEC or MEC. The main reasons for guideline inconsisteny were lack of corticosteroids in the delayed phase for HEC and lack of NK1-RA for MEC. There remains room for improvement in nausea control. [Table: see text]
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Bubalo, Joseph S., Ian D. Schnadig, Gabrielle Meyers, et al. "A phase II pilot study of fosaprepitant (F) for the rescue of acute nausea and vomiting with moderately (MEC) or highly emetogenic chemotherapy (HEC) in adults." Journal of Clinical Oncology 31, no. 15_suppl (2013): e20627-e20627. http://dx.doi.org/10.1200/jco.2013.31.15_suppl.e20627.
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e20627^ Background: Patients receiving MEC or HEC continue to have breakthrough nausea and emesis despite antiemetic prophylaxis. Few trials have evaluated the efficacy of rescue antiemetics after failed prophylaxis. F, a prodrug of the neurokinin-1 antagonist (NK1a), aprepitant is FDA-approved for the prevention of acute and delayed nausea and vomiting associated with MEC and HEC. F’s safety and efficacy in the prophylactic setting make F an attractive potential rescue therapy. Methods: F 150mg was infused as the initial rescue agent in eligible patients receiving MEC or HEC who had either emesis or nausea despite guideline-based prophylaxis with a 5HT-3 antagonist and dexamethasone. The primary endpoint was improved nausea on a visual analogue scale (VAS) at 2 hours. Secondary endpoints included: VAS at 12 and 24 hrs, rescue medication use, emesis, nutritional intake, adverse events, and proof of the study design as a viable methodology. Results: Eleven adult patients, 6 males and 5 females, were treated per protocol and evaluable for the 24 hour study period. Chemotherapy regimens included HiDAC, R-CHOP, epirubicin/ifosfamide, EPOCH, R-ICE, 7+3, VAC, and HyperCVAD. 3 patients were treated for emesis and 8 for nausea. 91% of patients had improved nausea at 2 hrs, 100% at 12 hrs and 63.6% at 24 hrs. F prevented further emesis in 2 of 3 patients and no patient with initial nausea had subsequent emesis. 9 of 11 (81.8%) patients required additional rescue medication during the study period, mainly due to nausea. Appetite was improved in 8/11 patients. Food and fluid intake improved in 5/11. Adverse effects included headache 18%, dizziness 18%, hiccups 9%, indigestion 9%, and 1 case ifosfamide encephalopathy. The study design required greater than anticipated consented patients due to the success rates of standard antiemetic therapy. Conclusions: F improves breakthrough nausea and related symptoms, and may prevent further emesis but was suboptimal as a single agent in that the majority of patients required a second rescue agent within 24 hrs. Complete response, defined as no emesis and no rescue therapy, may be a more clinically relevant primary endpoint in future trial designs. Clinical trial information: NCT00939302.
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Roeland, Eric J., Thomas W. LeBlanc, Kathryn J. Ruddy, et al. "BPI19-019: Avoidable Acute Care Use Associated With Nausea and Vomiting Among Patients Receiving Highly Emetogenic Chemotherapy or Oxaliplatin." Journal of the National Comprehensive Cancer Network 17, no. 3.5 (2019): BPI19–019. http://dx.doi.org/10.6004/jnccn.2018.7192.
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Background: Avoiding acute care services can improve cancer care and reduce cost. The US Centers for Medicare and Medicaid Services’ (CMS) new oncology outcome measure (OP-35) defines 30-day post-chemotherapy inpatient (IP) and/or emergency department (ED) events (IP/ED) as “potentially avoidable” if involving any of 10 toxicities, including nausea or vomiting (NV). Evidence demonstrates meaningful gaps in oncologists’ adherence to antiemetic prophylaxis guidelines for highly emetogenic chemotherapy (HEC), and that NV-related IP use costs >$10,000; yet the incidence of avoidable acute care events involving NV is not well studied. Methods: We assessed chemotherapy courses using IBM Explorys electronic health records (4Q 2012–1Q 2018). We identified rates of IP/ED ≤30 days post-chemotherapy, and OP-35 toxicities (NV, anemia, dehydration, diarrhea, fever, neutropenia, pain, pneumonia, or sepsis) by ICD-9, ICD-10, procedure codes, and CMS criteria. We evaluated cisplatin, anthracycline + cyclophosphamide (AC), carboplatin (>14 days apart, as a proxy for AUC ≥4), oxaliplatin (OX), and other non-HEC chemotherapy. We assessed guideline adherence, defined as triple prophylaxis (NK1 RA + 5HT3 RA +dexamethasone) rates at HEC initiation. Results: In 17,609 HEC and 56,624 non-HEC courses, we observed 30-day IP/ED utilization in 29% and 19% of courses, respectively (Table 1). For HEC, 76% of IP/ED use involved ≥1 of the 10 CMS toxicities, most often anemia (42%), pain (41%), dehydration (24%), and NV (24%). Rates of all-cause IP/ED, IP/ED with OP-35 toxicity, and NV-related IP/ED were consistent for HEC and OX. Gaps in triple prophylaxis were common in HEC. Conclusion: Roughly one-third of patients receiving HEC or OX experienced IP/ED events ≤30 days after chemotherapy. Three-quarters of IP/ED events involved ≥1 of 10 OP-35 toxicities linked by CMS to potentially avoidable acute care; of these, one-third involved NV. NV-associated acute care use is considerable, costly, and potentially avoidable with better adherence to antiemesis guidelines.
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Feyer, Petra, Franziska Jahn, and Karin Jordan. "Prophylactic Management of Radiation-Induced Nausea and Vomiting." BioMed Research International 2015 (2015): 1–8. http://dx.doi.org/10.1155/2015/893013.
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The incidence of nausea and vomiting after radiotherapy is often underestimated by physicians, though some 50–80% of patients may experience these symptoms. The occurrence of radiotherapy-induced nausea and vomiting (RINV) will depend on radiotherapy-related factors, such as the site of irradiation, the dosing, fractionation, irradiated volume, and radiotherapy techniques. Patients should receive antiemetic prophylaxis as suggested by the international antiemetic guidelines based upon a risk assessment, taking especially into account the affected anatomic region and the planned radiotherapy regimen. In this field the international guidelines from the Multinational Association of Supportive Care in Cancer (MASCC)/European Society of Medical Oncology (ESMO) and the American Society of Clinical Oncology (ASCO) guidelines as well as the National Comprehensive Cancer Network (NCCN) are widely endorsed. The emetogenicity of radiotherapy regimens and recommendations for the appropriate use of antiemetics including 5-hydroxytryptamine (5-HT3) receptor antagonists, steroids, and other antiemetics will be reviewed in regard to the applied radiotherapy or radiochemotherapy regimen.
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Alamri, Abdulrahman, Yousef A. Alawlah, Yanru Qiao, and Junling Wang. "A retrospective review of treatment patterns of antiemetic agents for chemotherapy-induced nausea and vomiting." SAGE Open Medicine 6 (January 1, 2018): 205031211876723. http://dx.doi.org/10.1177/2050312118767234.
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Objectives: To evaluate the treatment pattern of antiemetic agents used for chemotherapy-induced nausea and vomiting in a tertiary hospital in Saudi Arabia. Methods: Over a period of 7 weeks, all new chemotherapy order sheets were collected and evaluated for chemotherapy-induced nausea and vomiting management. We compared each antiemetic regimen used for chemotherapy-induced nausea and vomiting prophylaxis with three international antiemetic guidelines by the following organizations: the Multinational Association of Supportive Care in Cancer, the American Society of Clinical Oncology, and the National Comprehensive Cancer Network for the clinician. Results: A total of 152 cancer patients were included in the study, for whom 289 chemotherapy physician orders included antiemetic regimens. Approximately 17.3% of the chemotherapy protocols had total minimal emetogenicity risk, 22.5% had low risk, 37.02% had moderate risk, and 23.18% had high risk. For acute emesis, 27.57% of the antiemetic regimens followed at least one of the three reference guidelines. For delayed emesis, only 20.16% of the antiemetic regimens adhered to at least one of the three reference guidelines. Conclusion: Adherence to treatment recommendations and antiemetics prescribing for chemotherapy-induced nausea and vomiting was suboptimal at this hospital. However, institutional antiemetic guidelines and oncology pharmacists could play an important role in better assessment and management of chemotherapy-induced nausea and vomiting.
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Miyamoto, Yuji, Hideo Baba, Yasushi Tsuji, et al. "Prospective observational study on chemotherapy-induced nausea and vomiting (CINV) for colorectal cancer patients by the CINV study group of Japan." Journal of Clinical Oncology 32, no. 3_suppl (2014): 652. http://dx.doi.org/10.1200/jco.2014.32.3_suppl.652.
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652 Background: The aim of this study is to investigate the incidence of Chemotherapy Induced Nausea and Vomiting (CINV) among moderately emetogenic chemotherapy-naive patients with colorectal cancer. We also assessed whether the medical staff accurately recognized the incidence of CINV in their own practices. Methods: A prospective observational study of patients receiving the first cycle of oxaliplatin or irinotecan-based chemotherapy was performed. A 7-day diary for CINV was provided to the patients prior to chemotherapy to record daily incidence of CINV. Observed incidence rates of acute (day1) and delayed (days 2-7) CINV were compared with medical staff's predictions. Results: A total of 191 patients (110 males and 81 females) were registered during the period from April 2011 to December 2012. All patients were treated with oxaliplatin-based (n = 175) or irinotecan-based chemotherapy (n = 16). Acute vomiting was observed in 4 patients (2.1%), while delayed vomiting was observed in 19 patients (10.0%). Acute nausea occurred in 14 patients (7.3%), while 63 patients (33%) were affected by delayed nausea. Irinotecan significantly induced acute nausea more frequently than oxaliplatin did (p = 0.019). The presence of motion sickness was significantly associated with the incidence of acute nausea (p < 0.001) and vomiting (p = 0.003). Antiemetics were given along the guideline to all patients. 58 patients were administered a neurokinin-1 (NK1) receptor antagonist. Patients with NK-1 receptor antagonist showed significantly less incidence of delayed vomiting than patients without one (3% vs 13%, p = 0.048). 30 patients (15.7%) required rescue antiemetics. The staff had estimated the incidence of acute CINV in 91 patients (47.6%). However, only 14 patients (7.3%) really experienced acute CINV. Conclusions: CINV seems to be controllable with appropriate management, but delayed CINV still remains an important problem to be targeted. The presence of motion sickness should be affected by efficient antiemetic management. The extent of CINV in this patient group seems to be overestimated.
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Nolte, M. J., R. Berkery, B. Pizzo, et al. "Assuring the optimal use of serotonin antagonist antiemetics: the process for development and implementation of institutional antiemetic guidelines at Memorial Sloan-Kettering Cancer Center." Journal of Clinical Oncology 16, no. 2 (1998): 771–78. http://dx.doi.org/10.1200/jco.1998.16.2.771.
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PURPOSE The need to foster the appropriate and cost-effective use of serotonin-antagonist antiemetic drugs spurred the creation of guidelines. The process by which institution-wide guidelines at Sloan-Kettering were developed, implemented, assessed, and modified is described. METHODS A multidisciplinary group working with disease-specific management teams assigned the emetic potential of chemotherapy programs to one of five categories. Antiemetic regimens, including a specified dose and schedule of a serotonin-antagonist and dexamethasone, were assigned to each emetic category. The information was collated by disease site and chemotherapy program into hospital-wide antiemetic regimen recommendations. Quality assessment was conducted initially and repeated each time the guidelines were modified. RESULTS Patient surveys demonstrated a high level of satisfaction with emetic control, which was similar to reported results. Data from the latest survey showed zero emetic episodes in 93% and 87% of participants given moderate and highly emetogenic chemotherapy, respectively. Compliance with the guidelines, initially in 73%, has been improved using a standardized chemotherapy order "check box" labeled, "Antiemetics as per Guidelines." Antiemetic drug expenditures decreased from a projected $2.8 million to $1.3 million annually. CONCLUSION The guidelines became an educational tool that ensured the delivery of optimal antiemetic therapy chosen by professionals with the greatest knowledge of both the particular chemotherapy regimen and cancer site. Implementation of the guidelines resulted in substantial savings while treating more patients. The guidelines were easily modified as new chemotherapeutic agents and antiemetic drugs became available.
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Kapoor, Akhil, Ashutosh Jain, Abhishek Sharma, et al. "Chemotherapy-Induced Nausea and Vomiting in Gastrointestinal Cancer Patients: Do We Need to Revisit Guidelines?" South Asian Journal of Cancer 09, no. 04 (2020): 245–49. http://dx.doi.org/10.1055/s-0041-1729493.
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Abstract Purpose The objective of this study was to assess the proportion of patients developing chemotherapy-induced nausea and vomiting (CINV) after receiving chemotherapy for gastrointestinal (GI) cancers, despite receiving antiemetic prophylaxis (AEP) as per the standard guidelines. Patients and Methods Between April 2019 and March 2020, all patients planned for chemotherapy were eligible for enrolment in the study. The primary endpoint of the study was the assessment of complete response (CR) rates. Results Overall, 1,276 consecutive patients were screened for this study, while 738 patients fulfilling the eligibility criteria were included. A total of 23.2% of the whole cohort failed to achieve CR. Also, 28.2, 16.9, and 16.6% of patients receiving moderately emetogenic chemotherapy (MEC), low emetogenic chemotherapy (LEC), and high emetogenic chemotherapy (HEC), respectively, failed to achieve CR. The differences in failure to achieve CR was statistically significant between MEC and HEC (p < 0.001) groups. Among MEC group, there was no difference between those who received oxaliplatin (27.8%) versus nonoxaliplatin regimens (25.8%) in terms of failure rates (p = 0.613). Conclusion Approximately one-fourth of patients failed to achieve a complete response from CINV in GI cancers despite using guideline-based AEP. Patients receiving MEC had the highest failure rates suggesting a need to improve AEP in these patients.
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Aapro, M., A. Molassiotis, M. Dicato, et al. "The effect of guideline-consistent antiemetic therapy on chemotherapy-induced nausea and vomiting (CINV): the Pan European Emesis Registry (PEER)." Annals of Oncology 23, no. 8 (2012): 1986–92. http://dx.doi.org/10.1093/annonc/mds021.
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Bun, S., S. Kunisawa, N. Sasaki, et al. "The concordance with antiemetic guideline for pediatric, adolescent and young adult patients with cancer using a large-scale administrative database." Annals of Oncology 29 (October 2018): viii639. http://dx.doi.org/10.1093/annonc/mdy300.116.
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Kim, Hoon-Kyo, Alexandre Chan, Ruey Kuen Hsieh, et al. "The burden of chemotherapy-induced nausea and vomiting in the Asia Pacific (AP) region: The Pan Australasian chemotherapy-induced emesis study." Journal of Clinical Oncology 31, no. 15_suppl (2013): e20580-e20580. http://dx.doi.org/10.1200/jco.2013.31.15_suppl.e20580.
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e20580 Background: There are limited data on CINV in AP, a region diverse in healthcare systems and standards of care. The primary objective was to estimate the country-specific percentage of patients with complete response (CR: no emesis and no use of rescue medication) in the overall phase (0-120 hours) during cycle 1 by regimen emetogenicity. Methods: This was a prospective, observational study of highly and moderately emetogenic chemotherapy (HEC/MEC)-naive adults from 6 AP countries. Patients completed a diary over a 120 hour period following chemotherapy. The study was designed to enroll a minimum of 45 patients by HEC/MEC and country to describe CR with a 95% CI +/-15%. Results: There were 648 evaluable patients enrolled at 31 sites from Aug. 2011 - Jul. 2012. The mean age was 55.8. 57.7% were female. The most common regimens were cisplatin-based (168/318; 52.8%) for HEC, and oxaliplatin-based (156/330; 47.3%) for MEC. Site of chemotherapy administration was outpatient/day case (51.4%; 333/648) and inpatient (48.6%; 315/648). Outpatient/day case chemotherapy administration was used for all patients in Australia and Singapore. Inpatient administration was common in China (85%, 130/153) and S. Korea (64.2%, 97/151). ASCO QOPI-recommended antiemetic prophylaxis was used in 38.7% (123/318) of HEC (5HT3-RA/steroid/NK1-RA) and 83.9% (277/330) of MEC (5HT3-RA/steroid). Prophylaxis differed between countries (p<0.001). CR is shown below. Conclusions: CINV outcomes, use of guideline-recommended prophylaxis, and site of chemotherapy administration significantly varied across AP countries. There is considerable room to improve CINV outcomes and use of recommended antiemetic prophylaxis in the region. [Table: see text]
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Hori, Katsuhito, Norihiro Kobayashi, Hitoshi Atsumi, et al. "Changes in compliance with Japanese antiemetic guideline for chemotherapy-induced nausea and vomiting: a nationwide survey using a distributed research network." Supportive Care in Cancer 22, no. 4 (2013): 969–77. http://dx.doi.org/10.1007/s00520-013-2048-4.
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