Preventing and Managing Chemotherapy-induced

Nausea and Vomiting: Adhering to Clinical

Guidelines

27

Pleasebeadvisedthatthisactivityisbeingaudioand/orvideorecordedforarchivalpurposesand,in
somecases,forrepurposingofthecontentforenduringmaterials.

28

Preventing and Managing Chemotherapy-induced Nausea and Vomiting:

Adhering to Clinical Guidelines

Agenda
6:15 a.m. 6:45 a.m.

Registration and Breakfast

6:45 a.m. 6:50 a.m.

Welcome Introductory Remarks

Edward Li, Pharm.D., BCOP

6:50 a.m. 7:40 a.m.

Preventing and Managing Chemotherapy-induced Nausea

and Vomiting: Adhering to Clinical Guidelines

7:40 a.m. 7:45 a.m.

Questions & Answers

Faculty
Edward Li, Pharm.D., BCOP
Associate Professor, Pharmacy Practice
University of New England College of Pharmacy
Portland, Maine

29

Preventing and Managing Chemotherapy-induced Nausea and Vomiting:

Adhering to Clinical Guidelines

Disclosure Statement
In accordance with the Accreditation Council for Continuing Medical Educations Standards for
Commercial Support and the Accreditation Council for Pharmacy Educations Guidelines for
Standards for Commercial Support, ASHP Advantage requires that all individuals involved in the
development of activity content disclose their relevant financial relationships. A commercial
interest is any entity producing, marketing, re-selling, or distributing health care goods or
services consumed by, or used on, patients. A person has a relevant financial relationship if the
individual or his or her spouse/partner has a financial relationship (e.g., employee, consultant,
research grant recipient, speakers bureau, or stockholder) in any amount occurring in the last
12 months with a commercial interest whose products or services may be discussed in the
educational activity content over which the individual has control. The existence of these
relationships is provided for the information of participants and should not be assumed to have
an adverse impact on presentations.
All faculty and planners for ASHP Advantage education activities are qualified and selected by
ASHP Advantage and required to disclose any relevant financial relationships with commercial
interests. ASHP Advantage identifies and resolves conflicts of interest prior to an individuals
participation in development of content for an educational activity.
The following faculty and planners report no relationships pertinent to this activity:

Edward Li, Pharm.D., BCOP

Erika Thomas, M.B.A., B.S.Pharm.
Kristi N. Hofer, Pharm.D.
Susan R. Dombrowski, M.S., B.S.Pharm.

ASHP staff has no relevant financial relationships to disclose.

30

Preventing and Managing Chemotherapy-induced Nausea and Vomiting:

Adhering to Clinical Guidelines

Activity Overview
Chemotherapy-induced nausea and vomiting (CINV) remains a serious complication of cancer
treatment and is among the adverse events most feared by patients. This educational activity
will review patients risk factors for developing CINV, taking into account personal risk factors
and category of emetic potential of the prescribed chemotherapeutic agents. Patient cases will
be used to illustrate a guidelines-based approach to preventing and managing CINV.

Learning Objectives
At the conclusion of this application-based educational activity, participants should be able to

Describe a patients risk for developing CINV, taking into consideration personal risk
factors and category of chemotherapy emetogenicity.

Discuss key updates to national and international guidelines on the prevention and
management of CINV.

Recommend treatment options for a patient at risk for developing acute and delayed
CINV.

Design a plan to improve the adherence to CINV guidelines in clinical practice.

31

Preve
enting and
d Managin
ng Chemo
otherapy-induced N
Nausea an
nd Vomitin
ng:
Adh
hering to Clinical G
Guideliness

Continu
C
uing Ed
ducation
n Accre
editatio
on
The Am
merican Society of Health
h-System Ph
harmacists is accredited
d by the
Accrediitation Council for Pharm
macy Educattion as a pro
ovider of con
ntinuing
pharma
acy education. This activ
vity provides 1 hour (0.1 CEU) of con
ntinuing
pharma
acy education credit (AC
CPE activity # 0204-0000
0-13-475-L01-P).
Attendee
es may print their official statements of continuin
ng pharmacyy education ccredit online
e
after com
mpletion of th
he online eva
aluation. All statements are availablle online at tthe ASHP
eLearning portal (http
p://elearning
g.ashp.org). For complette activity infformation, visit
www.cem
mornings.com
m
Complete
e instructions for receiving your statement of co
ontinuing pha
armacy educcation credit
online arre available on
o the next page.
p
Be sure to record the attendance code be
eginning with
h M
announced during the activity.

Your educatiional opp

portunitie
es
symposiu
um
extend beyond todays s

Available
A
in 2014
o

onducted on
n March 6, 20
014, where Edward Li, P
Pharm.D.,
A live webinar to be co
BCOP, will explore issu
ues raised by
y participantt questions in todays syymposium (1
hour of CPE
E).

Web-based
d activity ba
ased on toda
ays live sym
mposium (1 h
hour of CPE, but please note
that individu
uals who cla
aim CPE credit for the livve symposium are ineligible to claim
m
credit for the web-based activity).

For more information and to

o sign up tto receive
e e-mail up
pdates
abou
ut this edu
ucational sseries, vissit
www.cem
mornings
s.com

32

Preventing and Managing Chemotherapy-induced Nausea and Vomiting:

Adhering to Clinical Guidelines

Edward Li, Pharm.D., BCOP
Associate Professor, Pharmacy Practice
University of New England College of Pharmacy
Portland, Maine

Edward Li, Pharm.D., BCOP, is Associate Professor in the Department of Pharmacy Practice at
the University of New England (UNE) College of Pharmacy in Portland, Maine. Dr. Li maintains
a clinical practice in ambulatory oncology at the Maine Center for Cancer Medicine in
Scarborough. Dr. Li earned his Doctor of Pharmacy degree from the Philadelphia College of
Pharmacy. He completed a pharmacy practice residency at the University of Wisconsin Hospital
and Clinics in Madison and an oncology pharmacy practice residency at the University of
Maryland School of Pharmacy in Baltimore. Dr. Li is a board-certified oncology pharmacist.
Before joining UNE, Dr. Li was a member of the faculty at Wilkes University, Nesbitt College of
Pharmacy and Nursing in Wilkes-Barre, Pennsylvania, and most recently was Oncology
Pharmacy Manager at The National Comprehensive Cancer Network.
Dr. Li's research interests include the analysis of practice trends and outcomes research using
large claims databases, such as SEER-Medicare data and the Maine All-Payer Claims
Database.

33

CE IN THE MORNINGS
PreventingandManaging
ChemotherapyinducedNauseaand
Vomiting(CINV):AdheringtoClinical
Guidelines
EdwardLi,Pharm.D.,BCOP
AssociateProfessor
UniversityofNewEnglandCollegeofPharmacy
Portland,Maine

LearningObjectives
Describe a patients risk for developing CINV taking into
consideration personal risk factors and category of
chemotherapy emetogenicity.
Discuss key updates to national and international
guidelines on the prevention and management of CINV.
Recommend treatment options for a patient at risk for
developing acute and delayed CINV.
Design a plan to improve the adherence to CINV
guidelines in clinical practice.

PollingQuestion
Whatdoyouthinkisthemostfearedsideeffect
ofchemotherapy?
Alopecia
Vomiting
Progressivemultifocalleukoencephalopathy

34

ScopeoftheProblem
Mostfearedsideeffectrankings:
Overall
(N =255)

Women
(n=153)

Men
(n=102)

Alopecia

Vomiting

Infection

Nausea

Weightloss

Vomitingasoneofthetop4sideeffects:
Beforechemotherapy:51%
Afterchemotherapy:24%
Passik SD, et al. J Pain Symptom Manage. 2001;21(2):113-20.

TodaysOutline

PathophysiologyandPharmacologyofCINV
Drugsanddefinitions
CINVriskfactors
GuidelinesforCINV
AdheringtoGuidelines
Conclusion

PathophysiologyReview
Fear, dread,
anticipation

HigherCenters
(5HT3,NK1,D2,
GABA)

Inner ear;
motion

Cerebellum
(H1,M)

Blood-borne
emetics

Vagal, sympathetic,
glossopharyngeal
afferents

(5HT3)

Chemoreceptor
triggerzone
(5HT3,D2,M,
CB,opioid)

Emetic
centerin
themedulla
(NK1)

Vomiting

SolitaryTract
Nucleus
(5HT3,D2,M,
H,NK1,CB)
Goodman & Gilman's The Pharmacological Basis of Therapeutics, 12th edition.

35

Maindrugsfortodaysdiscussion
Corticosteroids
Dexamethasone

Serotoninreceptorantagonists(5HT3RA)

Dolasetron
Ondansetron
Granisetron
Palonosetron

Neurokinin1(NK1)receptorantagonists
Aprepitant
Fosaprepitant

Goodman & Gilman's The Pharmacological Basis of Therapeutics, 12th edition.

OtherNeurotransmitters,
Receptors,andDrugs
Histamine(H1)

Dopamine(D2)

Diphenhydramine(++++)
Promethazine(++++)
Prochlorperazine(++)

Muscarinicacetylcholine
receptors(M)
Scopolamine(++++)
Diphenhydramine(++)
Promethazine(++)

Haloperidol(++++)
Metoclopramide(+++)
Olanzapine(++++)
Prochlorperazine(++++)
Promethazine(++)

Cannabinoid(CB)
Dronabinol
Nabilone

GABA
Lorazepam

Goodman & Gilman's The Pharmacological Basis of Therapeutics, 12th edition.

Definitions
Acute nauseaoremesisthatoccursinthe
first24hoursafterchemotherapy
Delayed nauseaoremesisthatoccursafter
thefirst24hoursafterchemotherapy
Maylastupto23daysafterchemotherapy
administration
Commonlyseenwithcisplatin,carboplatin,
cyclophosphamide,ifosfamide,doxorubicin

36

Definitions
Anticipatory nauseaoremesisthatisa
learnedreflexresponseand
Triggeredbysights,sounds,orsmells
Duetopoorcontrolofnauseaoremesisin
previouschemotherapycycles

Breakthrough nauseaoremesisthatoccurs
despiteproperprophylaxis
MeasuredbyuseofPRNmedications

CINVRiskFactors:PatientSpecific

Anxiety,expectationofnausea
Women>men
Youngerage(i.e.,<50y/o)
Historyofmotionsickness
Pregnancyinducednausea/vomiting
Historyofalcoholuse
Antiemeticsinconsistentwithguidelines
Priorchemotherapyanddegreeofantiemetic
control
Molassiotis A, Aapro M, Dicato M, et al. J Pain Symptom Manage. 2013 Sep 24. Epub ahead of print.

CINVRiskFactors:RegimenSpecific
N/Visadoserelatedtoxicity
Singleagentchemotherapyriskcategories:

High(>90%incidenceinacuteanddelayed)
Moderate(3090%inacuteanddelayed)
Low(1030%inacute)
Minimal(<10%inacute)

Formultidrugregimens,thedrugthathasthe
highestlevelofemetogenicitydeterminesthe
regimensemeticrisklevel
Ettinger DS, et al. J Natl Compr Canc Netw. 2009;7(5):572-95.

37

EmeticRiskCategories
Originalpaper:HeskethPJ,KrisMG,GrunbergSM,et
al.JClinOncol.1997;15(1):1039.
Proposedfivecategoriesofemeticrisk
Algorithmformultidrugchemotherapy

Updatedpaper:GrunbergSM,OsobaD,HeskethPJ,
etal.SupportCareCancer.2005;13(2):804.
Consolidatedriskcategories

Nolongercalculateemetogenicityofmultidrug
regimens

NCCNGuidelineslistthese:
http://www.nccn.org/professionals/physician_gls/f_guideli
nes.asp#site

EmeticRiskCategories
High
Cyclophosphamide/doxorubicincombination
Cisplatin
Higherdosesofspecificchemotherapyagents

Moderate
Carboplatin,oxaliplatin
Anthracyclines(relativelylowerdoses)
Nitrogenmustards

Low
Antimicrotubules(e.g.,taxanes)andantimetabolites

Minimal
Monoclonalantibodies,vincaalkaloids
Grunberg SM, et al. Support Care Cancer. 2011;19 (Suppl 1):S43-7.

EmeticRiskCategories Oral
Moderatetohigh
Cytotoxicchemotherapy
Crizotinib

Minimaltolow
Capecitabine
nibs

Grunberg SM, et al. Support Care Cancer. 2011;19 (Suppl 1):S43-7.

38

OverallEmeticRisk
RegimenRisk
Factors

PatientRisk
Factors

OverallEmetic
Risk

Overallemeticriskwillneverbebelowtheregimens
risklevel
Thepresenceofpatientriskfactorsmay(ormaynot)
increasetheoverallemeticrisk

ProphylaxisforCINV:General
Principles
Anticipatory
Lorazepamiffearfulorpoorcontrolafterpreviouscycle

Acute
TypicallyadministeredIVintheinfusioncenter

Delayed
SomeIVdrugswillcoverdelayed
Mayreceiveprescriptiontotakeasscheduled

Breakthrough
ShouldalwaysreceiveaprescriptionthatisPRN
UseadifferentMOAthanforprophylaxis

CINVGuidelines
ASCO1

ESMO/MASCC2

NCCN3

Multinational(10
countries,5
continents)

Representatives
fromNCCN member
institutions

Multidisciplinary? Some

High

Some

Methodology

Systematicreview

Systematicreview

Consensusbased

Lastupdated

June2011

Jan2013

Aug2013

Comments

Addressespediatrics Multiorganization
andradiation
collaboration

Expertpanel

SelectASCO
members

Tiedto
reimbursementvia
compendium

1. Basch E, et al. J Clin Oncol. 2011; 29(31):4189-98.

2. Roila F, et al. Ann Oncol. 2010; 21 (Suppl 5):v232-43.
3. NCCN Clinical Practice Guidelines: Antiemesis. http://www.nccn.org/professionals/physician_gls/pdf/antiemesis.pdf

39

SingledayChemotherapy:
ProphylaxisPrinciples
Emetic risk
(emesisincidence)

Day1

Day2

Day3

Day4

High
(>90%)
Moderate
(3090%)
Low
(1030%)
Minimal
(<10%)

GuidelineRecommendations:
HighEmetogenicity,Acute
Day 1 of single-day regimens
ASCO1

ESMO/MASCC2

NCCN3

NK1 RA

Yes

Yes

Yes

Dexamethasone

Yes

Yes

Yes

5HT3 RA

Yes

Yes

Yes palonosetron
preferred

Drug

Alternateregimen
Otherssupportive
care

Olanzapine instead
ofNK1RA
Lorazepam
Diphenhydramine

Consider:
Lorazepam
H2blocker,PPI

GuidelineRecommendations:
HighEmetogenicity,Delayed
Days 2 through 4 of single-day regimens
Drug
NK1 RA
Dexamethasone
5HT3 RA

ASCO1

ESMO/MASCC2

NCCN3

Days23

Days 23

Days23

Days23or
Days24

Days 24

Days24

No

No

No
(palonosetron
preferred)

Alternateregimen
Other supportive
care

Olanzapineinstead
ofNK1 RA
Lorazepam
Diphenhydramine

Consider:
Lorazepam
H2blocker,PPI

40

GuidelineRecommendations:
ModerateEmetogenicity,Acute
Day 1 of single-day regimens
ASCO1

ESMO/MASCC2

NCCN3

Mayadd

No

May add

8mg

8mg

12mg

Yes palonosetron

Yes palonosetron

Yes
(palonosetron
preferred)

Drug
NK1 RA
Dexamethasone
5HT3 RA

Alternateregimen
Other supportive
care

Olanzapine +5HT3
RA+Dex
Lorazepam
Diphenhydramine

Consider:
Lorazepam
H2blocker,PPI

GuidelineRecommendations:
ModerateEmetogenicity,Delayed
Days 2 through 3 of single-day regimens
ASCO1

ESMO/MASCC2

NK1 RA

Mayadd

No

Dexamethasone

Days23

Drug

5HT3 RA
No(palonosetron
preferred)
Alternateregimen
Other supportive
care

NCCN3

Considerone:
Nothing if
Days 23
palonosetron
usedinacute
No(palonosetron
NK1RA+/ dex
preferred)
ifusedinacute
Olanzapine

Lorazepam
Diphenhydramine

Consider:
Lorazepam
H2blocker,PPI

Summary:OneScenario
High Emetogenicity Chemotherapy (HEC)
NK1 RA

Day1

Day 2

Fosaprep 150mgIV

Nofurtherdosing needed

Day3

Day4

Dex

12mgIV

8mgPO

8mgPO

8mgPO

5HT3RA

Yes

No

No

No

Moderate Emetogenicity Chemotherapy (HEC)

Day1

Day 2

Day3

NK1 RA

No

No

No

Dex

8mgIV/PO

8mgPO

8mgPO

5HT3RA

Palonosetron 0.25
mgIV

Day4

PRN for breakthrough required through all days

Consider lorazepam and acid suppression

41

CINV:LowandMinimal
Low
Administerone
dosebeforechemo:

ASCO1

ESMO/MASCC2

NCCN3

Dexamethasone
8mg

Dexamethasone
OR
5HT3 RA
OR
DopamineRA
(metoclopramide)

Dexamethasone
OR
5HT3 RA
OR
DopamineRA
(metoclopramide,
prochlorperazine)

Minimal
Noroutineprophylaxis

SomethingforPRN(Breakthrough)
Attackadifferentreceptor

Prochlorperazine10mgIV/POQ6hrPRN
Metoclopramide1040mgIV/POQ46hrPRN
Promethazine12.525mgIV/POQ4hrPRN
5HT3dosingvaries(justmakesureitsnotabovethemax
recommendeddoseperday)
Haloperidol0.52mgPOQ46hrPRN
Dronabinol510mgPOQ36hrPRN
Nabilone12mgPOBIDPRN
Dexamethasone12mgPO/IVdailyifnotalreadygiven
Olanzapine10mgPOdailyfor3days
Droperidol2.55mgIVQ46hrPRN

Big3DosingPearls
NK1receptorantagonists
PO:Aprepitant125mg1hourbeforechemotherapyonday1,then80
mgondays2and3
IV/PO:Fosaprepitant115mgIV30minutesbeforechemotherapyon
day1,thenaprepitant80mgPOondays2and3
IV:Fosaprepitant150mgIV30minutesbeforechemotherapyonday1
(thisislikegiving3daysofaprepitant)

5HT3receptorantagonists
Palonosetronhasalonghalflife(3040hours);likegivingmultiday
dosesofshorthalflife5HT3RAs
Dosesofother5HT3RAshavebeengoingdown

Dexamethasone
Doseisgenerally816mg/day
Upwardsof20mgusedwithoutaprepitant/fosaprepitant

42

MultidayChemotherapyRegimens
E.g.,Cisplatin25mg/m2 andetoposide100mg/m2
ondays1,2,&3;every3weekcycle
Basicprinciples:
Nogoodevidence;notsystematicallyaddressedinGLs
Considertheriskofacuteemesiseverydaythat
chemotherapyisgiven
Considerdrugsthatmaycausedelayedemesisandnote
timing
PatientsmaybeatriskforbothacuteANDdelayedon
specificdaysofthecycle
1. Basch E, et al. J Clin Oncol. 2011; 29(31):4189-98.
2. Roila F, et al. Ann Oncol. 2010; 21 Suppl 5:v232-43.
3. NCCN Clinical Practice Guidelines: Antiemesis. http://www.nccn.org/professionals/physician_gls/pdf/antiemesis.pdf

MultidayChemoScenario
Cisplatin

Etoposide

Final
Antiemetic
regimen

Day1

Day2

Day3

Day4

Day5

Day6

High

High

High

Delayed

Delayed

Delayed

Dex
NK1RA
5HT3RA

Dex
NK1RA
5HT3RA

Dex
NK1RA
5HT3RA

Dex
NK1RA

Dex
NK1RA

Dex

Low

Low

Low

Dex

Dex

Dex

DexIV
AprepPO
OndanIV

DexIV
AprepPO
OndanIV

Dex IV
AprepPO
OndanIV

DexPO
AprepPO*

DexPO
AprepPO*

DexPO

*Unlabeled use based on the reference: Jordan K, et al. Eur J Cancer. 2009;45(7):1184-7.

AntiemeticDosingConcerns:
MultidayChemo
5HT3RAs:
Palonosetroneveryotherdaydosing(e.g.,days1,
3,and5)
Considerlongactingformulations

NK1RAs:
Optimaldurationnotyetdefined
Dailyfor5days?
StartingonDay3ofa5dayregimen?
1. Basch E, et al. J Clin Oncol. 2011; 29(31):4189-98.
2. Roila F, et al. Ann Oncol. 2010; 21 Suppl 5:v232-43.
3. NCCN Clinical Practice Guidelines: Antiemesis. http://www.nccn.org/professionals/physician_gls/pdf/antiemesis.pdf

43

AdherencetoGuidelines:
BendingtheCurve
EmesisSurvivalCurve HighEmetogenicity

Percentageofpatients
withoutemesis

100
Increased adherence to guidelines

80
60
40

Current situation at institution

20
0
0

24

48
72
Hoursafterchemotherapy

96

120

PollingQuestion
Atmyinstitution,ouradherencetoCINV
guidelinesis:
High
Acceptable
Low
Dontknow

WhatareCINVadherencerates?
Study1:
AdherencetoESMO/MASCCguidelines
Chartreviewof299patientsbetweenNov2008
April2009

Study2:
PopulationbasedstudyofpatientsintheTexas
CancerRegistryMedicarelinkeddatabase(2001
2007)
4,566patientswithlungcancer
Study 1: Burmeister H, et al. Support Care Cancer. 2012;20(1):141-7.
Study 2: Gomez DR, et al. Cancer. 2013; 119(7):1428-36.

44

CINVAdherenceRates:Study1
OveralladherenceratetoESMO/MASCC
recommendations:
Acute:61%(181/299)
Delayed:11%(17/148)

Highemetogenicity
Day1adherence:71%(69/97) mostlyincorrectuseof
aprepitant
Day2and3adherence:20%and35% overuseof5HT3RA
Corticosteroidusewasmostlyappropriate(didnotlower
doseforaprepitant)
Burmeister H, et al. Support Care Cancer. 2012;20(1):141-7.

CINVAdherenceRates:Study1
Moderateemetogenicity
Day1adherence:66%(66/100) incorrectuseofNK1
antagonist
Day2and3adherence:33%and52% overuseof5HT3RA

Lowemetogenicity
11%adherence(6/54) toomanydrugs

Burmeister H, et al. Support Care Cancer. 2012;20(1):141-7.

CINVAdherenceRates:Study1
Predictorsofnonadherence
Lowandmoderateemetogenicity
Betteradherence:
Higherage
Solidtumors
Inpatient

Summary
Adherencenotoptimal
5HT3antagonistsanissue!
SomeissueswithNK1antagonists
Burmeister H, et al. Support Care Cancer. 2012;20(1):141-7.

45

CINVAdherenceRates:Study2
OveralladherenceratetoNCCNrecommendations:
Cisplatinbased(High)
5HT3:78%adherence
Dexamethasone:65%adherence
Aprepitant:toolowtocount(n<11)

Carboplatinbased(Moderate)
5HT3:83%adherence
Dexamethasone:66%adherence
Aprepitant:toolowtocount(n<11)
Gomez DR, et al. Cancer. 2013; 119(7):1428-36.

CINVAdherenceRates:Study2
Adherenceto5HT3RAandDexamethasonetrended
upwardwithtime
Predictorsofadherence/nonadherence
Race
Income(higher=moreadherence)
Education(higher=moreadherence)
Comorbidity

Gomez DR, et al. Cancer. 2013; 119(7):1428-36.

DatawithAdherence
Prospective,observational,multicenterstudyin
patientswithsolidtumorsreceivingHECorMEC
Twocohorts:
Guidelineconsistent(GC),n=287
Guidelineinconsistent(GI),n=704

GChadhigherratesof:

Completeresponse:60%vs.51%;p=0.008
Noemesis:63%vs.59%(NS)
Nonausea:48%vs.41%NS)
NoCINV:43%vs.34%;p=0.016
Aapro M, et al. Ann Oncol. 2012;23(8):1986-92.

46

BarrierstoGuideline
Implementation&Adherence
Lackofknowledgeofguideline
recommendations
Differencesinguidelinerecommendations
confusion
Cost/financial
Educationofhealthcareproviders
Institutionalenforcement
Measuringqualityofcare&outcomes
Grunberg SM. J Natl Compr Canc Netw. 2009;7(5):601-5.

SystematicReview:Whatworksto
implementguidelines?
Effective
Decisionsupportsystems
Interactiveeducationalmeetings(e.g.,tumor
boards)
Educationaloutreach(detailing)
Proceduraljustification
Remindersystem
Multifacetedinterventions
Prior M, et al. J Eval Clin Pract. 2008;14(5):888-97.

SystematicReview:Whatworksto
implementguidelines?
Inconsistenteffectiveness
Audits,feedback,orpeerreview
Education(CME)
Financialincentives
Localopinionleaders

Ineffective
Disseminationonlyinformation
Traditionaleducation(e.g.,grandrounds)
Prior M, et al. J Eval Clin Pract. 2008;14(5):888-97.

47

AnyevidencewithCINV?
Institution#1
Steps:

Developedlocalguidelines(includedRPh)
Education
Prospectivelymonitoredadherence
Providedadherence/outcomedatatoprescribers

Results
Baselineadherencewaspoor
Improvedwithguidelinedissemination(notsustained)
Sustainedimprovementwithoutcomedatasharing

Nolte MJ, et al. J Clin Oncol. 1998;16(2):771-8.

AnyevidencewithCINV?
Institution#2
Steps:
Formedmultidisciplinarygroup(includingRPh)todevelop
institutionalguidelines
Guidelinedisseminationandeducation
Guidelineenforcement:calledprescriber
Pharmacistmanagedoption:AntiemeticsperGuidelines
Preprintedorderforms

Results:
Goodpatientreportedsatisfactionrates
Goodadherenceafterpharmacistdrivenordering(>98%)
Mertens WC, et al. J Clin Oncol. 2003;21(7):1373-8.

ImplementingGuidelines:
Summary
Localguidelinedevelopment
Educationofproviders
Decisionsupportisprobablythemostpowerfultool
Preprintedordertemplates(paper)
CPOE

Challenges
Softwarefororderingsystems
Updatingofordersets
Lackofcentralizedauthority

48

PollingQuestion
Howdoyoufeelaboutusingpredefinedorder
setstomaximizeadherencetoCINVGLs?
Loveit!
Hateit!
Lovehaterelationship!

Conclusion
CINVisanimportantsideeffecttomanage
Guidelinesareavailablefrommany
institutionsandauthoritativegroups
Institutionsshouldcreatetheirownguideline
andimplementationprocess
Useofdecisionsupporttoolsiskey

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Adhering to Clinical Guidelines

Selected References
Aapro M, Molassiotis A, Dicato M et al. The effect of guideline-consistent antiemetic therapy on
chemotherapy-induced nausea and vomiting (CINV): the Pan European Emesis Registry
(PEER). Ann Oncol. 2012; 23:1986-92.
Basch E, Prestrud AA, Hesketh PJ et al. Antiemetics: American Society of Clinical Oncology
clinical practice guideline update. J Clin Oncol. 2011; 29:4189-98.
Brunton LL, Chabner BA, Knollmann BC, eds. Goodman & Gilman's The Pharmacological Basis
of Therapeutics, 12th ed. Philadelphia, PA: The McGraw-Hill Companies; 2011.
Burmeister H, Aebi S, Studer C et al. Adherence to ESMO clinical recommendations for
prophylaxis of chemotherapy-induced nausea and vomiting. Support Care Cancer. 2012;
20:141-7.
Gomez DR, Liao KP, Giodano S et al. Adherence to national guidelines for antiemesis
prophylaxis in patients undergoing chemotherapy for lung cancer: a population-based study.
Cancer. 2013; 119:1428-36.
Grunberg SM, Osoba D, Hesketh PJ et al. Evaluation of new antiemetic agents and definition of
antineoplastic agent emetogenicityan update. Support Care Cancer. 2005; 13:80-4.
Grunberg SM, Warr D, Gralla RJ et al. Evaluation of new antiemetic agents and definition of
antineoplastic agent emetogenicity--state of the art. Support Care Cancer. 2011; 19(Suppl
1):S43-7.
Grunberg SM. Obstacles to the implementation of antiemetic guidelines. J Natl Compr Canc
Netw. 2009; 7:601-5.
Hesketh PJ, Kris MG, Grunberg SM et al. Proposal for classifying the acute emetogenicity of
cancer chemotherapy. J Clin Oncol. 1997; 15:103-9.
Jordan K, Kinitz I, Voigt W et al. Safety and efficacy of a triple antiemetic combination with the
NK-1 antagonist aprepitant in highly and moderately emetogenic multiple-day chemotherapy.
Eur J Cancer. 2009; 45:1184-7.
Mertens WC, Higby DJ, Brown D 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. J Clin Oncol. 2003; 21:1373-8.
Molassiotis A, Aapro M, Dicato M et al. Evaluation of risk factors predicting chemotherapyrelated nausea and vomiting: results from a European prospective observational study. J Pain
Symptom Manage. 2013 Sep 24. [Epub ahead of print]

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Preventing and Managing Chemotherapy-induced Nausea and Vomiting:

Adhering to Clinical Guidelines

National Comprehensive Cancer Network. Clinical practice guidelines in oncology: antiemesis.
v.1.2014. http://www.nccn.org/professionals/physician_gls/pdf/antiemesis.pdf (accessed 2013
Oct 30).
Nolte MJ, Berkery R, Pizzo B 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. J Clin Oncol. 1998; 16:771-8.
Passik SD, Kirsh KL, Rosenfeld B et al. The changeable nature of patients' fears regarding
chemotherapy: implications for palliative care. J Pain Symptom Manage. 2001; 21:113-20.
Prior M, Guerin M, Grimmer-Somers K. The effectiveness of clinical guideline implementation
strategiesa synthesis of systematic review findings. J Eval Clin Pract. 2008; 14:888-97.
Roila F, Herrstedt J, Aapro M et al. Guideline update for MASCC and ESMO in the prevention of
chemotherapy- and radiotherapy-induced nausea and vomiting: results of the Perugia
consensus conference. Ann Oncol. 2010; 21(Suppl 5):v232-43.

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Preventing and Managing Chemotherapy-induced Nausea and Vomiting:

Adhering to Clinical Guidelines

SelfAssessment Questions

1. Which of the following is NOT a patient-specific risk factor for chemotherapy-induced

nausea and vomiting?
a. Age
b. History of previous surgery
c. Gender
d. History of alcohol use
2. The ASCO, ESMO/MASCC, and NCCN guidelines all prefer _____________ as the 5HT3
receptor antagonist of choice to be given on day 1 of moderately emetogenic chemotherapy.
a. Dolasetron
b. Granisetron
c. Ondansetron
d. Palonosetron
3. Which of the following regimens best describes the Day 1 antiemetic regimen that should be
prescribed for a patient receiving highly emetogenic chemotherapy?
a. Dexamethasone alone
b. Dexamethasone + 5HT3 receptor antagonist
c. Dexamethasone + 5HT3 receptor antagonist + NK1 receptor antagonist
d. No routine antiemetics are necessary
4. Based on a systematic review of the evidence, which of the following strategies have been
shown to be effective in incorporating treatment guidelines into practice?
a. Decision support systems
b. Multifaceted interventions
c. Traditional educational session (e.g., grand rounds)
d. A and B
5. Based on published reports of institutional experience with implementing CINV guidelines,
the strategies that seemed to work best was:
a. Allowing pharmacists to order antiemetics with an Antiemetics per Guidelines checkbox
b. Providing lectures about CINV at grand rounds
c. Offering financial incentives to prescribers for adherence
d. Bringing in local opinion leaders to educate prescribers

Answers
1.
2.
3.
4.
5.

b
d
c
d
a

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