2023 Japan Society of clinical oncology clinical practice guidelines update for antiemesis

JSCO · 2024 · Japan

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Authors: Hirotoshi Iihara, Masakazu Abe, Makoto Wada et al.
Title: 2023 Japan Society of clinical oncology clinical practice guidelines update for antiemesis
Journal: International Journal of Clinical Oncology, 2024
DOI: 10.1007/s10147-024-02535-x
Licence: CC BY 4.0
Changes: Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC11196343

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Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Background questions and future research questions with statements

For highly emetogenic risk antineoplastic agents, a four-drug combination therapy using olanzapine, a 5-HT3 receptor antagonist, an NK1 receptor antagonist, and dexamethasone is administered. In cases where the use of olanzapine is challenging, a three-drug combination therapy with a 5-HT3 receptor antagonist, an NK1 receptor antagonist, and dexamethasone is administeredAgreement rate %: 100; Agreement rate Number: 24/24
For highly emetogenic risk antineoplastic agents, in the context of three-drug combination therapy, the acute antiemetic effect is nearly equivalent between first-generation (e.g., granisetron) and second-generation (e.g., palonosetron) agents. However, there is a tendency for palonosetron to exhibit a better delayed antiemetic effect. In cases of four-drug combination therapy, either first-generation or second-generation agents can be chosen. Yet, in situations where it is necessary to shorten the administration period of dexamethasone or when the use of olanzapine is challenging, palonosetron is prioritizedAgreement rate %: 100; Agreement rate Number: 24/24
For acute nausea and vomiting associated with moderate emetogenic risk antineoplastic agents, a combination of a 5-HT3 receptor antagonist and dexamethasone is administered. Carboplatin (AUC ≥ 4), which is at the high end of the moderate emetogenicity category, is administered as a triplet, with an NK1 receptor antagonist added to the regimenAgreement rate %: 100; Agreement rate Number: 24/24
For moderately emetogenic risk antineoplastic agents, a two-drug combination therapy using the second-generation 5-HT3 receptor antagonist, palonosetron, and dexamethasone is administered. However, when adding an NK1 receptor antagonist, the first-generation 5-HT3 receptor antagonist can also be chosenAgreement rate %: 100; Agreement rate Number: 24/24
There is no clear evidence for prophylactic antiemetic therapy for low emetogenic risk antineoplastic agents, but in actual clinical practice, antiemetics such as dexamethasone and 5-HT3 receptor antagonists are widely administered. For minimal emetogenic risk antineoplastic agents, prophylactic antiemetic therapy is not administeredAgreement rate %: 100; Agreement rate Number: 25/25
Optimal management involves achieving complete control of acute and delayed nausea and vomiting caused by cancer chemotherapy, with the goal of preventing patients from experiencing these symptoms. In cases of anticipatory nausea and vomiting, benzodiazepine anxiolytics are administeredAgreement rate %: 100; Agreement rate Number: 24/24
Perform an emetogenic risk classification based on the site of radiation exposure and implement antiemetic therapy tailored to the risk. For high risk (total body irradiation), it is recommended to proactively administer 5-HT3 receptor antagonists and dexamethasone for prevention. For moderate risk (e.g., upper abdomen, craniospinal irradiation), it is advisable to administer 5-HT3 receptor antagonists prophylactically, and concurrent use of dexamethasone may also be consideredAgreement rate %: 100; Agreement rate Number: 24/24
There is no difference in the antiemetic effects of 5-HT3 receptor antagonists and NK1 receptor antagonists or in systemic side effects between intravenous and oral administration at approved routes and doses, and the choice of route should be based on the patient's conditionAgreement rate %: 100; Agreement rate Number: 19/19
Notable side effects of antiemetics include constipation and headache with 5-HT3 receptor antagonists and NK1 receptor antagonists, injection site reactions with fosaprepitant due to peripheral intravenous administration, somnolence and dizziness with olanzapine, insomnia and transient hyperglycemia with dexamethasone, and extrapyramidal symptoms (akathisia, acute dystonias, etc.) with metoclopramideAgreement rate %: 100; Agreement rate Number: 23/23
If immune checkpoint inhibitors are co-administered, antiemetic therapy should be selected based on the emetogenic risk of chemotherapy. Do not reduce the dose of dexamethasone antiemetic therapy because of the administration of immune checkpoint inhibitorsAgreement rate %: 100; Agreement rate Number: 24/24
Patient-related factors that may decrease the effectiveness of antiemetic therapy include young age, female gender, non-habitual alcohol consumption, and a history of motion sickness or morning sickness. Consider reinforcing antiemetic therapy tailored to the patient's backgroundAgreement rate %: 100; Agreement rate Number: 22/22
Support patients in appropriately assessing their symptoms and encourage them to promptly contact or visit the hospital in case of severe symptoms or concerns. Provide guidance on the proper use of rescue medications to help patients control nausea and vomiting even at homeAgreement rate %: 100; Agreement rate Number: 19/19
In addition to explanations from the physician, the healthcare team, including nurses and pharmacists, should provide continuous information and support before the initiation of therapy. This involves detailing the expected severity, timing, and duration of nausea and vomiting; their impact on daily life; types of antiemetic agents and their side effects; emergency contact procedures; and lifestyle adjustments. While utilizing educational materials that patients can refer to as needed, tailor the approach based on individual needsAgreement rate %: 100; Agreement rate Number: 19/19
For the prevention of nausea and vomiting associated with low emetogenic risk antineoplastic agents, there is no clear evidence, but in actual clinical practice, dexamethasone and 5-HT3 receptor antagonists are widely administeredAgreement rate %: 100; Agreement rate Number: 22/22
There is no evidence to support the use of antiemetics to prevent nausea and vomiting caused by oral antineoplastic agents. Management includes prescribing rescue medications and adjusting dosages or interrupting treatment as neededAgreement rate %: 100; Agreement rate Number: 22/22
There is no evidence to recommend the addition of olanzapine after initial treatment with olanzapine for breakthrough nausea and vomiting. Consider administration of antiemetics other than olanzapine for managementAgreement rate %: 100; Agreement rate Number: 22/22

CQ1: Is the addition or concurrent use of olanzapine recommended for the prevention of nausea and vomiting associated with highly emetogenic risk antineoplastic agents using a triplet antiemetic regimen (a 5-HT3 receptor antagonist + an NK1 receptor antagonist + dexamethasone)?

RecommendationWe recommend the addition or concurrent use of olanzapine to a triplet antiemetic regimen to prevent nausea and vomiting associated with antineoplastic agents with high emetogenic risk.
[Strength of recommendation: 1; Quality of evidence: B; Agreement rate: 95.7% (22/23)].

CQ2: Is it recommended to shorten the administration duration of dexamethasone to one day for the prevention of nausea and vomiting associated with highly emetogenic risk antineoplastic agents?

RecommendationWe suggest shortening the duration of dexamethasone administration to one day to prevent the nausea and vomiting associated with antineoplastic agents with a high emetogenic risk, especially in the case of AC regimens.
[Strength of recommendation: 2; Quality of evidence: B, Agreement rate: 95.5% (21/22)].

CQ3: Is the administration of an NK1 receptor antagonist recommended for the prevention of nausea and vomiting associated with moderately emetogenic risk antineoplastic agents?

RecommendationWe recommend the administration of NK1 receptor antagonists to prevent the nausea and vomiting associated with carboplatin regimens in moderate-emetogenic-risk antineoplastic agents.
[Strength of recommendation: 1;quality of evidence: A, Agreement rate: 100% (22/22)]

CQ4: Is the addition or concurrent use of olanzapine to the triplet antiemetic regimen (a 5-HT3 receptor antagonist + an NK1 receptor antagonist + dexamethasone) recommended for the prevention of nausea and vomiting associated with moderately emetogenic risk antineoplastic agents?

RecommendationWe suggest the addition or concurrent use of olanzapine to the triplet antiemetic regimen to prevent the nausea and vomiting associated with moderate-risk emetogenic antineoplastic agents.
[Strength of recommendation: 2; Quality of evidence: C, Agreement rate: 87.5% (21/24)].

CQ5: Is the addition or concurrent use of olanzapine to the doublet antiemetic regimen (a 5-HT3 receptor antagonist + dexamethasone) recommended for the prevention of nausea and vomiting associated with moderately emetogenic risk antineoplastic agents?

RecommendationNo consensus was reached.

CQ6: Is it recommended to shorten the administration duration of dexamethasone to one day for the prevention of nausea and vomiting associated with moderate emetogenic risk antineoplastic agents?

RecommendationWe recommend shortening the duration of dexamethasone administration to one day to prevent the nausea and vomiting associated with moderate-risk emetogenic antineoplastic agents, especially when administering palonosetron as a 5-HT3 receptor antagonist.
[Strength of recommendation: 1; Quality of evidence: B, Agreement rate: 90.5% (19/21)].

CQ7: Is it recommended to omit the administration of an NK1 receptor antagonist for the prevention of nausea and vomiting in R ± CHOP regimens?

RecommendationWe suggest not to omit the administration of an NK1 receptor antagonist for the prevention of nausea and vomiting in R ± CHOP regimens.
[Strength of recommendation: 2; Quality of evidence: C; Agreement rate: 91.7% (22/24)].

CQ8: Is the administration of metoclopramide recommended for breakthrough nausea and vomiting?

RecommendationWe suggest the administration of metoclopramide for breakthrough nausea and vomiting.
[Strength of recommendation: 2; Quality of evidence: B, Agreement rate: 95.8% (23/24)].

CQ9: Is daily antiemetic therapy recommended for patients receiving daily intravenous administrations of cytotoxic antineoplastic agents?

RecommendationWe recommend the implementation of daily antiemetic therapy in patients receiving daily intravenous cytotoxic antineoplastic agents.
[Strength of recommendation: 1; Quality of evidence: D, Agreement rate: 95.8% (23/24)].

CQ10: Is the concurrent use of non-pharmacological therapy recommended for the prevention of nausea and vomiting?

RecommendationWe suggest not to perform non-pharmacological interventions for the management of nausea and vomiting.
[Strength of recommendation: 2; Quality of evidence: D, Agreement rate: 83.3% (20/24)].

CQ11: Is non-pharmacological therapy recommended for anticipatory nausea and vomiting?

RecommendationWe suggest not to perform non-pharmacological interventions for anticipatory nausea and vomiting.
[Strength of recommendation: 2; Quality of evidence: D, Agreement rate: 95.8% (23/24)].

CQ12: Is the use of patient-reported outcomes recommended for the assessment of nausea and vomiting?

RecommendationWe recommend using patient-reported outcomes to assess nausea and vomiting.

Abstract

Background: The Japan Society of Clinical Oncology Clinical Practice Guidelines for Antiemesis 2023 was extensively revised to reflect the latest advances in antineoplastic agents, antiemetics, and antineoplastic regimens. This update provides new evidence on the efficacy of antiemetic regimens.

Methods: Guided by the Minds Clinical Practice Guideline Development Manual of 2017, a rigorous approach was used to update the guidelines; a thorough literature search was conducted from January 1, 1990, to December 31, 2020.

Results: Comprehensive process resulted in the creation of 13 background questions (BQs), 12 clinical questions (CQs), and three future research questions (FQs). Moreover, the emetic risk classification was also updated.

Conclusions: The primary goal of the present guidelines is to provide comprehensive information and facilitate informed decision-making, regarding antiemetic therapy, for both patients and healthcare providers.

Contents of the original publication

The section headings of the original.

Introduction
Methods
Guiding principles for the development
The classification and terminology of the questions in this guideline
Emetic risk classification of the antineoplastic agents
Literature search
Results
Emetic risk classification of antineoplastic agents
Background questions and future research questions with statements
Clinical questions and recommendations
CQ1: Is the addition or concurrent use of olanzapine recommended for the prevention of nausea and vomiting associated with highly emetogenic risk antineoplastic agents using a triplet antiemetic regimen (a 5-HT3 receptor antagonist + an NK1 receptor antagonist + dexamethasone)?
CQ2: Is it recommended to shorten the administration duration of dexamethasone to one day for the prevention of nausea and vomiting associated with highly emetogenic risk antineoplastic agents?
CQ3: Is the administration of an NK1 receptor antagonist recommended for the prevention of nausea and vomiting associated with moderately emetogenic risk antineoplastic agents?
CQ4: Is the addition or concurrent use of olanzapine to the triplet antiemetic regimen (a 5-HT3 receptor antagonist + an NK1 receptor antagonist + dexamethasone) recommended for the prevention of nausea and vomiting associated with moderately emetogenic risk antineoplastic agents?
CQ5: Is the addition or concurrent use of olanzapine to the doublet antiemetic regimen (a 5-HT3 receptor antagonist + dexamethasone) recommended for the prevention of nausea and vomiting associated with moderately emetogenic risk antineoplastic agents?
CQ6: Is it recommended to shorten the administration duration of dexamethasone to one day for the prevention of nausea and vomiting associated with moderate emetogenic risk antineoplastic agents?
CQ7: Is it recommended to omit the administration of an NK1 receptor antagonist for the prevention of nausea and vomiting in R ± CHOP regimens?
CQ8: Is the administration of metoclopramide recommended for breakthrough nausea and vomiting?
CQ9: Is daily antiemetic therapy recommended for patients receiving daily intravenous administrations of cytotoxic antineoplastic agents?
CQ10: Is the concurrent use of non-pharmacological therapy recommended for the prevention of nausea and vomiting?
CQ11: Is non-pharmacological therapy recommended for anticipatory nausea and vomiting?
CQ12: Is the use of patient-reported outcomes recommended for the assessment of nausea and vomiting?
Summary
Discussion

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