Joseph is a 57-year-old male with newly dx end stage lung disease with metastasis to the brain. He has undergone radiation therapy to the brain for his metastases and is starting chemotherapy next week. He has a history of Hypertension and no known drug allergies. He is experiencing N&V from the chemotherapy. 

What drug therapy would you prescribe and why

 

Antiemetics: American Society of Clinical Oncology Clinical Practice Guideline Update guideline provides updated recommendations to prevent and manage nausea and vomiting caused by antineoplastic agents or radiation therapy for cancer. 

Step-by-step explanation

High emetic risk radiation therapy

• Adult patients who are treated with high-emetic-risk radiation therapy should be offered a two-drug combination of a 5-HT3receptor antagonist and dexamethasone before each fraction and on the day after each fraction if radiation therapy is not planned for that day. (Type: evidence based, benefits outweigh harms; quality of evidence: high; strength of recommendation: strong.)

Moderate-emetic-risk radiation therapy

• Adult patients who are treated with moderate-emetic-risk radiation therapy should be offered a 5-HT3 receptor antagonist before each fraction, with or without dexamethasone before the first five fractions. (Type: evidence based, benefits outweigh harms; quality of evidence: high; strength of recommendation: moderate.)

Low-emetic-risk radiation therapy

•  Adult patients who are treated with radiation therapy to the brain should be offered rescue dexamethasone therapy. Patients who are treated with radiation therapy to the head and neck, thorax, or pelvis should be offered rescue therapy with a 5-HT3receptor antagonist, dexamethasone, or a dopamine receptor antagonist. (Type: informal consensus, benefits outweigh harms; quality of evidence: low; strength of recommendation: weak.)

Minimal-emetic-risk radiation therapy

• Adult patients who are treated with minimal-emetic-risk radiation therapy should be offered rescue therapy with a 5-HT3receptor antagonist, dexamethasone, or a dopamine receptor antagonist. (Type: informal consensus, benefits outweigh harms; quality of evidence: low; strength of recommendation: weak.)

Concurrent radiation and antineoplastic agent therapy

• Adult patients who are treated with concurrent radiation and antineoplastic agents should receive antiemetic therapy that is appropriate for the emetic risk level of antineoplastic agents, unless the risk level of the radiation therapy is higher. During periods when prophylactic antiemetic therapy for antineoplastic agents has ended and ongoing radiation therapy would normally be managed with its own prophylactic therapy, patients should receive prophylactic therapy that is appropriate for the emetic risk of the radiation therapy until the next period of antineoplastic therapy, rather than receiving rescue therapy for antineoplastic agents as needed. (Type: informal consensus, benefits outweigh harms; quality of evidence: intermediate; strength of recommendation: moderate.)