PURPOSE

Prevention of chemotherapy-induced nausea and vomiting (CINV) remains an essential supportive care need for patients receiving cancer treatment. Due to inadequate access to antiemetics in many countries, guideline-recommended CINV prophylaxis is not always possible. Our goal was to formulate antiemetic recommendations for resource-limited settings and define alternative antiemetic regimens for the CINV prophylaxis after highly (HEC) and moderately emetic chemotherapy (MEC), when NK-receptor antagonists are not accessible.

METHODS

The recommendations based on the MASCC/ESMO 2023 Guideline Update were considered as the best option. The stratification based on a meta-analysis published by Filetti et al. (2023) was used in order to select and rank NK-receptor antagonist-free regimens by their probability of achieving complete response. Alternative NK-receptor antagonist-free regimens based on olanzapine are proposed, ranked by their efficacy as "better" and "good" options when "best" regimens recommended by the MASCC/ESMO 2023 Guideline Update were not available or affordable.

RESULTS

For the prevention of acute CINV, in patients receiving HEC (HEC-cisplatin and AC-HEC) with no access to an NK-receptor antagonist, a 3-drug regimen including single doses of a 5-HT-receptor antagonist, dexamethasone, and olanzapine given before chemotherapy is recommended as an alternative option. Olanzapine and dexamethasone are recommended days 2-4 after chemotherapy. The O10PD regimen (10 mg olanzapine, palonosetron, and dexamethasone) is suggested as the alternative regimen in the category "better." Other 5-HT-receptor antagonists (ondansetron, granisetron) may be used if palonosetron is not affordable (category "good"). No guideline is possible for the alternative regimens to prevent acute CINV following MEC because of limited (carboplatin, AUC ≥ 5) or unavailable data (oxaliplatin chemotherapy in women aged < 50 years). Limited data are also available on the management of CINV following trastuzumab-deruxtecan.

CONCLUSION

The most effective prevention of CINV recommended by the MASCC/ESMO 2023 Guideline Update must be given when available and affordable. These recommendations were developed to facilitate decision on which regimen to use when the best MASCC/ESMO 2023 recommended regimen is not accessible because NK-receptor antagonists are either not available or not affordable.