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Chemotherapy Induced Nause and Vomiting (CINV) – Guideline adherence for Low and Minimal Emetogenic Regimens

ICON supports appropriate and adequate anti-emesis for all patients receiving chemotherapy. This is crucial to improving quality of life during chemotherapy treatment and has an impact on patient outcomes (1).


Modern antiemetic regimens have relegated chemotherapy induced nausea and vomiting (CINV) to a much less feared side effect of chemotherapy. Most current international antiemetic guidelines are divided into classes that look at frequency and type (acute/delayed) of emesis caused by various chemotherapy drugs and regimens.

The 2018 ICON Protocols ADDENDUM 1: ANTIEMETIC GUIDELINES (attached) is based on both ASCO and NCCN Guidelines (4;5). The 2016 MASCC/ESMO Guidelines (6) are a practical, evidence-based guide that could also be used as the basis for a practice specific antiemetic protocol. A list of low and minimal emetogenic single agent chemotherapy medicines, as per MASCC/ESMO 2016 Guidelines (6) is a useful indicator of oncology drugs that do not need the addition of palonosetron or aprepitant to prevent CINV. (See Annexure A.)

However, recent studies looking at the use of internationally recognised antiemetic guidelines have shown suboptimal adherence (2).
An African study from Sudan, published in the South African Journal of Oncology (SAJO) in 2017, showed very poor adherence to the ASCO guidelines with both over and under usage of antiemetics in that country (3).

ICON believes that the approach to antiemetic use should be relooked at from time to time as new agents, both antineoplastic and antiemetic, become available and international guidelines are updated. Ensuring that patients are spared CINV is central to this review process.

Patient access to appropriate cancer treatment and improving outcomes also includes ensuring that the oncology benefits of every patient is maximally utilised. Identifying areas of oncology treatment where waste can be reduced, or eliminated, is part of ICON’s mandate.

In line with this, ICON identified the reduction of the use of high-cost antiemetics for low or minimal emetogenic antineoplastic regimens as a potential area where oncology benefits could be saved. This specific cohort was chosen as there are no international antiemetic guidelines that recommend the use of either of these two agents for these emetogenic classes of chemotherapy.

A data analysis on the authorisation of the high-cost agents aprepitant and palonosetron for patients receiving low or minimally emetogenic chemotherapy regimens was undertaken. Authorisation data from eAuth® was used in this analysis.

The eAuth® data review seems to indicate a large variation across practices and regions. Certain ICON practices have a relatively high incidence of the authorisation of palonosetron and aprepitant for low or minimally emetogenic chemotherapy regimens while many do not.

The reasons for this variation are unclear. A brief survey done by the ICON Clinical Team seems to indicate a correlation between practices where antiemetic protocols are followed by the staff – oncologist, chemotherapy nurses and authorisation clerks, etc. – and the low use of these inappropriate and expensive antiemetics.

We can postulate that in practices where no standard antiemetic protocols exist, ‘pre-emptive’ authorisation of support drugs, including these expensive antiemetics, may be followed by authorisation staff who do not have a practice-standard antiemetic protocol.
ICON has looked at this in a very broad way to date and further data analysis will be done over the next few months.
ICON strongly encourages all practices to use evidence-based antiemetic protocols in standard daily practice. We believe this offers the best route to a pragmatic and consistent approach to managing CINV.
In addition, we believe that this approach will be cost-effective. Cost saving in this area may also allow increased access to the oncological medicines that really make a difference to longer term outcomes for patients as well as reduce their exposure to co-payments.
The alignment of ICON practices with the attached Antiemetic Guidelines in the ICON Protocols, based on ASCO and NCCN guidelines will go a long way to achieving these goals.

References:

  1. Abunahlah N, Sancar M, Dane F, Özyavuz MK. Impact of adherence to antiemetic guidelines on the incidence of chemotherapy-induced nausea and vomiting and quality of life. Int J Clin Pharm. 2016 Dec;38(6):1464-1476. Epub 2016 Oct 28.
  2. Clark-Snow R, Affronti, ML, Rittenberg CN. Chemotherapy-induced nausea and vomiting (CINV) and adherence to antiemetic guidelines: results of a survey of oncology nurses. Support Care Cancer. 2018; 26(2): 557–564. Published online 2017 Sep 4. doi: 10.1007/s00520-017-3866-6
  3. Moawia M.A. Elhassan, Arwa A.S.A. Ali, Mohamed O.M. Elmustafa. Adherence to guidelines on prophylaxis of chemotherapy-induced nausea and vomiting in the National Cancer Institute, Sudan. SAJO 2017;1(0), a9. https://doi.org/10.4102/sajo.v1i0.9
  4. Hesketh PJ, Kris MG, Basch E, Bohlke K, Barbour SY, et al. Antiemetics: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol 35:3240-3261. http://www.ascopost.com/issues/october-25-2017/asco-clinical-practice-guideline-update-on-antiemetics-in-patients-with-cancer/
  5. Berger MJ, et al. NCCN Guidelines Insights: Antiemesis, Version 2.2017. J Natl Compr Canc Netw 2017; 15:883-893. http://www.jnccn.org/content/15/7/883.full
  6. Roila F, Molassiotis A, Herrstedt J, Aapro M, RGralla RJ, et al. 2016 MASCC and ESMO guideline update for the prevention of chemotherapy- and radiotherapy-induced nausea and vomiting and of nausea and vomiting in advanced cancer patients. Ann Oncol, 27(5), Issue suppl_5, 2016;v119–v133. https://academic.oup.com/annonc/article/27/suppl_5/v119/2237028

ANNEXURE A: Low and Minimal Emetogenic Potential of Single Antineoplastic Agents

EMETOGENIC POTENTIALINTRAVENOUSORAL
LOWAflibercept
Bortezomib
Brentuximab
Cabazitaxel
Cetuximab
Cytarabine < 1000 mg/m²
Docetaxel
Eribulin
Etoposide
5-Fluorouracil
Gemcitabine
Ipilimumab
Ixabepilone
Methotrexate
Mitomycin
Mitoxantrone
Nab-paclitaxel
Paclitaxel
Panitumumab
Pemetrexed
Pegylated liposomal doxorubicin
Pertuzumab
Temsirolimus
Topotecan
Trastuzumab-emtansine
Vinflunine
Capecitabine
Dasatinib
Everolimus
Etoposide
Fludarabine
Ibrutinib
Lapatinib
Lenalidomide
Nilotinib
Pazopanib
Regorafenib
Sunitinib
Thalidomide
Vorinostat
MINIMALBevacizumab
Bleomycin
Busulfan
Cladribine
Fludarabine
Nivolumab
Pembrolizumab
Rituximab
Trastuzumab
Vinblastine
Vincristine
Vinorelbine
Chlorambucil
Erlotinib
Gefitinib
Hydroxyurea
Melphalan
Methotrexate
Ruxolitinib
Sorafenib
6-Thioguanine
Vemurafenib
Vismodegib

Based on the MASCC/ESMO 2016: https://doi.org/10.1093/annonc/mdw270 (6)

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