化療藥高中低致吐性與止吐藥搭配組套

Q1: 化療藥高中低致吐性與止吐藥搭配組套

分類

1.          Acute emesis：N&V 發生於化療後 0-24hr，需積極預防。

2.          Delayed emesis：N&V 發生於化療完 24 hr後，止吐藥作用時間需夠長。

3.          Anticipatory emesis：N&V 發生於化療前 24 hr內，屬於條件反射，給予抗焦慮劑 alprazolam 或 lorazepam。

4.          Breakthrough emesis：已靠藥物控制住 N&V，但兩三天後又出現。

機轉

1.          Peripheral pathway：化療藥刺激胃腸道，使enterochromaffin cell 釋放 serotonin活化迷走神經，主要涉及 acute emesis。

2.          Central pathway：化療藥刺激脊髓，使迷走神經釋放 substance P 活化 NK1 receptors，主要涉及 delayed emesis。

3.          因此止吐藥多為抑制 serotonin 及 substance P。

致吐風險

High (>90%)
Anthracycline/cyclophosphamide combination Carmustine Cisplatin Cyclophosphamide ≥1500 mg/m2			Dacarbazine Mechlorethamine Streptozocin
Moderate (30 to 90%)		Low (10 to 30%)
Alemtuzumab Arsenic trioxide Azacitidine Bendamustine Busulfan Carboplatin Clofarabine Cyclophosphamide <1500 mg/m2 Cytarabine >1000 mg/m2 Daunorubicin Daunorubicin and cytarabine liposome Doxorubicin Epirubicin Fam-trastuzumab deruxtecan-nxki Idarubicin Ifosfamide Irinotecan Irinotecan liposomal inj Oxaliplatin Romidepsin Oral Temozolomide Thiotepa (from pediatric trials) Trabectedin		Aflibercept Axicabtagene  ciloleucel Belinostat Blinatumomab Bortezomib Brentuximab Cabazitaxel Carfilzomib Catumaxumab Cetuximab Copanlisib Cytarabine ≤1000 mg/m2 Decitabine Docetaxel Elotuzumab Eribulin Etoposide Fluorouracil  Gemcitabine Gemtuzumab   ozogamicin			Inotuzumab ozogamicin Ixabepilone Methotrexate Mitomycin Mitoxantrone Moxetumomab pasudotox Nab-paclitaxel Necitumumab Nelarabine Paclitaxel Panitumumab Pegylated liposomal doxorubicin Pemetrexed Pertuzumab Tagraxofusp-erzs Temsirolimus Tisagenlecleucel Topotecan Trastuzumab-emtansine Vinflunine
Minimal (<10%)
Atezolizumab Avelumab Bevacizumab Bleomycin Cemiplimab 2-Chlorodeoxyadenosine Cladribine Daratumumab	Durvalumab Emapalumab Fludarabine Ipilimumab Nivolumab Obinutuzumab Ofatumumab Pembrolizumab			Polatuzumab vedotin Pralatrexate Ramucirumab Rituximab Trastuzumab Vinblastine Vincristine Vinorelbine

Risk category	Agent	Dosing on day of chemotherapy (D1)	Dosing on subsequent days (D2-)
High emetic risk* (>90%) Option 1 四種藥	NK1R antagonist (擇一):
	Aprepitant	125 mg oral	80 mg oral daily on D2-3.
	Fosaprepitant	150 mg IV
	5-HT3 antagonist (擇一):
	Granisetron	2 mg oral; 1 mg or 0.01 mg/kg IV; 1 經皮貼片; 10 mg SC
	Ondansetron	24 mg single PO, or 8 mg (or 0.15 mg/kg) single IV
	Palonosetron	0.5 mg oral; 0.25 mg IV
	Dexamethasone	12 mg oral or IV	若用 aprepitant : 8 mg/day PO or IV on D2-4.Δ
	Olanzapine	5 to 10 mg◊	5 to 10 mg daily on D2-4.◊
High emetic risk* (>90%) Option 2 四種藥	Netupitant + palonosetron (Akynzeo ) ST 1hr before Chemo
	Dexamethasone	12 mg oral or IV	8 mg oral QD on D2-4(cisplatin only).
	Olanzapine	5 to 10 mg◊	5 to 10 mg daily on D2-4.◊
Moderate emetic risk‡ (30 to 90%) Non-carboplatin 兩藥	5-HT3 antagonist (擇一): 如同option 1， 若使用ondansetron ，劑量改為8 mg PO BID.
	Dexamethasone	8 mg oral or IV	8 mg oral or IV daily on D2-3.
Moderate emetic risk‡ (30 to 90%) Carboplatin based三藥	NK1R antagonist (擇一): 如同option 1
	5-HT3 antagonist (擇一): 如同option 1， 若使用ondansetron，劑量改為8 mg PO BID.
	Dexamethasone	12 mg oral or IV
Low emetic risk (10 to 30%) 一藥	以下擇一
	Dexamethasone	4 to 8 mg oral or IV
	5-HT3 antagonist (擇一):如同option 1， 若使用ondansetron ，劑量改為8 mg PO QD.
	Phenothiazine-type drug (eg, prochlorperazine (Novamin) )
Minimal emetic risk (<10%) 無藥	None	None	None.

   combination chemo時，需依最高致吐性藥物選擇止吐藥。

* 標準劑量之 cyclophosphamide + anthracycline 應視為高致吐風險
¶ Netupitant, aprepitant, fosaprepitant 抑制dexamethasone代謝，增加濃度，若沒使用NK1R antagonis，dexa劑量應20 mg/day on D1 and 16 mg/day on D2-4.
Δ 使用 anthracycline/cyclophosphamide for乳癌或用 carboplatin-containing regimen, 取消D2-4 of dexamethasone.
◊ olanzapine 5mg 優於10mg for cisplatin-based 高致吐regimen，因為效果似、副作用低. 但for anthracycline +cyclophosphamide regiment就不一定
‡ NK1R antagonist通常用於carboplatin AUC ≥4 mg/mL/min、非乳癌含anthracycline/cyclophosphamide之化療

 

Q2: 針對Pemetrexed + Cisplatin (Q3W)的標準化療組套 (病人BSA 1.65 m²)

1.          1/2NS 1000 ml IVD 4-6 hrs for hydration

2.          Furosemide 20 mg IVA 10 min at the last 200 ml 1/2NS hydration

3.          Aprepitant (Emend ® ) 80 mg PO QD x 3 days or Palonosetron/netupitant (Akynzeo®複方) PO ST 1 hour before chemotherapy

4.          Dexamethasone 10 mg or Betamethasone 4-8 mg IVA 10 mins at 30 mins before chemotherapy.

5.          Granisetron 3 mg or Tropisetron 5 mg or Ondansetron 16 mg or Palonosetron (Aloxi®) 0.25 mg IVA 10 mins at 15 mins before chemotherapy

Pemetrexed (500 mg/m²) 825 mg in NS 100ml IF 10 min ST

Cisplatin (75 mg/m²) 123 mg in NS 250-500ml IF 120 min ST

*此病人有降劑量，給65 m/m²

6.          1/2 NS 500ml IVD 2 hr

7.          Furosemide 20 mg IVA 10 mins ST (Total IV volume: 1/2NS: 1500 ml, NS: 600 ml) If I>O more than 1500 ml or body weight increase over 1 kg/ day.

 

Ref: 台 北 榮 總 肺 癌 化 療 組 套V.2.0 2020 https://wd.vghtpe.gov.tw/cmd/files/%E8%82%BA%E7%99%8C%E5%8C%96%E7%99%82%E7%B5%84%E5%A5%97-20201018%E6%9C%80%E7%B5%82%E7%89%88.pdf