Emetogenic Potential of Antineoplastic Agents

EMETOGENIC POTENTIAL OF ANTINEOPLASTIC AGENTS
INTRAVENOUS/INJECTABLE AGENTS
HIGH RISK (>90% frequency)^†
AC combination: any regimen containing anthracycline + cyclophosphamide Carboplatin AUC ≥4 Carmustine (BiCNU) >250mg/m² Cisplatin Cyclophosphamide >1,500mg/m²	Dacarbazine Doxorubicin ≥60mg/m² Epirubicin (Ellence) >90mg/m² Ifosfamide (Ifex) ≥2g/m² per dose Mechlorethamine Streptozocin (Zanosar)
MODERATE RISK (>30−90% frequency)^†
Aldesleukin (Proleukin) >12−15 million IU/m² Amifostine (Ethyol) >300mg/m² Arsenic trioxide (Trisenox) Azacitidine (Vidaza) Bendamustine (Treanda) Busulfan (Busulfex) Carboplatin AUC <4* Carmustine (BiCNU) ≤250mg/m²* Clofarabine (Clolar) Cyclophosphamide ≤1,500mg/m² Cytarabine >200mg/m² Dactinomycin (Cosmegen)* Daunorubicin (Cerubidine)*	Dual-drug liposomal cytarabine + daunorubicin (Vyxeos) Dinutuximab (Unituxin) Doxorubicin <60mg/m²* Epirubicin (Ellence) ≤90mg/m²* Idarubicin (Idamycin PFS) Ifosfamide (Ifex) <2g/m² per dose* Interferon alfa (Intron A) ≥10 million IU/m² Irinotecan (Camptosar)* Melphalan (Alkeran, Evomela) Methotrexate ≥250 mg/m²* Oxaliplatin (Eloxatin)* Temozolomide (Temodar) Trabectedin (Yondelis)*
LOW RISK (10−30% frequency)^†
Ado-trastuzumab emtansine (Kadcyla) Aldesleukin (Proleukin) ≤12 million IU/m² Amifostine (Ethyol) ≤300mg/m² Axicabtagene ciloleucel (Yescarta) Belinostat (Beleodaq) Brentuximab vedotin(Adcetris) Cabazitaxel (Jevtana) Carfilzomib (Kyprolis) Copanlisib (Aliqopa) Cytarabine (low dose) 100−200mg/m² Docetaxel (Taxotere) Doxorubicin liposomal (Doxil) Eribulin (Halaven) Etoposide (Etopophos) Floxuridine Fluorouracil (5-FU) Gemcitabine (Gemzar) Gemtuzumab ozogamicin Inotuzumab ozogamicin (Besponsa)	Interferon alfa (Intron A) >5−<10 million IU/m² Ixabepilone (Ixempra) Methotrexate >50mg/m²−<250mg/m² Mitomycin Mitoxantrone Necitumumab (Portrazza) Olaratumab (Lartruvo) Omacetaxine (Synribo) Paclitaxel (Taxol) Paclitaxel albumin (Abraxane) Pemetrexed (Alimta) Pentostatin Pralatrexate (Folotyn) Romidepsin (Istodax) Talimogene laherparepvec (Imlygic) Thiotepa (Tepadina) Tisagenlecleucel (Kymriah) Topotecan (Hycamtin) Ziv-aflibercept (Zaltrap)
MINIMAL RISK (<10% frequency)^†
Alemtuzumab (Campath) Atezolizumab (Tecentriq) Avelumab (Bavencio) Asparaginase (Erwinaze) Bevacizumab (Avastin) Bleomycin Blinatumomab (Blincyto) Bortezomib (Velcade) Cetuximab (Erbitux) Cladribine Cytarabine <100mg/m² Daratumumab (Darzalex) Decitabine (Dacogen) Denileukin diftitox (Ontak) Dexrazoxane (Totect, Zinecard) Durvalumab (Imfinzi) Elotuzumab (Empliciti) Fludarabine Interferon alfa (Intron A) ≤5 million IU/m² Ipilimumab (Yervoy) Methotrexate ≤50mg/m²	Nelarabine (Arranon) Nivolumab (Opdivo) Obinutuzumab (Gazyva) Ofatumumab (Arzerra) Panitumumab (Vectibix) Pegaspargase (Oncaspar) Peginterferon (Sylatron) Pembrolizumab (Keytruda) Pertuzumab (Perjeta) Ramucirumab (Cyramza) Rituximab (Rituxan) Rituximab + hyaluronidase (Rituxan Hycela) Siltuximab (Sylvant) Temsirolimus (Torisel) Trastuzumab (Herceptin) Valrubicin (Valstar) Vinblastine Vincristine Vincristine liposomal (Marqibo) Vinorelbine (Navelbine)
ORAL AGENTS
MODERATE TO HIGH RISK (≥30% frequency)^†
Altretamine (Hexalen) Busulfan (Myleran) ≥4mg/day Ceritinib (Zykadia) Crizotinib (Xalkori) Cyclophosphamide ≥100mg/m²/day Dabrafenib (Tafinlar) Enasidenib (Idhifa) Estramustine (Emcyt) Etoposide Lenvatinib (Lenvima)	Lomustine single day (Gleostine) Midostaurin (Rydapt) Mitotane (Lysodren) Niraparib (Zejula) Olaparib (Lynparza) Procarbazine (Matulane) Rucaparib (Rubraca) Temozolomide (Temodar) >75mg/m²/day Trifluridine/tipiracil (Lonsurf)
MINIMAL TO LOW RISK (<30% frequency)^†
Abemaciclib (Verzenio) Acalabrutinib (Calquence) Afatinib (Gilotrif) Alectinib (Alecensa) Axitinib (Inlyta) Bexarotene (Targretin) Binimetinib (Mektovi) Brigatinib (Alunbrig) Bosutinib (Bosulif) Busulfan (Myleran) <4mg/day Cabozantinib (Cabometyx, Cometriq) Capecitabine (Xeloda) Chlorambucil (Leukeran) Cobimetinib (Cotellic) Cyclophosphamide <100mg/m²/day Dacomitinib (Vizimpro) Dasatinib (Sprycel) Duvelisib (Copiktra) Encorafenib (Braftovi) Erlotinib (Tarceva) Everolimus (Afinitor) Fludarabine Gefitinib (Iressa) Gilteritinib (Xospata) Glasdegib (Daurismo) Hydroxyurea (Hydrea) Ibrutinib (Imbruvica) Idelalisib (Zydelig) Imatinib (Gleevec) Ivosidenib (Tibsovo) Ixazomib (Ninlaro) Lapatinib (Tykerb)	Larotrectinib (Vitrakvi) Lenalidomide (Revlimid) Lorlatinib (Lorbrena) Melphalan (Alkeran) Mercaptopurine Methotrexate Neratinib (Nerlynx) Nilotinib (Tasigna) Osimertinib (Tagrisso) Palbociclib (Ibrance) Panobinostat (Farydak) Pazopanib (Votrient) Pomalidomide (Pomalyst) Ponatinib (Iclusig) Regorafenib (Stivarga) Ribociclib (Kisqali) Ruxolitinib (Jakafi) Sonidegib (Odomzo) Sorafenib (Nexavar) Sunitinib (Sutent) Talazoparib tosylate (Talzenna) Temozolomide (Temodar) ≤75mg/m²/day Thalidomide (Thalomid) Thioguanine Topotecan (Hycamtin) Trametinib (Mekinist) Tretinoin Vandetanib (Caprelsa) Vemurafenib (Zelboraf) Venetoclax (Venclexta) Vismodegib (Erivedge) Vorinostat (Zolinza)
NOTES
^† Frequency of emesis in the absence of effective antiemetic prophylaxis. ^* May be highly emetogenic in certain patients.
REFERENCES
National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Antiemesis. Version 1.2019 – February 28, 2019. http://www.nccn.org/professionals/physician_gls/PDF/antiemesis.pdf. Accessed January 23, 2020. (Rev. 2/2020)

EMETOGENIC POTENTIAL OF ANTINEOPLASTIC AGENTS

INTRAVENOUS/INJECTABLE AGENTS

HIGH RISK (>90% frequency)^†

AC combination: any regimen containing anthracycline + cyclophosphamide

Carboplatin AUC ≥4

Carmustine (BiCNU) >250mg/m²

Cisplatin

Cyclophosphamide >1,500mg/m²

Dacarbazine

Doxorubicin ≥60mg/m²

Epirubicin (Ellence) >90mg/m²

Ifosfamide (Ifex) ≥2g/m² per dose

Mechlorethamine

Streptozocin (Zanosar)

MODERATE RISK (>30−90% frequency)^†

Aldesleukin (Proleukin) >12−15 million IU/m²

Amifostine (Ethyol) >300mg/m²

Arsenic trioxide (Trisenox)

Azacitidine (Vidaza)

Bendamustine (Treanda)

Busulfan (Busulfex)

Carboplatin AUC <4*

Carmustine (BiCNU) ≤250mg/m²*

Clofarabine (Clolar)

Cyclophosphamide ≤1,500mg/m²

Cytarabine >200mg/m²

Dactinomycin (Cosmegen)*

Daunorubicin (Cerubidine)*

Dual-drug liposomal cytarabine + daunorubicin (Vyxeos)

Dinutuximab (Unituxin)

Doxorubicin <60mg/m²*

Epirubicin (Ellence) ≤90mg/m²*

Idarubicin (Idamycin PFS)

Ifosfamide (Ifex) <2g/m² per dose*

Interferon alfa (Intron A) ≥10 million IU/m²

Irinotecan (Camptosar)*

Melphalan (Alkeran, Evomela)

Methotrexate ≥250 mg/m²*

Oxaliplatin (Eloxatin)*

Temozolomide (Temodar)

Trabectedin (Yondelis)*

LOW RISK (10−30% frequency)^†

Ado-trastuzumab emtansine (Kadcyla)

Aldesleukin (Proleukin) ≤12 million IU/m²

Amifostine (Ethyol) ≤300mg/m²

Axicabtagene ciloleucel (Yescarta)

Belinostat (Beleodaq)

Brentuximab vedotin(Adcetris)

Cabazitaxel (Jevtana)

Carfilzomib (Kyprolis)

Copanlisib (Aliqopa)

Cytarabine (low dose) 100−200mg/m²

Docetaxel (Taxotere)

Doxorubicin liposomal (Doxil)

Eribulin (Halaven)

Etoposide (Etopophos)

Floxuridine

Fluorouracil (5-FU)

Gemcitabine (Gemzar)

Gemtuzumab ozogamicin

Inotuzumab ozogamicin (Besponsa)

Interferon alfa (Intron A) >5−<10 million IU/m²

Ixabepilone (Ixempra)

Methotrexate >50mg/m²−<250mg/m²

Mitomycin

Mitoxantrone

Necitumumab (Portrazza)

Olaratumab (Lartruvo)

Omacetaxine (Synribo)

Paclitaxel (Taxol)

Paclitaxel albumin (Abraxane)

Pemetrexed (Alimta)

Pentostatin

Pralatrexate (Folotyn)

Romidepsin (Istodax)

Talimogene laherparepvec (Imlygic)

Thiotepa (Tepadina)

Tisagenlecleucel (Kymriah)

Topotecan (Hycamtin)

Ziv-aflibercept (Zaltrap)

MINIMAL RISK (<10% frequency)^†

Alemtuzumab (Campath)

Atezolizumab (Tecentriq)

Avelumab (Bavencio)

Asparaginase (Erwinaze)

Bevacizumab (Avastin)

Bleomycin

Blinatumomab (Blincyto)

Bortezomib (Velcade)

Cetuximab (Erbitux)

Cladribine

Cytarabine <100mg/m²

Daratumumab (Darzalex)

Decitabine (Dacogen)

Denileukin diftitox (Ontak)

Dexrazoxane (Totect, Zinecard)

Durvalumab (Imfinzi)

Elotuzumab (Empliciti)

Fludarabine

Interferon alfa (Intron A) ≤5 million IU/m²

Ipilimumab (Yervoy)

Methotrexate ≤50mg/m²

Nelarabine (Arranon)

Nivolumab (Opdivo)

Obinutuzumab (Gazyva)

Ofatumumab (Arzerra)

Panitumumab (Vectibix)

Pegaspargase (Oncaspar)

Peginterferon (Sylatron)

Pembrolizumab (Keytruda)

Pertuzumab (Perjeta)

Ramucirumab (Cyramza)

Rituximab (Rituxan)

Rituximab + hyaluronidase (Rituxan Hycela)

Siltuximab (Sylvant)

Temsirolimus (Torisel)

Trastuzumab (Herceptin)

Valrubicin (Valstar)

Vinblastine

Vincristine

Vincristine liposomal (Marqibo)

Vinorelbine (Navelbine)

ORAL AGENTS

MODERATE TO HIGH RISK (≥30% frequency)^†

Altretamine (Hexalen)

Busulfan (Myleran) ≥4mg/day

Ceritinib (Zykadia)

Crizotinib (Xalkori)

Cyclophosphamide ≥100mg/m²/day

Dabrafenib (Tafinlar)

Enasidenib (Idhifa)

Estramustine (Emcyt)

Etoposide

Lenvatinib (Lenvima)

Lomustine single day (Gleostine)

Midostaurin (Rydapt)

Mitotane (Lysodren)

Niraparib (Zejula)

Olaparib (Lynparza)

Procarbazine (Matulane)

Rucaparib (Rubraca)

Temozolomide (Temodar) >75mg/m²/day

Trifluridine/tipiracil (Lonsurf)

MINIMAL TO LOW RISK (<30% frequency)^†

Abemaciclib (Verzenio)

Acalabrutinib (Calquence)

Afatinib (Gilotrif)

Alectinib (Alecensa)

Axitinib (Inlyta)

Bexarotene (Targretin)

Binimetinib (Mektovi)

Brigatinib (Alunbrig)

Bosutinib (Bosulif)

Busulfan (Myleran) <4mg/day

Cabozantinib (Cabometyx, Cometriq)

Capecitabine (Xeloda)

Chlorambucil (Leukeran)

Cobimetinib (Cotellic)

Cyclophosphamide <100mg/m²/day

Dacomitinib (Vizimpro)

Dasatinib (Sprycel)

Duvelisib (Copiktra)

Encorafenib (Braftovi)

Erlotinib (Tarceva)

Everolimus (Afinitor)

Fludarabine

Gefitinib (Iressa)

Gilteritinib (Xospata)

Glasdegib (Daurismo)

Hydroxyurea (Hydrea)

Ibrutinib (Imbruvica)

Idelalisib (Zydelig)

Imatinib (Gleevec)

Ivosidenib (Tibsovo)

Ixazomib (Ninlaro)

Lapatinib (Tykerb)

Larotrectinib (Vitrakvi)

Lenalidomide (Revlimid)

Lorlatinib (Lorbrena)

Melphalan (Alkeran)

Mercaptopurine

Methotrexate

Neratinib (Nerlynx)

Nilotinib (Tasigna)

Osimertinib (Tagrisso)

Palbociclib (Ibrance)

Panobinostat (Farydak)

Pazopanib (Votrient)

Pomalidomide (Pomalyst)

Ponatinib (Iclusig)

Regorafenib (Stivarga)

Ribociclib (Kisqali)

Ruxolitinib (Jakafi)

Sonidegib (Odomzo)

Sorafenib (Nexavar)

Sunitinib (Sutent)

Talazoparib tosylate (Talzenna)

Temozolomide (Temodar) ≤75mg/m²/day

Thalidomide (Thalomid)

Thioguanine

Topotecan (Hycamtin)

Trametinib (Mekinist)

Tretinoin

Vandetanib (Caprelsa)

Vemurafenib (Zelboraf)

Venetoclax (Venclexta)

Vismodegib (Erivedge)

Vorinostat (Zolinza)

NOTES

^† Frequency of emesis in the absence of effective antiemetic prophylaxis. ^* May be highly emetogenic in certain patients.

REFERENCES

National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Antiemesis. Version 1.2019 – February 28, 2019. http://www.nccn.org/professionals/physician_gls/PDF/antiemesis.pdf. Accessed January 23, 2020.

(Rev. 2/2020)

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