Chemotherapy Induced Nausea and Vomiting in Children and Young People with Cancer - Guideline for the Prevention and Management of

Publication: 23/09/2014  --
Last review: 10/06/2019  
Next review: 01/06/2022  
Clinical Guideline
CURRENT 
ID: 3959 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for the Prevention and Management of Chemotherapy Induced Nausea and Vomiting in Children and Young People with Cancer

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Summary of Guideline

This policy has been developed and agreed in order to ensure that the prophylaxis and treatment of chemotherapy and radiotherapy induced nausea and vomiting is provided in a manner, which aims to take account of the emetogenic stimulus and the known actions of the individual cytotoxic drugs.      
It aims to provide a logically consistent framework for the prevention and treatment of chemotherapy induced nausea and vomiting.

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Section 1: Background

Chemotherapy-induced nausea and vomiting (CINV) are common and well documented side-effects of childhood cancer treatment (Wood et al. 2015). If poorly managed CINV can lead to physical and psychological problems. Physical problems include anorexia, malnutrition, electrolyte imbalance and dehydration. Psychological sequale include development of anticipatory nausea and vomiting and non-compliance with future treatments. Severe CINV can lead to time lost from school for patients, time lost at work for caregivers and increased access to healthcare systems (Dewan, Singhal and Harit, 2010). Such problems are an avoidable burden on patients, their families and for the NHS. Prevention of CINV is, therefore, a cornerstone of supportive care for all children treated with significantly emetogenic chemotherapy.

Nausea and vomiting are reflexes initiated by the body to expel toxic substances from the stomach and intestine (Navari, 2013). Emesis is co-ordinated by the vomiting centre situated in the medulla. The vomiting centre receives input from the chemoreceptor trigger zone (CTZ) located in the area postrema outside of the blood-brain barrier. The CTZ possesses many 5HT₃ receptors, NK1 receptors and Dopamine receptors (D2). The vomiting centre has many stimuli including drugs (such as chemotherapy), smells, sights, emotions. The gastrointestinal tract can also stimulate the vomiting centre. CINV may result from chemotherapy or cerebrospinal fluid acting directly on the CTZ, in the vomiting Centre or by chemotherapy induced release of serotonin and substance P from cells within the gastric mucosa.

CINV can be classified into three stages depending on the time of onset; acute (0-24hrs after 1st dose); delayed (24hrs-5 days post chemotherapy) and anticipatory (prior to the start of chemotherapy). Physiological differences exist between acute and delayed CINV. Acute CINV is mediated by the neurotransmitter serotonin, whereas delayed CINV is mediated by substance P acting on NK1 receptors. Therefore optimal management of CINV may require combined antagonism of peripheral serotonin pathways and of the central NK1 receptor pathways.

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Section 2: Principles of antiemetic prescribing

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2.1 Drug Choice

All children and young people should receive antiemetic therapy that as far as can be predicted, is appropriate to the emetogenic potential of the prescribed chemotherapy and their previous experience of receiving chemotherapy.

Consider:                  

  • Emetogenicity of cytotoxic drugs (Refer to Appendix 1)
  • Regime emetogenicity on each day of the course.
  • Previous adverse drug reactions and drug allergies.
  • Patient’s antiemetic control with previous chemotherapy
  • Any medical complications or concurrent medications that may contribute to nausea and vomiting

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2.2 Route

All antiemetics are to be prescribed orally whenever possible. Those patients who cannot tolerate oral medication or if antiemetic drugs are due overnight, can be given parenterally. 2,3 Patients must not be discharged home with intravenous antiemetics.

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2.3 Cautions to the prescribing of dexamethasone

Dexamethasone must not be prescribed as an antiemetic to children and young people :

  • With brain tumours - this may reduce blood-brain barrier penetration of chemotherapy
  • With acute myeloid leukaemia - as immunosuppressive effects of steroids further increase the risk of fungal infection
  • Receiving Mifamurtide - Dexamethasone is predicted to decrease the efficacy of Mifamurtide, this combination should therefore be avoided. Mifamurtide has low emetogenicity so antiemetics are not usually required. If the patient is having Cisplatin chemotherapy before or after administration of the Mifamurtide then Dexamethasone therapy must not be given on the same day as the Mifamurtide treatment.
  • Who are receiving steroids as part of their treatment.
  • Dexamethasone should also be avoided if possible in patients with Osteosarcoma receiving high dose Methotrexate. This is to reduce steroid exposure by restricting use. In exceptional circumstances (ie uncontrollable nausea and vomiting) steroids may be indicated but should only be prescribed with consultant approval.
  • In patients undergoing stem cell transplantation, dexamethasone use should be restricted to the shortest possible course length, ideally 48-72 hours, for patients receiving highly and very highly emetogenic chemotherapy only. Short weaning courses can be given if vomiting is severe.

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2.4 Dopamine antagonists: Use of Domperidone

Domperidone is no longer recommended for routine use in the policy due to concerns related to cardiac toxicity issued by the MHRA in April 20144. Domperidone could be considered in children who have failed or who cannot tolerate other antiemetic drugs. Such therapy must be initiated by the child’s consultant. Any patient on Domperidone therapy must have cardiac monitoring before and at appropriate agreed timescales during therapy. Domperidone is contraindicated in any patient with any cardiac abnormalities or in patients with significant electrolyte disturbances. Domperidone should not be administered concomitantly with drugs that prolong the QT interval (such as Ondansetron) or potent CYP3A4 inhibitors. Always check for interactions before prescribing domperidone.

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2.5 Dopamine antagonists: Use of Metoclopramide

To minimise the risk of neurological toxicity, Metoclopramide should usually only be added as second line therapy and should usually not be prescribed for more than five days5. If the drug is continued for more than five days this should be after medical review and the reason for continuation documented in the medical notes. Alternatives such as Levomepromazine and Chlorpromazine are more sedating. Patients should not be prescribed more than one dopamine antagonist (Metoclopramide, Levomepromazine, Chlorpromazine) at any time.

Dopamine antagonists can induce acute dystonic reactions. With Metoclopramide, dystonic reactions usually occur shortly after starting treatment and subside within 24 hours of stopping it. Any dystonic reaction must be treated immediately with Procyclidine1. Procyclidine should always be prescribed alongside Metoclopramide as per eMEDs protocols. Any child who has experienced an extra pyramidal reaction to Metoclopramide can receive Chlorpromazine or Levomepromazine as alternatives.  There is a reduced incidence of extrapyramidal side effects with these drugs and no cross sensitivity.

Metoclopramide is contraindicated in patients less than one year of age as per the MHRA safety alert.

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2.6 Criteria for changing antiemetics

Review antiemetics daily. Move to the next stage in protocol if the child experiences either:

a) More than two vomits in 4 hours or >4 vomits in 24 hours caused by chemotherapy.

b)The patient experiences nausea, which is prolonged, continuous and interferes with or prevents normal activities and ranks 4 on the PeNAT scale
(Appendix 3).  

Once control of nausea and vomiting is lost within an individual treatment block it is can be difficult to regain control. For the next block of chemotherapy of similar emetogenicity move up to the next effective line of treatment.

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2.7 Guidance for prescribing antiemetics for discharge home

Ondansetron, Dexamethasone and Metoclopramide are the agents of choice for preventing delayed symptoms. It is good practice to review past experience with the patients’ family and/or patient. Establish if any delayed nausea and/or vomiting had occurred in their last course of chemotherapy, which antiemetic agent was used and for how long before prescribing drugs for discharge home. Metoclopromide should not usually be taken for more than 5 days.

Very highly and highly emetogenic chemotherapy

Ondansetron: Prescribe for two to three days post chemotherapy (however  if a patient has a history of delayed nausea and vomiting  up to five days prophylaxis post-chemotherapy may be required).

Dexamethasone: For Cisplatin only:  Prescribe a reducing course for four days post chemotherapy.

For all other patients on highly emetogenic chemotherapy Dexamethasone should be stopped 24 hours after the last dose of chemotherapy. If a patient had delayed emesis with the last course of highly emetogenic chemotherapy then consider prescribing a reducing course of Dexamethasone on completion of chemotherapy. 

Metoclopramide:  Prescribe if required for a maximum total duration of 5 days.

Levomepromazine and Chlorpromazine should be reviewed and usually stopped 48 hours after completion of chemotherapy. They should not usually be prescribed for discharge home.

Moderately emetogenic chemotherapy

Continue antiemetics until 24 hours post chemotherapy. If patient has progressed beyond second line therapy then for antiemetics after chemotherapy treat as highly emetogenic.

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2.8 Day case chemotherapy

If a patient will receive a single dose of chemotherapy with short acting emetogenicity, for example Doxorubicin and Cyclophosphamide, give a dose of Ondansetron before chemotherapy. The patient should be discharged home with a stat dose of Ondansetron to take that evening.

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2.9 Cautions when prescribing Ondansetron

Following advice from  the MHRA in 2012 and 2013 to minimise the risks of QT interval prolongation and cardiac arrhythmia for patients on Ondansetron the following cautions must be followed:

  • Intravenous Ondansetron should always be given as a slow IV infusion over 15 minutes.
  • Ondansetron must be used with caution in patients with risk factors for QT interval prolongation or cardiac arrhythmias. These include: electrolyte abnormalities*, use of other medicines that prolong QT interval (including cytotoxic drugs) or that may lead to electrolyte abnormalities, congestive heart failure, bradyarrhythmias, or use of medicines that lower heart rate.

*Hypokalaemia and hypomagnesaemia should be corrected before Ondansetron administration.

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2.10 Role of Nabilone

Highly and very highly emetogenic regimes - If treatment failure on 1st, 2nd and 3rd line antiemetics consider Nabilone for the next course of treatment. Do not prescribe with Aprepitant, Levomepromazine or Lorazepam10,15. Nabilone should not be prescribed to children under the age of six years.

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2.11 Guidance on Aprepitant/Fosaprepitant

The neurokinase inhibitors Aprepitant and Fosaprepitant should be started 1 hour prior to the (very) highly emetogenic chemotherapy. Aprepitant is the oral preparation while Fosaprepitant is the intravenous preparation which should only be prescribed when the oral route is not possible (IV Fosaprepitant is three times the cost of oral Aprepitant at a price of £152.79 for a three day course). It should be documented, ideally on the eMeds prescription, why IV Fosaprepitant is required rather than oral. If Dexamethasone is prescribed concomitantly with Aprepitant or Fosaprepitant, it must be prescribed at half the regular dose (see Appendix 2). It is essential to check for drug interactions before prescribing these agents as there use is contraindicated with a number of drugs (see Appendix 5).

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Section 3: Treatment / Management

These are divided into six sections, based on age, contraindication for steroids, and by diagnosis/treatment:

  • 3.1 Antiemetic treatment guideline for children less than six months of age
  • 3.2 Antiemetic treatment guideline for children over six months of age and for teenagers and young people
  • 3.3 Antiemetic treatment guidelines  for children  less than six  months  of age where  steroids are cautioned during this course of chemotherapy
  • 3.4 Antiemetic treatment guidelines for children over six months of age and for teenagers and young people where steroids are cautioned during  this course of chemotherapy
  • 3.5 Antiemetic treatment guidelines for prevention of anticipatory nausea and vomiting. 
  • 3.6 Antiemetic treatment guidelines for patients undergoing stem cell transplantation.

Where any doubt as to if a contraindication for steroids exists (Section 2.3), the user of the guideline should contact the Consultant Paediatric Haematology/Oncologist.

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3.1 Antiemetic Treatment Guidelines For Children Less than 6 months of Age

NB Please refer to section 3.3 for the guidelines for children where steroids are cautioned (see section 2.3) and for children receiving steroids during this course of chemotherapy.

Antiemetics during chemotherapy. 2,3,,8,9,10,

Very highly emetogenic
1st Line:        Ondansetron and Dexamethasone
2nd Line:       Add Levomepromazine*
3rd Line:        Increase Levomepromazine* dose as tolerated

 

Highly emetogenic
1st Line:         Ondansetron
2nd Line:       Add Dexamethasone
3rd Line:        Add Levomepromazine*
4th Line:        Increase Levomepromazine* dose as tolerated

Moderately emetogenic
1st Line:         Ondansetron
2nd Line        Add Dexamethasone
3rd Line:        Add Levomepromazine*
4th Line:        Increase Levomepromazine* dose as tolerated

Low to moderately emetogenic
Ondansetron if needed only. If required then usually just a stat dose before chemotherapy is sufficient.

Rescue Therapy
Add Lorazepam (stop Levomepromazine)  3

 *Levomepromazine should not be prescribed in children under the age of 1 month

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3.2 Antiemetic Treatment Guidelines For Children Over 6 months Of Age And For Teenagers And Young People

NB Please refer to section 3.4 for the guidelines when steroids are cautioned (see section 2.3) and for patient’s receiving steroids during this course of chemotherapy. 

Always check for interactions before prescribing Aprepitant

Antiemetics during chemotherapy 2,3,8,9,10,12, 29, 30

Very highly emetogenic
1st line:          Ondansetron, Dexamethasone at 50% usual dose and Aprepitant
2nd line:        Add Levomepromazine. 10,11,12,14,15
3rd line:          Increase Levomepromazine dose (see Appendix 2)

Highly emetogenic
1st line:          Ondansetron and Dexamethasone 9
2nd line:        Add Levomepromazine*

*For subsequent courses for patients who have been escalated to second line therapy, start with ondansetron, dexamethasone (at 50% of normal dose) and aprepitant. If aprepitant is contraindicated, substitute with levomepromazine.

Moderately emetogenic
1st line:          Ondansetron
2nd line:        Add Dexamethasone
3rd line:          Add Metoclopramide*
4th line:          Change Metoclopramide* to Levomepromazine

Low to Moderately emetogenic
Ondansetron if needed only. If required then usually just a stat dose before chemotherapy is sufficient.

Rescue Therapy
Lorazepam (stop Levomepromazine)

*Metoclopramide should not be prescribed in children under 1 year.

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3.3 Antiemetic Treatment Guidelines For Children Less than 6 months of Age Where Steroids are Cautioned During This Course Of Chemotherapy 

Antiemetic Drugs During Chemotherapy 2,3,8,9,10

Dexamethasone is cautioned as an antiemetic. 13

Very highly emetogenic
1st Line:         Ondansetron and Levomepromazine*
2nd Line:       Increase Levomepromazine* dose as tolerated

Highly and Moderately emetogenic
1st Line:         Ondansetron
2nd Line:       Add Levomepromazine*
3rd Line:        Increase Levomepromazine* dose as tolerated

Low to Moderately emetogenic
Ondansetron if needed only. If required then usually just a stat dose before chemotherapy is sufficient.

Rescue Therapy
Add Lorazepam (stop Levomepromazine)

*Levomepromazine should not be prescribed in children under the age of 1 month

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3.4 Antiemetic Treatment Guidelines For Children Over 6 months of Age And Teenagers And Young People Where  Steroids Are Cautioned During This Course Of Chemotherapy

Antiemetics during chemotherapy 2,3,8,9,10, 29, 30

Always check for interactions before prescribing Aprepitant

Dexamethasone is cautioned as an antiemetic. 13

Very highly
1st Line:         Ondansetron and Levomepromazine and Aprepitant 10,14,15
2nd Line:       Increase Levomepromazine dose.

Highly emetogenic
1st line:          Ondansetron and Levomepromazine
2nd line:        Increase Levomepromazine dose* (see Appendix 2).  

*For subsequent courses for patients who have been escalated to second line therapy, start with ondansetron and aprepitant. If aprepitant is contraindicated, substitute with levomepromazine.

Moderately emetogenic
1st line:          Ondansetron
2nd line:        Add Metoclopramide**  
3rd line:          Change Metoclopramide to Levomepromazine.

Low to moderately emetogenic
Ondansetron if needed only. If required then usually just a stat dose before chemotherapy is sufficient.

Rescue Therapy
Lorazepam  (Stop Levomepromazine)

**Metoclopramide should not be prescribed in children under 1 year.

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3.5  Antiemetic Treatment Guidelines for the Prevention of Anticipatory Nausea and Vomiting.

A significant percentage of patients experience symptoms of anticipatory nausea and vomiting which has gone unrecognised. Good symptom control is the best way to prevent anticipatory symptoms. They may be helped, particularly in adolescent patients, by the administration of Lorazepam or Nabilone (depending on patient choice) for 48 hours prior to the treatment block.1,3 

If a patient has been escalated to second or third line anti-emetic management, consider prescribing Lorazepam or Nabilone on discharge for use prior to commencing their next chemotherapy cycle. Also consider referral to the psychology or play teams for further support.

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3.6 Antiemetic Treatment Guidelines For Patients Undergoing Stem Cell Transplantation

Nausea and vomiting associated with bone marrow transplantation is multifactorial. A combination of chemotherapy, total body irradiation (TBI), altered dietary input can all cause nausea and emesis. Following transplant, infection and Graft Versus Host Disease (GVHD) may also play a role. As post-transplant causes are varied and individual, this guideline will concentrate on the conditioning period only.

The conditioning period can vary in length, typically starting seven days before transplant, but it may be longer. During this period, drugs of varying emetogenicity are used and antiemetic use should be titrated as such. It is important to consider the increasing emetogenicity of the regime over time as other chemotherapy agents/TBI are added in and to adjust the antiemetics accordingly. Anti-emetic use should be reviewed 48-72 hours after the last conditioning agent (including TBI). If nausea and vomiting is not present at this point, then anti-emetics should be stopped. If nausea and vomiting is still a problem, then anti-emetic use should be reviewed daily until it is appropriate to stop. The management of nausea and vomiting after the conditioning period should be reviewed individually and the most appropriate agent for the likely cause should be given.

Antiemetics during conditioning period

Very highly and Highly emetogenic
1st line:          Aprepitant, Dexamethasone (50% dose), Ondansetron
2nd line:        Add in Levomepromazine
3rd line:          Consider increasing dose of Levomepromazine if tolerated

Dexamethasone use should be restricted to the shortest possible course length, ideally 48-72 hours. Short weaning courses can be given if vomiting is severe.

Moderately emetogenic
1st line:          Ondansetron
2nd line:        Add Metoclopramide*  
3rd line:          Change Metoclopramide* to Levomepromazine
4th line:          Add Dexamethasone (short course- no weaning required)

*Prescribe levomepromazine for patients less than 1 year of age. The dose of levomepromazine can be increased as tolerated (Appendix 2).

Low to Moderate emetogenicity:
Ondansetron if needed only. If required then usually just a stat dose before chemotherapy is sufficient.

Rescue therapy
If the nausea/vomiting is associated with opioid use, then consider the addition of Cyclizine (stop Levomepromazine). If secretions or motion appear a contributing factor (ie when travelling for TBI) then consider the use of a Hyoscine patch. Consider the use of lorazepam or nabilone if anticipatory or anxiety related nausea and vomiting is present.

Emetogenicity of conditioning regimes

 

Very high

High

Moderate

Low

Busulfan/Melphalan (Bu/Mel)

Fludarabine/Treosulfan/

Thiotepa (FTT)

Busulfan/

Fludarabine

Alemtuzumab

Cyclophosphamide

/TBI

Cyclophosphamide/

Fludarabine/Alemtuzumab

Fludarabine/

Treosulfan

Busulfan

Single agent Melphalan

Busulfan/Cyclophosphamide

 

 

Busulfan/ Cyclophosphamide/ Melphalan (Bu/Cy/Mel)

High dose Etoposide

 

 

 

 

Carmustine/  Etoposide/ Cytarabine/ Melphalan (BEAM)

High dose Cyclophosphamide

 

 

 

Cumulative and additive toxicity are considered in the classification of the regimes. Treatment with fosaprepitant/aprepitant should commence on the first day of very highly/highly emetogenic chemotherapy

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Appendix 1 - Emetogenicity of cytotoxic drugs used in paediatric and  adolescent oncology/haematology  

Word Verison

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Appendix 2 - Drug information

Word Verison

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Appendix 3 - The Paediatric Nausea Assessment Tool (PeNAT)

Word Verison

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Appendix 4 - Antiemetics Flow diagram

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Appendix 5 - Aprepitant/Fosaprepitant Drug Interactions

Word Verison

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Provenance

Record: 3959
Objective:

Aims
To improve the management of chemotherapy induced nausea and vomiting.

Objectives
To provide evidence-based recommendations for appropriate prophylaxis, and management of chemotherapy induced nausea and vomiting.

Clinical condition:

Chemotherapy induced nausea and vomiting

Target patient group: Children and young people undergoing chemotherapy treatment
Target professional group(s): Pharmacists
Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

  1. British National Formulary for Children 2018-2019.
  2. Antonarakis E, Evans J, Heard G, Noonan L, Pizer B and Hain R.  Prophylaxis of Acute Chemotherapy –Induced Nausea and Vomiting in Children With Cancer: What Is the Evidence? Pediatric Blood and Cancer 2004;43: 651-658
  3. Gralla R, Osaba D, Kris M, Kirkbride P et al. Recommendations for the use of Antiemetics: Evidence-Based, Clinical Practice Guidelines. Journal of Clinical Oncology 1999;17(9): 2971-2994
  4. MHRA Press Release 25th April 2014.
  5. MHRA Drug Safety Update 11th December 2014
  6. Tavorath R and Hesketh P. Drug treatment of chemotherapy induced delayed emesis. Drugs 1996; 52(5): 639-648. 
  7. Italian Antiemetic Group: Ondansetron versus metoclopramide, both combined with dexamethasone, in the prevention of Cisplatin induced delayed emesis: Journal of Clinical Oncology 1997;15 (1): 124-130
  8. Roila F, Aapro M and Stewart A. Optimal selection of antiemetics in children receiving cancer chemotherapy. Supportive Care in Cancer 1998; 6: 215-220
  9. American Society of Health-System Pharmacists (ASHP) Therapeutic guidelines on the pharmacological management of nausea and vomiting in adult and paediatric patients receiving chemotherapy or radiation therapy or undergoing surgery. American Journal of Health System Pharmacy 1999; 56: 729-764
  10. Antonarakis E and Hain R. Nausea and vomiting associated with cancer chemotherapy: drug management in theory and in practice. Archives of Disease in Childhood 2004;89 (9): 887-880
  11. Graham-Pole J, Weare J, Engel S et al.  Antiemetics in children receiving cancer chemotherapy: a double-blind prospective randomized study comparing metoclopramide with chlorpromazine. Journal of Clinical Oncology 1996; 4: 1110-3
  12. Dupuis L, Nathan P. Options for the Prevention and Management of Acute Chemotherapy –Induced Nausea and Vomiting in Children. Pediatric Drugs 2003; 5 (9): 597-613
  13. Glaser A, Buxton N and Walker D. Corticosteroids in the management of central nervous system tumours. Archives of Disease in Childhood 1997;76 (1): 76-78
  14. Twycross R and Barkby G. The use of low dose levomepromazine in the management of nausea and vomiting. Progress in palliative care 1997; 5 (2): 49-52
  15. UCLH experience of low dose levomepromazine as second line antiemetic therapy for very highly emetogenic regimens. In house document.
  16. Alvarez O, Freeman A, Bedros A et al. Randomized double-blind crossover Ondansetron-dexamethasone versus ondansetron-placebo study for the treatment of chemotherapy –induced nausea and vomiting in paediatric patients with malignancies. Pediatric Hematology and Oncology 1995; 17: 145-150
  17. Tramer M, Carrol D, Campbell F et al. Cannibinoids for control of chemotherapy induced nausea and vomiting: quantative systematic review. British Medical Journal 2001; 323 (7303): 16
  18. Poli-Bigelli S et al: Addition of the neurokinin 1 receptor antagonist aprpitant to standard antiemetic therapy improves control of chemotherapy induced nausea and vomiting, Cancer 2003:97:3098-8.
  19. Aprepitant, UKMi New Medicines Profile. Issue No 04/04
  20. Hesketh P, Kris M, Grunberg S et al. Proposal for classifying the emetogenicity of cancer chemotherapy. Journal of Clinical Oncology1997; 15, 103-109
  21. British National Formulary , March to September 2019
  22. Medicines for Children. (2nd Edition) London 2003: Royal College of Paediatrics and Child Health.
  23. Hesketh of individual chemotherapeutic agents - classification of emetogenicity potential May 2007
  24. Dupus LL et al: Guidelines for the classification of the acute emetogenic potential of antineoplastic  medication in pediatric cancer patients. Paediatric Oncology Group of Toronto, 2009.
  25. Dupuis LL et al: Guidelines for the prevention of acute nausea and vomiting due to Antineoplastic medication in paediatric cancer patients. Paediatric Oncology Group of Toronto, 2012.
  26. Information on file from Alder Hey Children’s Hospital Medicines Information on Levomepromazine dosing in children.  
  27. Merck Sharp and Dohme Limited. 2018. EMEND 125mg powder for suspension.      Summary of Product Characteristics [online]. [Accessed 16th October 2018]. Available   from http://emc.medicines.org.uk
  28. Merck Sharp and Dohme Limited. 2018. IVEMEND 125mg powder for suspension. Summary of Product Characteristics [online]. [Accessed 16th October 2018]. Available from http://emc.medicines.org.uk 
  29. CCLG. 2018. CCLG guideline on the management of chemotherapy induced nausea and vomiting [online]. [Accessed 10th October 2018]. Available from www.piernetwork.org
  30. POGO. 2017. Guidelines for the management of chemotherapy induced nausea and vomiting [online]. [Accessed 10th October 2018]. Available from http://www.pogo.ca/healthcare/practiceguidelines/
  31. APPM Master Formulary. 2017. The Association of Paediatric Palliative Medicine Master Formulatry 4th Edition [Online]. [Accessed 13th May 2019]. Available from https://www.appm.org.uk/guidelines-resources/appm-master-formulary/
  32. Taketomo, C.K., Hodding, J.H., Kraus, D.M. 2019. Lexicomp Pediatric and Neonatal Dosage Handbook 18th Edition. American Pharmacist’s Association. Hudson, Ohio,  Wolters Kluwer Clinical Drug Information, Inc.

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Trust Clinical Guidelines Group

Document history

LHP version 1.0

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