Detail-Document #241104

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PHARMACIST’S LETTER / PRESCRIBER’S LETTER
November 2008 ~ Volume 24 ~ Number 241104

Comparison of Antiemetics
Postoperative nausea and vomiting (PONV) is one of the most common complications after surgery, and the most commonly reported fear before
elective surgery.1 Chemotherapy-induced nausea and vomiting (CINV) is noted as one of the most feared side effects of chemotherapy.2 In many
cases, nausea and vomiting is preventable, or at least treatable. As a matter of fact, it’s been noted that with newer developments in antiemetic
therapy, nausea and vomiting can be prevented in up to 70% of patients receiving highly emetogenic chemotherapy.2 Sancuso, a granisetron
transdermal patch, and Aloxi (palonosetron) oral capsules are two of the most recently approved antiemetic products. The following chart includes a
comparison of the antiemetic agents currently available on the U.S. market.

Drug Name Indication(s)* Adult Dose* Cost/Comments

5-HT3 inhibitors
Dolasetron3,4 IV:
Anzemet •Prevention of CINV
•Prevention of PONV
•Treatment of PONV
PO:
•Prevention of CINV
•Prevention of PONV
Granisetron5-7 IV:
Kytril •Prevention of CINV
Sancuso (transdermal) •Prevention of PONV
•Treatment of PONV
PO:
•Prevention of CINV
•Prevention of radiation-
induced N/V
Transdermal:
•Prevention of CINV
Pharmacist’s Letter / Prescriber’s Letter ~ P.O. Box 8190, Stockton, CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
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IV: 100 mg/5 mL vial: $37.67
Prevention of CINV: 100 mg 30 min before chemo 12.5 mg/2 mL syringe: $15.00
Prevention/treatment of PONV: 12.5 mg 15 min before 100 mg tablet: $27.61
end of anesthesia OR at onset of N/V
PO:
Prevention of CINV: 100 mg one hour before chemo
Prevention of PONV: 100 mg two hours before surgery
IV: 1 mg/mL vial (generic): $10.79
Prevention of CINV: 10 mcg/kg 30 min before chemo 1 mg tablet (generic): $3.37
Prevention/treatment of PONV: 1 mg before induction Sancuso: $287.51 for one
of anesthesia OR immediately before reversal of 3.1 mg/24 hr patch.
anesthesia OR at onset of N/V
PO: •Sancuso is specifically
Prevention of CINV or radiation-induced N/V: indicated for prevention of
2 mg one hour before chemo or radiation OR 1 mg one CINV in patients receiving
hour before chemo and 1 mg 12 hours later moderately and/or highly
emetogenic chemotherapy for up
Transdermal: to five consecutive days.
Prevention of CINV: One patch 24 to 48 hours before • Sancuso: Avoid sun exposure
chemo. The patch can be worn for up to seven days. to application site during use
Remove the patch a minimum of 24 hours after and for 10 days after removal.
completion of chemo.
More. . .
Copyright © 2008 by Therapeutic Research Center
 (Detail-Document #241104: Page 2 of 6)

Drug Name Indication(s)* Adult Dose* Cost/Comments

5-HT3 inhibitors, continued
Ondansetron8,9 IM/IV: IM/IV: 4 mg/2 mL vial (generic): $1.68
Zofran •Prevention of PONV Prevention/treatment of PONV: 4 mg IV/IM before 40 mg/20 mL vial (generic):
•Treatment of PONV induction of anesthesia OR at onset of N/V. A second $9.57
dose of 4 mg can be given for treatment of PONV if 4 mg tablet (generic): $0.37
needed.

IV: IV:
•Prevention of CINV Prevention of CINV: 32 mg 30 minutes before chemo
OR 0.15 mg/kg/dose 30 minutes before chemo and Q4H
X2 doses

PO:
•Prevention of CINV
•Prevention of PONV
•Prevention of N/V with
radiation
PO:
Prevention of CINV: 24 mg 30 minutes before highly
emetogenic chemo OR 8 mg 30 minutes before
moderately emetogenic chemo and then eight hours
later, followed by 8 mg Q12H for one to two days after
completion of chemo
Prevention of PONV: 16 mg one hour before induction
of anesthesia
Prevention of N/V with radiation: 8 mg Q8H starting
one to two hours before radiation

Palonosetron10,11 IV: IV: 0.075 mg/1.5 mL vial: $37.00

Aloxi •Prevention of CINV
•Prevention of PONV
PO:
•Prevention of CINV
Prevention of CINV: 0.25 mg 30 minutes before 0.25 mg/5 mL vial: $124.86
chemo Cost for Aloxi capsule not
Prevention of PONV: 0.075 mg before induction of available.
anesthesia
•Palonosetron has a longer half-
PO: life (around 36 to 48 hours)
Prevention of CINV: 0.5 mg one hour before chemo compared to other 5-HT3
inhibitors.

More. . .
Copyright © 2008 by Therapeutic Research Center
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 (Detail-Document #241104: Page 3 of 6)

Drug Name Indication(s)* Adult Dose* Cost/Comments

Anticholinergics
Scopolamine12 Transdermal: Prevention of PONV: Apply patch the evening before 1.5 mg patch: $7.00 each
Transderm Scop •Prevention of motion surgery OR four hours before the end of surgery.13
sickness Apply one hour prior to cesarean section. Discard
•Prevention of PONV patch after 24 hours.
Motion Sickness: Apply patch 4 hours before needed.
Replace after 3 days.
Trimethobenzamide14,15 IM, PO: IM: 200 mg TID or QID 200 mg/2 mL syringe (generic):
Tigan •Treatment of nausea PO: 300 mg TID or QID $2.00
with gastroenteritis 300 mg cap (generic): $0.40
•Treatment of PONV •Injectable is contraindicated in
pediatric patients.
Antidopaminergics
Chlorpromazine16 IM/PO: IM: 25 mg initial dose. If no hypotension occurs, use 25 mg/mL amp (generic): $6.92
Thorazine •Treatment of N/V 25 to 50 mg Q3H to Q4H PRN. 10 mg or 25 mg tab (generic):
PO: 10 to 25 mg Q4H to Q6H PRN $0.12

Metoclopramide17 IM: IM: 10 mg/2 mL vial (generic):

Reglan •Prevention of PONV Prevention of PONV: 10 to 20 mg IM near the end of $0.50
surgery 10 mg tab (generic): $0.03
IV: IV: (Note: oral metoclopramide only
•Prevention of CINV Prevention of CINV: 1 to 2 mg/kg/dose 30 minutes indicated for GERD and
before chemo, then Q2H X2 doses, then Q3H X3 doses gastroparesis).

Prochloperazine18 IM/IV/PO/PR: IM: 5 to 10 mg IM Q3H to Q4H PRN 25 mg/2 mL vial (generic):

Compazine •Control of severe N/V IV: 2.5 to 10 mg IV Q3H to Q4H PRN $2.32
5 mg tab (generic): $0.04
PO: 10 mg tab (generic): $0.33
5 to 10 mg TID to QID 25 mg supp (generic): $0.50
PR:
25 mg BID
IM/IV:
•Prevention of PONV Prevention/treatment of PONV: 5 to 10 mg IV at end of
•Treatment of PONV surgery.13 Give 5 to 10 mg IM or IV at onset of N/V.
More. . .
Copyright © 2008 by Therapeutic Research Center
Pharmacist’s Letter / Prescriber’s Letter ~ P.O. Box 8190, Stockton, CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.pharmacistsletter.com ~ www.prescribersletter.com
 (Detail-Document #241104: Page 4 of 6)

Drug Name Indication(s)* Adult Dose* Cost/Comments

Antidopaminergics, continued
Promethazine19 IM/IV/PO/PR: IM/IV/PO/PR: 12.5 to 25 mg repeated Q4H to Q6H if 25 mg/mL vial (generic): $2.60
Phenergan •Prevention of PONV needed. (Dose provided in product labeling nonspecific 25 mg tab (generic): $0.22
•Treatment of PONV as to indication.) 25 mg supp (generic): $0.50

IV: •Injectable promethazine can

Prevention of PONV: 12.5 to 25 mg at end of cause severe chemical irritation
surgery.13 and damage to tissues.
Cannabinoids
Dronabinol20 PO: PO: 2.5 mg cap (generic): $3.83
Marinol •Treatment of CINV in 5 mg/m2/dose, one to three hours before chemo, then 5 mg cap (generic): $7.96
patients who have not Q2H to Q4H after chemo, for a total of four to six doses 10 mg cap (generic): $14.65
responded to daily. Increase dose by 2.5 mg/m2 to a max of •Dronabinol is a Schedule III
conventional antiemetics 15 mg/m2/dose as necessary. controlled substance.
•Dronabinol is not a first-line
agent because a substantial
portion of patients can be
expected to experience
disturbing psychotomimetic
reactions not observed with
other antiemetic agents.
Nabilone21 PO: PO: 1 mg cap: $15.45
Cesamet •Treatment of CINV in 1 to 2 mg BID to TID. Give the first dose one to three
patients who have not hours before chemo. A dose given the evening before •Nabilone is a Schedule II
responded to might be useful. Continue for 48 hours after the last controlled substance.
conventional antiemetics dose of chemo if necessary. •Nabilone is not a first-line agent
because a substantial portion of
patients can be expected to
experience disturbing
psychotomimetic reactions not
observed with other antiemetic
agents.

More. . .
Copyright © 2008 by Therapeutic Research Center
Pharmacist’s Letter / Prescriber’s Letter ~ P.O. Box 8190, Stockton, CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.pharmacistsletter.com ~ www.prescribersletter.com
 (Detail-Document #241104: Page 5 of 6)

Drug Name Indication(s)* Adult Dose* Cost/Comments

Miscellaneous
Aprepitant22,23 IV (fosaprepitant): IV (fosaprepitant): 80 mg cap: $80.00
Emend •Prevention of CINV, in Prevention of CINV: 115 mg 30 minutes before chemo 125 mg cap: $120.00
combination with other on first day of chemo only, as a substitute for 125 mg 115 mg/10 mL vial: $170.00
antiemetics PO dose of aprepitant
•Aprepitant is a neurokinin-1
antagonist
PO: PO:
•Prevention of CINV, in Prevention of CINV: 125 mg one hour before chemo, •Aprepitant inhibits CYP3A4
combination with other then 80 mg daily for two days and should not be used with
antiemetics Prevention of PONV: 40 mg three hours prior to pimozide, a CYP3A4 substrate,
•Prevention of PONV induction of anesthesia because increased levels of
pimozide can cause QT
prolongation
Droperidol24 IM/IV: IM/IV: 2.5 mg/mL vial: $1.35
Inapsine •Prevention of PONV 2.5 mg IM/IV is the maximum recommended dose.
•Treatment of PONV Give additional doses of 1.25 mg PRN. •Droperidol has a Black Box
Warning because it can prolong
IV: QT interval and cause torsade de
Prevention of PONV: 0.625 to 1.25 mg at end of pointes.
surgery13
*Indication and dose per FDA-approved product labeling unless otherwise noted.

Users of this document are cautioned to use their own professional judgment and consult any other necessary or appropriate sources prior to making clinical
judgments based on the content of this document. Our editors have researched the information with input from experts, government agencies, and national
organizations. Information and Internet links in this article were current as of the date of publication.

More. . .
Copyright © 2008 by Therapeutic Research Center
Pharmacist’s Letter / Prescriber’s Letter ~ P.O. Box 8190, Stockton, CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.pharmacistsletter.com ~ www.prescribersletter.com
 (Detail-Document #241104: Page 6 of 6)

Project Leader in preparation of this Detail- 10. Product information for Aloxi injectable. MGI.
Document: Stacy A. Hester, R.Ph., BCPS, Bloomington, MN 55437. August 2007.
11. Product information for Aloxi capsule. MGI.
Assistant Editor Bloomington, MN 55437. August 2008.
12. Product information for Transderm Scop. Novartis.
References Summit, NJ 07901. July 2001.
1. American Society of PeriAnesthesia Nurses 13. Williams KS. Postoperative nausea and vomiting.
PONV/PDNV Strategic Work Team. ASPAN’s Surg Clin North Am 2005;85:1229-41.
evidence-based clinical practice guideline for the 14. Product information for Tigan injectable. JHP.
prevention and/or management of PONV/PDNV. J Rochester, MI 48307. January 2008.
Perianesth Nurs 2006;21:230-50. 15. Product information for Tigan capsules. Monarch.
2. Anon. Evidence-based prevention of CINV: what’s Bristol, TN 37620. August 2007.
new in ASCO guidelines. J Support Oncol 16. Product information for chlorpromazine. Sandoz.
2008;6:71-2. Princeton, NJ 08540. March 2008.
3. Product information for Anzemet injection. Sanofi- 17. Product information for Reglan injectable. Schwarz.
Aventis. Bridgewater, NJ 08807. June 2006. Milwaukee, WI 53201. April 2006.
4. Product information for Anzemet tablets. Sanofi- 18. Product information for Compazine.
Aventis. Bridgewater, NJ 08807. June 2006. GlaxoSmithKline. Research Triangle Park, NC
5. Product information for Sancuso. ProStrakan. 27709. July 2004.
Bedminster, NJ 07921. July 2008. 19. Product information for Phenergan injectable.
6. Product information for Kytril injectable. Roche. Baxter. Deerfield, IL 60015. December 2006.
Nutley, NJ 07110. November 2005. 20. Product information for Marinol. Unimed. Marietta,
7. Product information for Kytril tablets. Roche. Nutley, GA 30062. July 2006.
NJ 07110. November 2005. 21. Product information for Cesamet. Valeant. Costa
8. Product information for Zofran injectable. Mesa, CA 92626. May 2006.
GlaxoSmithKline. Research Triangle Park, NC 22. Product information for Emend capsules. Merck.
27709. February 2006. Whitehouse Station, NJ 08889. November 2007.
9. Product information for Zofran tablets, orally 23. Product information for Emend injectable. Merck.
disintegrating tablets, oral solution. Whitehouse Station, NJ 08889. January 2008.
GlaxoSmithKline. Research Triangle Park, NC 24. Product information for Inapsine. Taylor. Decatur,
27709. February 2006. Illinois 62522. April 2006.

Cite this Detail-Document as follows: Comparison of antiemetics. Pharmacist’s Letter/Prescriber’s Letter

2008;24(11):241104.

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Copyright © 2008 by Therapeutic Research Center

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