Jacqueline Flank

Guideline for the prevention of acute chemotherapy‐induced nausea and vomiting in pediatric cancer patients: A focused update

This update of the 2013 clinical practice guideline provides clinicians with guidance regarding the use of aprepitant and palonosetron for the prevention of acute chemotherapy‐induced nausea and vomiting (CINV) in children. The recommendations were based on three systematic reviews. Substantive changes were made to the guideline recommendations including the inclusion of palonosetron to the 5‐HT3 antagonists recommended for children receiving highly emetogenic chemotherapy (HEC) and the recommendation of aprepitant for children 6 months of age or older receiving HEC. To optimize CINV control in children, future work must focus on closing critical research gaps.

Olanzapine for treatment and prevention of acute chemotherapy-induced vomiting in children: A retrospective, multi-center review

This retrospective review provides preliminary data regarding the safety and efficacy of olanzapine for chemotherapy‐induced vomiting (CIV) control in children.

Guideline for the Treatment of Breakthrough and the Prevention of Refractory Chemotherapy-Induced Nausea and Vomiting in Children With Cancer

This clinical practice guideline provides an approach to the treatment of breakthrough chemotherapy‐induced nausea and vomiting (CINV) and the prevention of refractory CINV in children. It was developed by an international, interprofessional panel and is based on systematic literature reviews. Evidence‐based interventions for the treatment of breakthrough and prophylaxis of refractory CINV are recommended. Gaps in the evidence used to support the recommendations made in this clinical practice guideline were identified. The contribution of these recommendations to breakthrough and refractory CINV control in children requires prospective evaluation.

Nausea and vomiting in children and adolescents receiving intrathecal methotrexate: A prospective, observational study

The prevalence of nausea and vomiting after receipt of intrathecal methotrexate (IT‐MTX) in pediatric oncology patients is unknown.

Comparative effectiveness research in antineoplastic-induced nausea and vomiting control in children.

Antineoplastic-induced nausea and vomiting (AINV) is one of the most distressing adverse effects experienced by adult and pediatric patients receiving antineoplastic agents. Despite this, evidence of the efficacy and safety of antiemetic interventions in children is limited, and prevention and treatment approaches vary widely between centers. The purpose of this review is: first, to describe the barriers to comparative antiemetic effectiveness research in AINV control in children; second, to highlight limitations of the currently available pediatric AINV evidence; third, to summarize and discuss comparative effectiveness research specific to AINV control in children, with a focus on agents recommended in evidence-based guidelines developed for acute phase AINV control; and finally, to offer guidance regarding future comparative effectiveness research in this field.

Comment on: Olanzapine for chemotherapy-induced nausea: Lessons learned from child and adolescent psychiatry

To the Editor: We are responding to a recent commentary regarding olanzapine use for chemotherapy-induced nausea and vomiting (CINV).1 Olanzapine is currently recommended only for the management of breakthrough or refractory CINV in pediatric patients.2 These areweak recommendations based on low or very low quality evidence. Published evidence describing the use of olanzapine for CINV prophylaxis in pediatric oncology patients is not sufficient to recommend its routine use.3 Samsel et al. warn of metabolic effects, sedation, extrapyramidal symptoms, and QTc prolongation in pediatric patients receiving long-term olanzapine. We are apprehensive that the safety concerns voiced by Samsel et al. may create unnecessary barriers to the shortterm use of olanzapine for pediatric patients who experience CINV despite administration of clinical practice guideline (CPG)-consistent prophylaxis. Whenweighing the risks andbenefits of olanzapineas anantiemetic in pediatric patients, consideration of its safety in pediatric psychiatry and its efficacy in adult oncology is important. In a meta-analysis describing adverse effects associated with olanzapine use in pediatric patients with psychiatric conditions, the adverse effects most commonly reportedwereweight gain and sedation.4 Extrapyramidal symptoms or electrocardiogram abnormalities were reported in 9% (95%CI 4-21) and 14% (95% CI 7-26), respectively. QTc prolongation was not observed in any patient with electrocardiogram abnormalities. In descriptions of olanzapine use for CINV prophylaxis in pediatric oncology patients,4,5 olanzapine was well tolerated, with sedation being the most common adverse effect. Changes in body weight were not observed.We are concerned that regular measuring of waist circumference, as recommended by Samsel et al., may be detrimental in youth who have body image concerns. Since QTc prolongation has not been reported in adult patients receiving serotonin-receptor antagonist andolanzapine-containing regimens forCINVprophylaxis,6 we do not believe that a baseline electrocardiogram is required in patients without known risk factors for QTc prolongation. We agree with the suggestion that clinicians be mindful of hyperglycemia in patients receiving olanzapine. Further, an association with olanzapine should be considered in patients with hyperprolactinemia, hyperamylasemia, or elevated hepatic transaminase concentrations. The contribution of olanzapine toCINVprevention in adult patients iswell recognized.6 In adults, olanzapine 10mgPOonce daily is recommended startingwith the first dose of chemotherapy andending3days later.7 Initiation several days before chemotherapy administration is not required. The optimal pediatric olanzapine dose for CINV prophylaxis is unknown. Samsel et al. recommend an olanzapine dose of 1.25 mg or 2.5 mg BID. We have suggested an initial oral olanzapine dose of 0.1mg/kg/dose (maximum: 10mg/dose) once daily beginning just prior to the first chemotherapy dose.5 We do not advocate intramuscular olanzapine administration for CINV treatment or prophylaxis. Randomized controlled trials are required to determine an accurate picture of the benefits and risks of including olanzapine in the antiemetic regimen of pediatric oncology patients. If not being offered in the context of a trial, olanzapine may be offered judiciously to pediatric patients who have failed CPG-consistent CINV prophylaxis and for whom the benefits are likely to outweigh the risks.