Journal of Oncology Pharmacy Practice - January 2022 - 122

122
Journal of Oncology Pharmacy Practice 28(1)
Table 1. Baseline characteristics.
Age (years) - median (range)
Age<50 years - n (%)
Female sex - n (%)
Corrected calcium þ/ 7 days of DA-EPOCH-R (mg/dL) - median (range)
CNS involvement of lymphoma - n (%)
Received intrathecal chemotherapy - n (%)
Gastroprotectant medication administration - n (%)
Omeprazole
Famotidine
Pre-rituximab hydrocortisone administered - n (%)
Pre-phase corticosteroids administered - n (%)
Prednisone
Dexamethasone
Methylprednisolone
Prophylactic antiemetic - n (%)
5HT3 antagonistþprednisone 60 mg/m2 twice daily*
Ondansetronþprednisone 60 mg/m2 twice daily*
Palonosetronþprednisone 60 mg/m2 twice daily*
5HT3 antagonistþprednisone 60 mg/m2 twice daily*þNK1 receptor antagonist**
Ondansetronþprednisone 60 mg/m2 twice daily*þNK1 receptor antagonist**
Palonosetronþprednisone 60 mg/m2 twice daily*þNK1 receptor antagonist**
63 (21-81)
21 (29)
34 (47)
9.9 (7.2-13.0)
3 (4)
26 (36)
67 (92)
63 (86)
4 (5)
72 (99)
18 (25)
8 (11)
8 (11)
2 (3)
73 (100)
60 (82)
56 (77)
4 (5)
13 (18)
8 (11)
5 (7)
*Note: all patients received at least prednisone 60 mg/m2 orally twice daily as part of the chemotherapy regimen for corticosteroids portion of
antiemetic prophylaxis regimen.
**Note: 11 patients received IV fosaprepitant for 1 dose and 2 patients received oral aprepitant 125 mg on day 1 and 80mg on days 2-3.
5HT3: 5-hydroxytryptamine; NK1: neurokinin-1.
(7%) patients experienced vomiting over 120 hours.
Antiemetics used for breakthrough CINV included lorazepam
(n¼38, 52%), ondansetron (n¼16, 22%),
prochlorperazine (n¼17, 23%), and metoclopramide
(n¼3, 4%). Of the patients evaluated, 34 (47%) had
documented nausea in the EMR by nursing, mid-level
practitioner, physician, or nutrition progress notes
from chemotherapy initiation through 120 hours after
chemotherapy initiation.
No patients required an emergency department visit
or hospital admission between cycle 1 and cycle 2 of
DA-EPOCH-R for uncontrolled nausea or vomiting,
but 5 (7%) patients did have escalation in their prophylactic
antiemetic regimens from the cycle 1 to cycle 2.
For this subset of patients, an NK1 antagonist was
started upon initiation of cycle 2 of DA-EPOCH-R in
4 (5%) of the patients and one patient (1%) had scheduled
prochlorperazine added to their prophylactic
antiemetic regimen.
Discussion
In this retrospective analysis of patients with aggressive
lymphoma receiving their first cycle of DA-EPOCH in
the hospital, we found that most patients did not
receive triple antiemetic prophylaxis. It is important
to note that although aprepitant has a known interaction
with dexamethasone due to the CYP3A4 inhibition
of aprepitant, prednisone does not have a similar
drug-drug interaction to warrant omission of an NK-1
receptor antagonist from antiemetic prophylaxis regimens.
Furthermore, we found that two-thirds of
patients experienced suboptimal CINV outcomes for
overall complete response, including both acute and
delayed phases, as well as for complete control. These
findings were similar to those previously reported for
DA-EPOCH-R.15,20 The incidence of complete
response in this multiday regimen was significantly
lower compared to a study that evaluated the use of
palonosetron alone in single-day anthracycline combination
regimens, which achieved 90.7% acute complete
response rate in the same patient population.14
Collectively, these data contribute to the growing evidence
of CINV outcomes in patients with hematologic
malignancies receiving multiday chemotherapy.10,11,21
Overall, the majority of patients who had documented
nausea and/or vomiting experienced these in
the delayed phase, 25 to 120 hours after chemotherapy
initiation. Increased CINV in the delayed phase compared
to the acute phase may be due to the routine
administration of a 5HT3 receptor antagonist as this
pathway is primarily associated with the acute peripheral
pathway of CINV.22 Most of the patients received
ondansetron 16mg daily on days 1-5 with only 4
patients receiving palonosetron. At our institution,
ondansetron is the preferred 5HT3 receptor antagonist
in the inpatient setting given issues of cost and patient
adherence is maximized by nurse administration of
Journal of Oncology Pharmacy Practice - January 2022

Table of Contents for the Digital Edition of Journal of Oncology Pharmacy Practice - January 2022
