Anti-emetic guidance for patients undergoing radiotherapy

Abdomen

Pelvis (large volume)

Hemi-body - upper

Brain

Head & neck

Thorax

Pelvis (small volume)

Breast 

Extremities

Granisetron* 1mg od oral 

Metoclopramide 10mg tds oral

Granisetron* 1mg od oral

Metoclopramide 10mg as required oral

Metoclopramide 10mg tds oral

Granisetron* 1mg as required oral

Granisetron* 2mg od

Dexamethasone (only after discussion with transplant team)

Prochlorperazine as required or regular (see notes below for dose information)

Granisetron* 2mg od

Metoclopramide 10mg oral regular

Prochlorperazine as required or regular (see notes below for dose information)

Granisetron* 1mg od regular

Prochlorperazine as required or regular (see notes below for dose information)

Metoclopramide 10mg oral as required or regular

Granisetron 1mg oral as required or regular

Prochlorperazine as required or regular (see notes below for dose information)

Weekly review of medicines

Stop or reduce as required when possible

Monitor for side effects and prescribe alternatives or add in supportive medications such as laxatives when needed

1-2mg OD

Can be used BD if OD dosing is ineffective

May reduce lower bowel motility, patients with signs of sub-acute intestinal obstruction should be monitored following administration. As for other 5-HT3 antagonists, ECG changes including QT interval prolongation have been reported. Therefore, caution should be exercised in patients with cardiac rhythm or conduction disturbances, in patients using other medications that prolong QT interval (see Table 7), in patients treated with anti-arrhythmic agents or beta-adrenergic blocking agents and in patients with significant electrolyte disturbances (low potassium, magnesium or calcium). Concomitant use of cardio-toxic drugs (e.g. anthracyclines) may increase risk of arrhythmias.

Common side effects: headache and constipation - consider laxatives, caution in patients with history of migraines

4mg BD (usual dose)

Dose range 4-8mg up to TDS

Administer with caution to patients who have or may develop prolongation of QTc.(see above for information beside granisetron). Ondansetron is known to increase large bowel transit time; patients with signs of sub-acute intestinal obstruction should be monitored following administration.

Interactions: Potent inducers of CYP3A4 such as phenytoin, carbamazepine, and rifampicin, may increase the oral clearance of ondansetron and decrease ondansetron blood concentrations.  Data from small studies indicate that ondansetron may reduce the analgesic effect of tramadol.

10mg TDS or 6 hourly as required,

Max of 3 doses in 24 hrs (oral liquid available)

The EMEA issued advice on use of metoclopramide in 2013 (ECC metoclopramide statement) restricting the dose and duration of use of the medicine to minimise the known risks of potentially serious neurological SE’s.

Metoclopramide is associated with agitation and extra-pyramidal symptoms particularly in young females, in addition prolonged use may lead to neurological side effects in elderly patients in particular. Caution is advised in patients with Parkinson’s Disease and taking concurrent neuroleptics.

Bowel transit time can be reduced and it is contra-indicated in GI obstruction.

May cause drowsiness.

Avoid in liver or renal dysfunction, Parkinson’s disease, cardiac failure and hypothyroidism.

Buccal preparation (Buccastem®) useful for the vomiting patient as absorbed from the oral mucosa.

May induce / unmask/ destabilise diabetes – advise patients of symptoms of thirst / increased diuresis, increase BM monitoring in patients with diabetes as per ECC guidelines.