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NCCN Flash Updates: NCCN Guidelines Updated for Antiemesis

NCCN has published updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®), and the NCCN Drugs & Biologics Compendium (NCCN Compendium®) for Antiemesis. These NCCN Guidelines® are currently available as Version 1.2023.

Link directly to the Updates section of the NCCN Guidelines: Antiemesis


  • Language modified to be sensitive and inclusive.


  • High emetic risk, new agent added: Fam-trastuzumab deruxtecan-nxki.
  • Moderate emetic risk, agents removed:
    • Amivantamab-vmjw
    • Azacitidine
    • Fam-trastuzumab deruxtecan-nxki


  • Low emetic risk, new agents added:
    • Amivantamab-vmjw
    • Azacitidine
    • Ciltacabtagene autoleucel
    • Tebentafusp-tebn
  • Minimal emetic risk:
    • Agent removed: Denileukin diftitox
    • New agents added:
      • Nivolumab/relatlimab-rmbw
      • Sirolimus-albumin
      • Teclistamab-cqyv
      • Tremelimumab-actl


  • Footnote d revised: Corticosteroid antiemetic premedication should be avoided for 3–5 days prior to and 90 days after chimeric antigen receptor (CAR) T-cell therapies. Upon disease progression, corticosteroids may be resumed if needed. Antiemetic regimens used during lymphodepleting chemotherapy regimens should also employ a corticosteroid-sparing approach to antiemetic prophylaxis.


  • Footnote i revised: Especially for patients with anticipatory, anxiety-related, or breakthrough nausea, may consider adding lorazepam 0.5–1 mg PO or IV or sublingual (SL) every 6 hours as needed on days 1–4. Use the lowest effective dose and dosage interval possible. Start with 0.5 mg for patients who are naïve to lorazepam. May be administered with or without H2 blocker or proton pump inhibitor (PPI) if patient exhibits reflux symptoms. See Principles of Emesis Control for the Cancer Patient with Cancer(AE-1). (Also pages AE-6, AE-9, AE-10, and AE-13)
  • Footnote k revised: Data suggest that a 5-mg dose of olanzapine is efficacious. Consider this dose especially for patients who are elderly older or who are over sedated patients. Hashimoto H, et al. Lancet Oncol 2020;21:242-249. Mukhopadhyay S, et al. Future Oncol 2021;17:2041-2056. Pharmacologic Considerations for Antiemetic Prescribing (AE-B).
  • Footnote removed: Available as a fixed combination product only.


  • Following Low, top option revised: Start before anticancer therapy (order does not imply preference).


  • Significant changes made to Emetogenic Potential of Oral Anticancer Agents table in order to provide additional guidance for prophylaxis for moderate to high emetic risk.
    • Agent removed: Altretamine.


  • Minimal to low emetic risk oral anticancer agents:
    • Agents added:
      • Futibatinib
      • Pacritinib
    • Agents removed:
      • Infigratinib
      • Umbralisib


  • Following Low to minimal emetic risk, second option revised: Nausea/vomiting (Breakthrough Treatment for Anticancer Therapy-Induced Nausea/Vomiting [AE-10] and consider escalating to a higher level of antiemetic prevention [ie Moderate-High and consider prophylaxis] for the next cycle).


  • First column, second bullet, second sub-bullet removed: Nabilone 1–2 mg PO two times per day (BID).


  • New page added: Emetogenic Potential of Radiopharmaceutical Anticancer Agents


  • Following Chemotherapy and RT (Including TBI), option revised: See emesis prevention for chemotherapy-induced nausea/vomiting (High [AE-4], Moderate [AE-5], Low and Minimal [AE-6], and Oral [AE-9]). If radiation combined with chemotherapy, antiemetic prophylaxis is based upon the modality (chemotherapy or radiation) with the highest emetic risk (AE-1).

AE-A (2 of 3)

  • Serotonin receptor antagonists (5-HT3 RA), second bullet, second sub-bullet revised: Repeat dosing of palonosetron 0.25 mg IV at 48–72 hours appears is likely to be safe, based on available evidence and effective.
  • New heading added: Atypical antipsychotics.
    • New bullet added: If olanzapine is being used prophylactically as part of the antiemetic regimen, it may be used once daily (prior to chemotherapy or at bedtime) and continued for 2–3 days after chemotherapy for regimens that are likely to cause significant delayed emesis.

AE-A (3 of 3)

  • New reference added: Gao J, Zhao J, Jiang C, et al. Olanzapine (5 mg) plus standard triple antiemetic therapy for the prevention of multiple-day cisplatin chemotherapy-induced nausea and vomiting: a prospective randomized controlled study. Support Care Cancer 2022;30:6225-6232.

AE-B (1 of 4)

  • NK1 RAs:
    • New bullets added:
      • Fosaprepitant contains polysorbate 80, which may be implicated in infusion hypersensitivity reactions. Aprepitant emulsion and fosnetupitant do not contain polysorbate 80.
      • Although no head-to-head clinical trial data with a superiority endpoint have been published, emerging clinical evidence (non-inferiority endpoints) and anecdotal evidence suggest there may be differences in efficacy.

AE-B (2 of 4)

  • Corticosteroids:
    • New bullet added: Dexamethasone may cause hiccups.
    • Seventh bullet revised: Corticosteroid antiemetic premedication should be avoided for 3–5 days prior to and 90 days after CAR T-cell therapiesUpon disease progression, corticosteroids may be resumed if needed.
  • Olanzapine:
    • New bullet added: Use caution and monitor ECG in patients with other risk factors for QT prolongation.
    • Fourth bullet, new sub-bullet added: Consider increasing dose to 10 mg if the previously administered 5 mg dose was ineffective.
  • Footnote removed: Use caution and monitor ECG in patients with other risk factors for QT prolongation.
  • New footnote a added: Use diphenhydramine 25–50 mg PO/IV either every 4 or every 6 h for dystonic reactions. If allergic to diphenhydramine, use benztropine at 1–2 mg IV or IM x 1 dose, followed by PO dose of 1–2 mg daily or BID if needed. May consider using amantadine 100 mg BID-TID as treatment of drug-induced dystonic reactions for those patients intolerant of anticholinergic medications.

AE-B (3 of 4)

  • Cannabinoid, new bullet added: Excessive cannabinoid use can lead to cannabinoid hyperemesis.
  • New footnote b added: Use caution and monitor ECG in patients with other risk factors for QT prolongation.

AE-B (4 of 4)

  • References updated.


  • Eighth bullet, sub-bullet revised: Possibly switch Consider changing to a different NK1 RA with different pharmacokinetic/pharmacodynamic profile. Although no available head-to-head clinical trial data support this, anecdotal evidence suggests it may be helpful.


  • New section added: Abbreviations.


For the complete updated versions of the NCCN Guidelines, NCCN Guidelines with NCCN Evidence Blocks™, the NCCN Drugs & Biologics Compendium (NCCN Compendium®), the NCCN Biomarkers Compendium®, the NCCN Chemotherapy Order Templates (NCCN Templates®), the NCCN Radiation Therapy Compendium™, and the NCCN Imaging Appropriate Use Criteria (NCCN Imaging AUC™), please visit NCCN.org.

To view the NCCN Guidelines for Patients®, please visit NCCN.org/patientguidelines.

Free NCCN Guidelines apps for iPhone, iPad, and Android devices are now available! Visit NCCN.org/apps.

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