【原】美国临床肿瘤学会临床实践指南更新：止吐药

　　2017年7月31日，美国临床肿瘤学会《临床肿瘤学杂志》在线发表马萨诸塞州伯灵顿莱希医院及医学中心（塔夫茨大学、哈佛大学、波士顿大学的教学医院）、达纳法伯癌症研究所、纪念斯隆凯特林癌症中心、北卡罗来纳大学、杜克大学医学中心、美国临床肿瘤学会、弗吉尼亚肿瘤学会、堪萨斯大学癌症中心、德克萨斯大学MD安德森癌症中心、新泽西州海茨敦患者代表、华盛顿大学弗雷德哈钦森癌症研究中心、加拿大渥太华医院、渥太华大学、多伦多大学、多伦多儿童医院、德国柏林非凡医院集团新克尔恩医院、海德堡大学的美国临床肿瘤学会临床实践指南更新：止吐药。

　　1999年，美国临床肿瘤学会首次发表止吐药临床实践指南，并于2006、2011、2015年进行更新，此次重新召集专家小组对2009年11月～2016年6月发表的医学文献进行了系统回顾。

　　本次系统回顾共评审出41篇文献。Ⅲ期随机对照研究表明，加入奥氮平进行止吐预防，可以减少成人患者对高致吐风险抗肿瘤药产生恶心的可能性。随机对照研究还支持加入神经激肽1受体拮抗药（目前中国仅有阿瑞匹坦）对化疗患者的作用。

　　其中，蒽环类＋环磷酰胺联合治疗患者止吐预防推荐意见，主要根据乳腺癌患者研究。

　　主要更新推荐意见包括：

• 推荐将奥氮平加入接受高致吐抗肿瘤药或突发恶心呕吐的成人止吐方案；

• 推荐仅对接受蒽环类和环磷酰胺化疗的成人在化疗第一天给予地塞米松；

• 推荐对接受卡铂曲线下面积≥4mg/mL/min或大剂量化疗的成人、接受高致吐抗肿瘤药的儿科患者，加入神经激肽1受体拮抗药（目前中国仅有阿瑞匹坦）；

• 对放疗所致恶心呕吐，推荐根据解剖区域和风险水平对止吐给药方案进行调整；

• 推荐补救疗法单独用于低致吐风险放疗，例如对于致吐风险最低的四肢、乳房放疗，推荐5-羟色胺3受体拮抗药（昂丹司琼、格拉司琼）、皮质激素（地塞米松）、多巴胺受体拮抗药（普鲁氯哌嗪、甲氧氯普胺）补救疗法。

• 专家小组重申早期使用适合抗肿瘤药物或放疗的最有效止吐方案的重要性，该方案应被用于初始治疗，而非首先使用低效治疗以评估患者的呕吐反应。

J Clin Oncol. 2017 Jul 31. [Epub ahead of print]

Antiemetics: American Society of Clinical Oncology Clinical Practice Guideline Update.

Hesketh PJ, Kris MG, Basch E, Bohlke K, Barbour SY, Clark-Snow RA, Danso MA, Dennis K, Dupuis LL, Dusetzina SB, Eng C, Feyer PC, Jordan K, Noonan K, Sparacio D, Somerfield MR, Lyman GH.

Lahey Hospital and Medical Center, Burlington; Dana-Farber Cancer Institute, Boston, MA; Memorial Sloan Kettering Cancer Center, New York, NY; University of North Carolina at Chapel Hill, Chapel Hill; Duke University Medical Center, Durham, NC; American Society of Clinical Oncology, Alexandria; Virginia Oncology Associates, Virginia Beach; Virginia Oncology Associates, Norfolk, VA; University of Kansas Cancer Center, Westwood, KS; The University of Texas MD Anderson Cancer Center, Houston, TX; Patient Representative, Hightstown, NJ; Fred Hutchinson Cancer Research Center and University of Washington, Seattle, WA; The Ottawa Hospital and University of Ottawa, Ottawa; The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Vivantes Clinics Neukoelln, Berlin; University of Heidelberg, Heidelberg, Germany.

PURPOSE: To update the ASCO guideline for antiemetics in oncology.

METHODS: ASCO convened an Expert Panel and conducted a systematic review of the medical literature for the period of November 2009 to June 2016.

RESULTS: Forty-one publications were included in this systematic review. A phase III randomized controlled trial demonstrated that adding olanzapine to antiemetic prophylaxis reduces the likelihood of nausea among adult patients who are treated with high emetic risk antineoplastic agents. Randomized controlled trials also support an expanded role for neurokinin 1 receptor antagonists in patients who are treated with chemotherapy.

RECOMMENDATION: Key updates include the addition of olanzapine to antiemetic regimens for adults who receive high-emetic-risk antineoplastic agents or who experience breakthrough nausea and vomiting; a recommendation to administer dexamethasone on day 1 only for adults who receive anthracycline and cyclophosphamide chemotherapy; and the addition of a neurokinin 1 receptor antagonist for adults who receive carboplatin area under the curve ≥ 4 mg/mL per minute or high-dose chemotherapy, and for pediatric patients who receive high-emetic-risk antineoplastic agents. For radiation-induced nausea and vomiting, adjustments were made to anatomic regions, risk levels, and antiemetic administration schedules. Rescue therapy alone is now recommended for low-emetic-risk radiation therapy. The Expert Panel reiterated the importance of using the most effective antiemetic regimens that are appropriate for antineoplastic agents or radiotherapy being administered. Such regimens should be used with initial treatment, rather than first assessing the patient's emetic response with less-effective treatment.

PMID: 28759346

DOI: 10.1200/JCO.2017.74.4789