# Antiemetic prophylaxis for chemotherapy by emetic risk

Source: https://onco.cc/protocols/antiemetic-prophylaxis-by-emetic-risk/  
OnCo record `antiemetic-prophylaxis-by-emetic-risk` (Protocol). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Sickness from chemotherapy is now largely preventable. The anti-sickness medicines you are given depend on how likely your chemotherapy is to cause sickness: for the strongest regimens that is four medicines before treatment and some for the days after, for the mildest none at all. If you are still sick, tell your team: there is a next step.

## Summary

Prophylaxis is chosen by the emetic risk of the regimen, defined as the chance of vomiting in the first 24 hours without prophylaxis (high, above 90 per cent; moderate; low; minimal), adjusted for patient factors such as female sex and younger age. MASCC/ESMO (2023) recommend for high emetic risk a four-drug regimen before chemotherapy: a 5-HT3 receptor antagonist, dexamethasone, an NK1 receptor antagonist (aprepitant, fosaprepitant, netupitant or fosnetupitant with palonosetron, or rolapitant) and olanzapine (I, A). For delayed nausea after cisplatin and other non-anthracycline-cyclophosphamide regimens, dexamethasone and olanzapine continue on days 2 to 4 (II, B); after anthracycline with cyclophosphamide, dexamethasone stops after day 1 and olanzapine alone continues on days 2 to 4 (II, B). Olanzapine 10 mg is the best investigated dose; 5 mg or a bedtime dose is an option where sedation matters (II, B).

For moderate emetic risk, MASCC/ESMO add an NK1 receptor antagonist for carboplatin at AUC 5 or more and for women under 50 having oxaliplatin, use a 5-HT3 receptor antagonist with a steroid for other regimens, and limit the steroid to day 1. Low emetic risk gets a single agent before treatment and nothing for the delayed phase; minimal risk gets none. ASCO (2020) keeps dexamethasone when checkpoint inhibitors are given with chemotherapy and gives no routine prophylaxis for checkpoint inhibitors alone. For breakthrough nausea and vomiting the evidence favours olanzapine 10 mg once daily for 3 days (II, B); for high-dose chemotherapy before stem cell transplant, a 5-HT3 receptor antagonist with dexamethasone and aprepitant (I, A), with olanzapine to be considered.

## Fields

- Kind: Protocol
- Last checked: 2026-11-11
- Also known as: CINV prophylaxis; chemotherapy-induced nausea and vomiting prevention; antiemetic regimen by emetogenicity; anti-sickness medicines with chemotherapy
- Tags: protocol; nausea-and-vomiting; supportive-care

## Connected records

- fronts: [Supportive Care & Survivorship](https://onco.cc/fronts/supportive-care/)
- technologies: [Antiemetics for chemotherapy-induced nausea and vomiting](https://onco.cc/technologies/antiemetic-therapy/)
- drugs: [Aprepitant (and fosaprepitant)](https://onco.cc/drugs/aprepitant/), [Carboplatin](https://onco.cc/drugs/carboplatin/), [Cisplatin](https://onco.cc/drugs/cisplatin/), [Cyclophosphamide](https://onco.cc/drugs/cyclophosphamide/), [Dexamethasone](https://onco.cc/drugs/dexamethasone/), [Granisetron](https://onco.cc/drugs/granisetron/), [Netupitant and palonosetron](https://onco.cc/drugs/netupitant-palonosetron/), [Ondansetron](https://onco.cc/drugs/ondansetron/), [Oxaliplatin](https://onco.cc/drugs/oxaliplatin/), [Palonosetron](https://onco.cc/drugs/palonosetron/), [Rolapitant](https://onco.cc/drugs/rolapitant/)
- institutions: [American Society of Clinical Oncology (ASCO)](https://onco.cc/institutions/asco/), [European Society for Medical Oncology (ESMO)](https://onco.cc/institutions/esmo/), [Multinational Association of Supportive Care in Cancer](https://onco.cc/institutions/mascc/)
- ideas: [Low-dose olanzapine and generic antiemetic bundles in every guideline and formulary](https://onco.cc/ideas/idea-moon-olanzapine-antiemetic-everywhere/)
- protocols: [Anticipatory nausea and vomiting before chemotherapy: prevention and treatment](https://onco.cc/protocols/anticipatory-nausea-and-vomiting/), [Nausea and vomiting in advanced cancer not caused by cancer treatment](https://onco.cc/protocols/nausea-and-vomiting-in-advanced-cancer/)

---
JSON: https://onco.cc/api/v1/entities/antiemetic-prophylaxis-by-emetic-risk.json