Adapted with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines^®) for Antiemesis V.2.2025. © 2025 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines^® and illustrations herein may not be reproduced in any form for any purpose without the express written permission of NCCN. To view the most recent and complete version of the NCCN Guidelines, go online to NCCN.org. The NCCN Guidelines are a work in progress that may be refined as often as new significant data become available. NCCN makes no warranties of any kind whatsoever regarding their content, use or application and disclaims any responsibility for their application or use in any way.

^dFor details regarding recommendations and specific dosing information, please refer to the NCCN Guidelines for Antiemesis.

^eAntiemetic regimens should be chosen based on the drug with the highest emetic risk as well as patient-specific risk factors.

^fEspecially for patients with anticipatory or anxiety-related breakthrough nausea, may consider adding lorazepam 0.5-1 mg by mouth (PO) or IV or sublingual (SL) every 6 hours as needed on days 1-4. Use the lowest effective dose and dosage interval possible. May be administered with or without H₂ blocker or proton pump inhibitor (PPI) if patient exhibits reflux symptoms.

^gCategory 1 recommendations indicate uniform NCCN consensus (≥85% support of the Panel) that the intervention is appropriate based on high-level evidence (≥1 randomized Phase 3 trials or high-quality, robust meta-analyses).

^hIf not used previously, consider escalating to a 4-drug regimen (option A) if emesis occurred during a previous cycle of anticancer therapy with a 3-drug regimen (olanzapine-containing regimen B or NK1 RA-containing regimen C). Olanzapine-containing regimens may be useful for patients with severe nausea.

ⁱFor select patients with additional patient-related risk factors or for whom previous treatment with a 3-drug prophylactic regimen was ineffective, or who are receiving moderately emetogenic chemotherapy (MEC) known to be higher risk, a 4-drug regimen (see option A above) may be considered.

^jOnce daily or bedtime on Day 1; bedtime on Days 2-4. Data suggest that a 2.5-mg dose of olanzapine may be efficacious, especially when used as part of a 4-drug regimen. Olanzapine doses of 2.5-5 mg may be less effective than 10 mg when used as part of a 3-drug regimen. Consider lower doses, especially for patients who are older or who are over sedated.

^kIf netupitant/palonosetron or fosnetupitant/palonosetron fixed combination product is used, no further 5-HT3 RA is required.

^lWhen used in combination with an NK1 RA, there is no preferred 5-HT3 RA.

^mEmerging data and clinical practice suggest dexamethasone doses may be individualized. Higher doses may be considered, especially when an NK1 RA is not given concomitantly. Lower doses, given for shorter durations, or even elimination of dexamethasone on day 1 or subsequent days (for delayed nausea and emesis prevention) may be acceptable based on patient characteristics. If dexamethasone is eliminated on day 1 or subsequent days, consider the use of an antiemetic combination containing 5-HT3 RA, NK1 RA, and olanzapine on day 1, and olanzapine for delayed chemotherapy-induced nausea and vomiting.

ⁿUse of corticosteroid premedications should be avoided with cellular therapies. Clinicians may wish to consider a dexamethasone-sparing approach with immune checkpoint inhibitor therapy as well.