Notification



Notification Issue Date:



Policy Attachment


Attachment to Policy # 08.01.41c


Attachment:A

Policy #:08.01.41c

Description:Risk of Emesis Without Prophylaxis: Intravenous and Oral Antineoplastic Agents

Title:Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)



RISK OF EMESIS WITHOUT PROPHYLAXIS: INTRAVENOUS ANTINEOPLASTIC AGENTS

HIGHLY EMETIC: MORE THAN 90 PERCENT RISK OF EMESIS
AC combination (containing anthracycline [e.g., daunorubicin, doxorubicin, epirubicin, idarubicin] plus cyclophosphamide)
Carboplatin AUC ≥ 4
Carmustine > 250 mg/m2
Cisplatin
Cyclophosphamide > 1,500 mg/m2
Dacarbazine
Doxorubicin ≥ 60 mg/m2
Epirubicin > 90 mg/m2
Ifosfamide ≥ 2 g/m2/dose
Mechlorethamine
Streptozocin


MODERATELY EMETIC: 30 TO 90 PERCENT RISK OF EMESIS
Aldesleukin > 12 - 15 million IU/m2
Amifostine > 300 mg/m2
Arsenic trioxide
Azacytidine
Bendamustine
Busulfan
Carboplatin AUC < 4
Carmustine ≤ 250 mg/m2
Clofarabine
Cyclophosphamide ≤ 1,500 mg/m2
Cytarabine > 200 mg/m2
Dactinomycin
Daunorubicin
Dinutuximab
Doxorubicin < 60 mg/m2
Epirubicin ≤ 90 mg/m2
Idarubicin
Ifosfamide < 2 g/m2/dose
Interferon alfa ≥ 10 million IU/m2
Irinotecan
Melphalan
Methotrexate ≥ 250 mg/m2
Oxaliplatin
Temozolomide
Trabectedin


LOW EMETOGENICITY: 10 TO 30 PERCENT RISK OF EMESIS
Ado-trastuzumab emtansine
Aldesleukin ≤ 12 million IU/m2
Amisfostine ≤ 300 mg/m2
Atezolizumab
Belinostat
Blinatumomab
Brentuximab vedotin
Cabazitaxel
Carfilzomib
Cytarabine (low-dose) 100 - 200 mg/m2
Docetaxel
Doxorubicin (liposomal)
Eribulin
Etoposide
5-Fluorouracil
Floxuridine
Gemcitabine
Interferon alfa >5 to <10 million IU/m2
Irinotecan (liposomal)
Ixabepilone
Methotrexate > 50 mg/m2 to < 250 mg/m2
Mitomycin
Mitoxantrone
Necitumumab
Olaratumab
Omacetaxine
Paclitaxel
Paclitaxel-albumin
Pemetrexed
Pentostatin
Pralatrexate
Romidepsin
Talimogene laherparepvec
Thiotepa
Topotecan
Ziv-aflibercept


MINIMALLY EMETIC: LESS THAN 10 PERCENT RISK OF EMESIS
Alemtuzumab
Avelumab
Asparaginase
Bevacizumab
Bleomycin
Bortezomib
Cetuximab
Cladribine (2-chlorodeoxyadenosine)
Cytarabine < 100 mg/m2
Daratumumab
Decitabine
Denileukin diftitox
Dexrazoxane
Durvalumab
Elotuzumab
Fludarabine
Interferon alfa ≤ 5 million IU/m2
Ipilimumab
Methotrexate ≤ 50 mg/m2
Nelarabine
Nivolumab
Obinutuzumab
Ofatumumab
Panitumumab
Pegaspargase
Peginterferon
Pembrolizumab
Pertuzumab
Ramucirumab
Rituximab
Siltuximab
Temsirolimus
Trastuzumab
Valrubicin
Vinblastine
Vinblastine (liposomal)
Vincristine
Vincristine (liposomal)
Vinorelbine


RISK OF EMESIS WITHOUT PROPHYLAXIS: ORAL ANTINEOPLASTIC AGENTS

MODERATELY TO HIGHLY EMETIC: 30 PERCENT OR GREATER RISK OF EMESIS
Altretamine
Busulfan ≥ 4 mg/day
Ceritinib
Crizotinib
Cyclosphosphamide ≥ 100 mg/m2/day
Enasidenib
Estramustine
Etoposide
Lenvatinib
Lomustine (single day)
Midostaurin
Mitotane
Niraparib
Olaparib
Panobinostat
Procarbazine
Rucaparib
Temozolamide (> 75 mg/m2/day) when administered with concurrent radiotherapy
Trifluridine/tipiracil


MINIMALLY TO LOW EMETIC: LESS THAN 30 PERCENT RISK OF EMESIS
Abermaciclib
Afatinib
Alectinib
Axitinib
Bexarotene
Brigatinib
Bosutinib
Busulfan < 4 mg/day
Cabozantinib
Capecitabine
Chlorambucil
Cobimetinib
Cyclophosphamide < 100 mg/m2/day
Dasatinib
Dabrafenib
Erlotinib
Everolimus
Fludarabine
Gefitinib
Hydroxyurea
Ibrutinib
Idelalisib
Imatinib
Ixazomib
Lapatinib
Lenalidomide
Melphalan
Mercaptopurine
Methotrexate
Nilotinib
Neratinib
Osimertinib
Palbociclib
Pazopanib
Pomalidomide
Ponatinib
Regorafenib
Ribociclib
Ruxolitinib
Sonidegib
Sorafenib
Sunitinib
Temozolamide ≤ 75 mg/m2/day (when administered without radiotherapy)
Thalidomide
Thioguanine
Topotecan
Trametinib
Tretinoin
Vandetanib
Vemurafenib
Venetoclax
Vismodegib
Vorinostat


REFERENCE

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology - Antiemesis. V.3.2018. 06/11/18. [NCCN Web site]. Available at: https://www.nccn.org/professionals/physician_gls/pdf/antiemesis.pdf [via free subscription]. Accessed January 23, 2019.



Version Effective Date: 03/11/2019
Version Issued Date: 03/11/2019
Version Reissued Date: N/A

Connect with Us        


© 2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.