抗肿瘤治疗所致恶心呕吐全程管理上海专家共识（2024年版）

doi:10.19401/j.cnki.1007-3639.2024.01.008

摘要/Abstract

摘要：

恶性肿瘤患者在接受化疗、放疗、靶向治疗及免疫治疗等抗肿瘤治疗时都可能引发恶心呕吐。化疗所致恶心呕吐（chemotherapy-induced nausea and vomiting，CINV）是最为常见也是目前研究最为深入的不良反应；放疗所致恶心呕吐（radiation-induced nausea and vomiting，RINV）、靶向治疗及免疫治疗所致恶心呕吐（targeted therapy and immunotherapy-induced nausea and vomiting，TIINV）也越来越受到关注。本专家组在《化疗所致恶心呕吐全程管理上海专家共识（2018年版）》的基础上，根据近年来抗肿瘤治疗所致恶心呕吐（antineoplastic-induced nausea and vomiting，AINV）领域的循证医学新证据，结合上海一线肿瘤治疗专家的实际临床经验，最终形成《抗肿瘤治疗所致恶心呕吐全程管理上海专家共识（2024年版）》，以便进一步在上海地区积极、合理、规范、全程地预防和处理AINV，保障患者的治疗强度和医疗安全。

关键词: 抗肿瘤治疗, 恶心, 呕吐, 全程管理, 共识

Abstract:

Nausea and vomiting are common adverse reactions in tumor patients during anti-tumor therapy such as chemotherapy, radiotherapy, targeted therapy and immunotherapy. Although chemotherapy-induced nausea and vomiting (CINV) is the most common and the most intensively studied adverse event, radiation-induced nausea and vomiting (RINV), targeted therapy and immunotherapy-induced nausea and vomiting (TIINV) have also attracted more and more attention. Based on “Shanghai expert consensus on whole-process management of chemotherapy-induced nausea and vomiting (2018 edition)”, as well as new medical evidence of antineoplastic-induced nausea and vomiting (AINV) and experience of Shanghai experts in this field, the expert group finally developed “Shanghai expert consensus on whole-process management of antineoplastic-induced nausea and vomiting (2024 edition)”. This consensus will guide doctors in Shanghai to standardize the whole-process management of AINV, and to ensure the treatment intensity and medical safety of patients.

Key words: Antineoplastic, Nausea, Vomiting, Whole-process management, Consensus

中图分类号:

R730.53

上海市抗癌协会癌症康复与姑息治疗专业委员会, 上海市抗癌协会肿瘤药物临床研究专业委员会, 中国老年保健协会肿瘤防治与临床研究管理专业委员会. 抗肿瘤治疗所致恶心呕吐全程管理上海专家共识（2024年版）[J]. 中国癌症杂志, 2024, 34(1): 104-134.

Cancer Rehabilitation and Palliative Professional Committee of Shanghai Anti-Cancer Association , Cancer Drug Clinical Research Committee of Shanghai Anti-Cancer Association , Cancer Prevention and Clinical Research Committee of Chinese Aging Well Association . Shanghai expert consensus on whole-process management of antineoplastic-induced nausea and vomiting (2024 edition)[J]. China Oncology, 2024, 34(1): 104-134.

图/表 10

表1

常用抗肿瘤治疗药物的致吐风险分级"

给药途径	药物
静脉给药
高度致吐风险（呕吐发生率>90%）
	顺铂	异环磷酰胺≥2 g/m²	德曲妥珠单抗^#*
	AC方案或含有AC的方案（阿霉素或表阿霉素+环磷酰胺）	氮芥	戈沙妥珠单抗^#
	卡铂（AUC≥4）	氮烯咪胺（达卡巴嗪）	链脲菌素^*#▲
	环磷酰胺>1 500 mg/m²	卡莫司汀>250 mg/m²	美法仑≥140 mg/m^{2 #}
	表阿霉素>90 mg/m²	阿霉素>60 mg/m²
中度致吐风险（呕吐发生率30% ~ 90%）
	阿米福汀>300 mg/m²	伊立替康^*#	罗米地辛^*
	苯达莫司汀	更生霉素（放线菌素）	洛铂^▲
	卡莫司汀^△≤250 mg/m^{2 #}	柔红霉素^△#▲	氯法拉滨^*#▲
	环磷酰胺^△≤1 500 mg/m^{2 #}	阿仑珠单抗^*	美法仑<140 mg/m^{2 #}
	阿糖胞苷>200 mg/m²	阿扎胞苷^*#▲	奈达铂^▲
	奥沙利铂^△#	氨磷汀>300 mg/m^{2 #▲}	曲贝替定^△*#▲
	甲氨蝶呤^△≥250 mg/m^{2 #}	白细胞介素-2 12 ~ 15 mU/m^{2 #▲}	去甲氧柔红霉素^#▲
	卡铂^△（AUC<4）^#	白消安^*#▲	三氧化二砷^*#▲
	阿霉素^△≤60 mg/m^{2 #}	苯达莫司汀^*#▲	替莫唑胺^*#▲
	表阿霉素^△≤90 mg/m^{2 #}	恩杂鲁胺^▲
	伊达比星^{△ #}	放线菌素^△#▲
	异环磷酰胺^△<2 g/m^{2 #}	干扰素α≥10 mU/m^{2 ▲}
低度致吐风险（呕吐发生率10% ~ 30%）
	恩美曲妥珠单抗	恩美拉瑞妥昔单抗^*	卡非佐米^*#▲
	阿米福汀≤300 mg/m²	干扰素α 5 ~ 10 mU/m^{2 #▲}	卡妥索单抗^*
	卡巴他赛	高三尖杉酯碱^#▲	可泮利塞^#*
	阿糖胞苷100 ~ 200 mg/m²	依洛珠单抗^*	库潘尼西^#
	多西他赛	长春氟宁^*	莫格利珠单抗^#
	阿霉素（脂质体）	米托蒽醌	奈拉滨^*
	艾立布林	博纳吐单抗^*▲	耐昔妥珠单抗^*#▲
	依托泊苷	伊珠单抗奥唑米星^*#	帕尼单抗^*
	5-氟尿嘧啶	阿柏西普^*#▲	帕妥珠单抗^*
	氟尿苷	阿基仑赛^*#	喷司他丁^#▲
	吉西他滨	阿特珠单抗^▲	硼替佐米^*
	伊立替康（脂质体）	埃万妥单抗^#	溶瘤病毒T-Vec^#▲
	紫杉醇	艾基维仑赛^#	替朗妥昔单抗^#
	白蛋白结合型紫杉醇	艾日布林^#▲	替西罗莫司^#*
	培美曲塞喷司他丁	艾萨妥昔单抗^#	维博妥珠单抗^#
	普拉曲沙	氨磷汀≤300 mg/m^{2 #▲}	维布妥昔单抗^*
	塞替派	奥加米星吉妥组单抗^*	维恩妥人单抗^*#
	拓扑替康	白细胞介素-2≤12 mU/m^{2 #▲}	维泊妥组单抗^#
	伊沙匹隆	贝利司他^*#▲	西达基奥仑塞^#
	甲氨蝶呤50 ~ 250 mg/m²	本妥昔单抗^#▲	Mosunetuzumab-axgb^#
	丝裂霉素	西妥昔单抗^*
轻微致吐风险（呕吐发生率<10%）
	门冬酰胺酶	奥法木单抗^*#▲	纳武利尤单抗^*#▲
	博来霉素（平阳霉素）	奥妥珠单抗^*#▲	帕博利珠单抗^*#▲
	克拉屈滨（2-氯脱氧腺苷）	白蛋白结合型西罗莫司^#	培门冬酶^#▲
	阿糖胞苷<100 mg/m²	贝伐珠单抗^*#▲	匹杉琼^*
	长春瑞滨	达雷木单抗^▲	曲妥珠单抗^*#▲
	地西他滨	达雷妥尤单抗^*#	司妥昔单抗^#▲
	右丙亚胺	地尼白细胞介素^▲	特瑞普利单抗^▲
	氟达拉滨	度伐利尤单抗^*#	戊柔比星^#▲
	阿维鲁单抗^#	干扰素α≤5 mU/m^{2 ▲}	地加瑞克^#
	信迪利单抗^▲	甲氨蝶呤<50 mg/m^{2 #▲}	氟维司群^#
	伊匹木单抗^*#▲	聚乙二醇干扰素^▲	戈舍瑞林^#
	依马利尤单抗^*	卡瑞利珠单抗^▲	兰瑞肽^#
	右雷佐生^#	雷莫西尤单抗^*#▲	亮丙瑞林^#
	长春花碱^▲	利妥昔单抗^*#▲	奥曲肽^#
	长春碱^*#	罗特西普^#	曲普瑞林^#
	长春新碱^*#▲	马吉妥昔单抗^#
	长春新碱（脂质体）^▲	玛贝妥单抗^#
口服给药
中-高度致吐风险（呕吐发生率≥30%）
	六甲蜜胺	阿伐替尼^*#	芦卡帕利^*#▲
	白消安≥4 mg/d	阿扎胞苷^#	仑伐替尼^*#▲
	环磷酰胺≥100 mg/(m²·d^-1)	奥拉帕尼^#▲	米哚妥林^*#
	雌氮芥	贝美替尼^#	莫博替尼^#
	依托泊苷	博舒替尼>400 mg/d^#	尼拉帕利^*#
	环己亚硝脲（单日）	达拉非尼^#	帕比司他^▲
	米托坦	恩考芬尼^#	瑞波西利^*
	丙卡巴嗪（甲基苄肼）	非屈替尼^*#	塞利尼索^*#
	替莫唑胺>75 mg/(m²·d^-1)	卡博替尼^*#	色瑞替尼^*#▲
	TAS-102	克唑替尼^*#▲	伊马替尼>400 mg/d^#
	长春瑞滨	六甲基三聚氰胺^*	伊那尼布^*#
	阿贝西利^*	艾拉司群^#
轻微-低度致吐风险（呕吐发生率<30%）
	白消安<4 mg/d	达可替尼^*#	瑞派替尼^#
	卡培他滨	达沙替尼^*#▲	塞普替尼^#
	苯丁酸氮芥	度维利塞^*#	沙利度胺^*#
	环磷酰胺<100 mg/(m²·d^-1)	厄达替尼^*#	舒尼替尼^*#▲
	氟达拉滨	厄洛替尼^#▲	索拉非尼^*#▲
	羟基脲	恩曲替尼^*#	索立德吉^▲
	美法仑	凡德他尼^*#▲	索尼德吉^*#
	6-巯基嘌呤	呋喹替尼^▲	索托雷塞^#
	甲氨蝶呤	伏立诺他^*#▲	他拉唑帕利^*#
	替莫唑胺≤75 mg/(m²·d^-1)	格拉地吉^*#	泊马度胺^*#▲
	硫鸟嘌呤	吉非替尼^*#▲	他泽司他^*#
	拓扑替康	吉瑞替尼^*#	特泊替尼^#
	维甲酸	卡马替尼^#	替吉奥^▲
	伊沙佐米^*#▲	可美替尼^*#▲	托泊替康^#
	依维莫司^*#▲	拉罗替尼^*#	妥卡替尼^#
	泽布替尼^*#	拉帕替尼^*#▲	维罗非尼^▲
	阿卡替尼^*	来那度胺^*#▲	维莫德吉^*#▲
	阿法替尼^*#▲	来那替尼^*#	维莫非尼^*#
	阿可替尼^*#	劳拉替尼^*#	维奈克拉^*#▲
	阿来替尼^*#▲	利柏西利^#	西达本胺^▲
	阿帕替尼^▲	芦可替尼^*#	伊布替尼^*#▲
	阿培利司^*#	鲁索利替尼^▲	伊德利塞^#
	阿思尼布^#	尼洛替尼^*#▲	伊马替尼≤400 mg/d^#
	阿西替尼^#*▲	帕博西尼^*▲	阿比特龙^#
	埃克替尼^▲	帕纳替尼^▲	阿那曲唑^#
	艾德拉尼^*▲	帕唑帕尼^*▲	阿帕他胺^#
	艾伏尼布^*#	哌柏西利^#	比卡鲁胺^#
	安罗替尼^▲	培唑帕尼^#	达罗他胺^#
	奥希替尼^*#▲	佩米替尼^#	恩杂鲁胺^#
	贝沙罗汀^*#▲	泊那替尼^*#	依西美坦^#
	贝组替凡^#	普拉替尼^#	氟他胺^#
	吡咯替尼^▲	巯嘌呤^#▲	来曲唑^#
	吡昔替尼^*#	曲氟尿苷替匹嘧啶^#	甲地孕酮^#
	博舒替尼≤400 mg/d^#	曲美替尼^*#▲	三苯氧胺^#
	布格替尼^*#	瑞戈非尼^*#▲	托瑞米芬^#

表1

表2

表3

图1

表4

图2

表5

表6

按放疗致吐风险等级划分的止吐药物推荐用法及用量"

致吐风险等级	剂量	用法
高度致吐风险
5-HT₃ RA
昂丹司琼	8 mg口服或0.15 mg/kg静脉注射	预防给药。放疗日每天1 ~ 2次，首剂在放疗之前给予。如果当天没有放疗计划，则在放疗之后的第2天给予，每天1 ~ 2次
格拉司琼	2 mg口服或1 mg口服或0.01 mg/kg静脉注射	预防给药。放疗日每天1次，于放疗之前给予。如果当天没有放疗计划，则在放疗之后的第2天给予，每天1次
皮质类固醇类药物
DXM	4 mg口服或静脉注射	预防给药。放疗日每天1次，于放疗之前给予。如果当天没有放疗计划，则在放疗之后的第2天给予，每天1次
中度致吐风险
5-HT₃ RA
昂丹司琼	8 mg口服或0.15 mg/kg静脉注射	预防给药。放疗日每天1 ~ 2次，首剂在放疗之前给予
格拉司琼	2 mg口服或1 mg口服或0.01 mg/kg静脉注射	预防给药。放疗日每天1次，于放疗之前给予
托烷司琼	5 mg口服或静脉注射	预防给药。放疗日每天1次，于放疗之前给予
皮质类固醇类药物
DXM	4 mg口服或静脉注射	预防给药。放疗前5次给予，放疗日每天1次，于放疗之前给予
低度致吐风险
5-HT₃ RA
昂丹司琼	8 mg口服或0.15 mg/kg静脉注射	治疗爆发性CINV
格拉司琼	2 mg口服或1 mg口服或0.01 mg/kg静脉注射	治疗爆发性CINV
皮质类固醇类药物
DXM	脑部放疗：若尚未使用皮质类固醇类药物，建议DXM 4 mg口服或静脉注射；对于其他部位，4 mg口服或静脉注射	治疗爆发性CINV。根据需要增加剂量，每天最多可口服或静脉注射16 mg
多巴胺受体拮抗剂
丙氯拉嗪	5 ~ 10 mg口服或静脉注射	治疗爆发性CINV。根据需要增加剂量，每天最多使用3 ~ 4次
甲氧氯普胺	5 ~ 20 mg口服或静脉注射	治疗爆发性CINV。根据需要增加剂量，每天最多使用3 ~ 4次
轻微致吐风险
5-HT₃ RA
昂丹司琼	8 mg口服或0.15mg/kg静脉注射	治疗爆发性CINV
格拉司琼	2 mg口服或1 mg口服或0.01 mg/kg静脉注射	治疗爆发性CINV
皮质类固醇类药物
DXM	4 mg口服或静脉注射	治疗爆发性CINV
多巴胺受体拮抗剂
丙氯拉嗪	5 ~ 10 mg口服或静脉注射	治疗爆发性CINV
甲氧氯普胺	5 ~ 20 mg口服或静脉注射	治疗爆发性CINV

表6

图附录Ⅱ-1

参考文献 74

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致吐风险	急性	延迟性
高度	5-HT3 RA + DXM + NK-1 RA^* + 奥氮平或5-HT3 RA/NK-1 RA复方制剂 + DXM + 奥氮平（优先）；备选1：5-HT3 RA + DXM + NK-1 RA；备选2：5-HT3 RA^▲ + DXM + 奥氮平	DXM + NK-1 RA^* + 奥氮平（优先）；备选1：DXM + NK-1 RA^*；备选2：DXM + 奥氮平
中度	5-HT3 RA^▲ + DXM±NK-1 RA^*#或±奥氮平^#； 5-HT3 RA/NK-1 RA复方制剂 + DXM	DXM±NK-1 RA^*#或±奥氮平^#
低度	5-HT3 RA/DXM/甲氧氯普胺/丙氯拉嗪	无需常规预防
轻微	无需常规预防	无需常规预防

预测因子	化疗周期前评分
基线得分	10
风险因素
年龄<60岁	+1
预期性恶心呕吐	+1
化疗前1天睡眠<7 h	+1
孕吐史	+1
接受铂类或蒽环类药物化疗	+2
在之前的化疗期间患者在家使用非处方止吐药	+3
在之前的治疗周期中发生过CINV	+5
接受前2个周期化疗	-5
接受≥3个周期化疗	-6

致吐风险等级	放疗部位
高度致吐风险（>90%）	全身
中度致吐风险（30% ~ 90%）	上腹部、全脑、全脊髓
低度致吐风险（10% ~ 30%）	头颈部、胸部、盆腔
轻微致吐风险（<10%）	四肢、乳腺