Reducing dexamethasone antiemetic prophylaxis during the COVID-19 pandemic: recommendations from Ontario, Canada
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ORIGINAL ARTICLE
Reducing dexamethasone antiemetic prophylaxis during the COVID-19 pandemic: recommendations from Ontario, Canada Robert C. Grant 1,2 & Coleman Rotstein 3 & Geoffrey Liu 1 & Leta Forbes 4 & Kathy Vu 4 & Roy Lee 1 & Pamela Ng 1 & Monika Krzyzanowska 1,4 & David Warr 1 & Jennifer Knox 1 Received: 24 April 2020 / Accepted: 18 June 2020 # Springer-Verlag GmbH Germany, part of Springer Nature 2020
Abstract Purpose People with cancer face an elevated risk of infection and severe sequelae from COVID-19. Dexamethasone is commonly used for antiemetic prophylaxis with systemic therapy for cancer. However, dexamethasone is associated with increased risk of viral and respiratory infections, and causes lymphopenia, which is associated with worse outcomes during COVID-19 infections. Our purpose was to minimize dexamethasone exposure during antiemetic prophylaxis for systemic therapy for solid tumors during the COVID-19 pandemic, while maintaining control of nausea and emesis. Methods We convened an expert panel to systematically review the literature and formulate consensus recommendations. Results No studies considered the impact of dexamethasone-based antiemetic regimens on the risk and severity of COVID-19 infection. Expert consensus recommended modifications to the 2019 Cancer Care Ontario Antiemetic Recommendations. Conclusion Clinicians should prescribe the minimally effective dose of dexamethasone for antiemetic prophylaxis. Single-day dexamethasone dosing is recommended over multi-day dosing for regimens with high emetogenic risk excluding high-dose cisplatin, preferably in combination with palonosetron, netupitant, and olanzapine. For regimens with low emetogenic risk, 5HT3 antagonists are recommended over dexamethasone. Keywords COVID-19 . Antiemetic . Supportive care . Chemotherapy . Glucocorticoids
Introduction The COVID-19 pandemic is growing exponentially, with over two million infections and 130,000 deaths worldwide as of April 15, 2020 [1]. Early evidence suggests that patients with cancer face an elevated risk for COVID-19 infection and a higher risk of adverse events after diagnosis [2–5], potentially because of nosocomial spread and suppressed immunity.
* Jennifer Knox [email protected] 1
Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
2
Ontario Institute for Cancer Research, Toronto, Canada
3
Division of Infectious Diseases, University of Toronto, Toronto, Canada
4
Cancer Care Ontario, Toronto, Canada
Several guidelines for pandemic era cancer care have been recently released [6–13]. These guidelines make prudent recommendations on optimizing the delivery of systemic therapy during the COVID-19 pandemic, including to: 1. Favor oral agents over intravenous agents when efficacy and toxicity profiles are similar [6, 7]. 2. Deliver oral agents and supportive medications directly to the homes of patients, rather than have them picked up in person at the pharmacy [6]. 3. Favor regimens with less frequent over more frequent IV dosing when efficacy and toxici
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