5-HT(3)-receptor antagonists in the management of nausea and vomiting in cancer and cancer treatment

The 5-HT(3)-receptor antagonists, considered as 'gold standard' therapy for cancer patients, are generally perceived to have similar efficacy and safety profiles, andmost antiemetic guidelines do not distinguish between agents. However, important pharmacological differences exist between agents, which may translate into potential benefits for some patients. In particular, 5-HT(3)-receptor antagonists vary in the nature of their receptor antagonism and plasma half-lives, possibly leading to differences in duration of action. Agents with a longer duration of action provide antiemetic protection throughout the acute emetic period (24 h) with a single daily dose, whereas shorter-acting agents, e.g. ondansetron, may require multiple dosing for full efficacy. Differences also exist between agents in their hepatic metabolism and cardiovascular safety, which may present particular problems for elderly patients who often receive additional medications for comorbid conditions, increasing the risk of drug-drug interaction. Recent antiemetic guidelines from the National Comprehensive Cancer Network recommend preferential use of palonosetron for moderately emetogenic chemotherapy; however, this agent is newly approved and key clinical questions remain unanswered by clinical trial data. Selection of an appropriate 5-HT(3)-receptor antagonist should be based on proven efficacy and safety, as well as on the individual characteristics of the patient.