Olanzapine for the Prevention of Chemotherapy-Induced Nausea and Vomiting in Autologous Hematopoietic Cell Transplant

Background: The use of olanzapine to prevent chemotherapy-induced nausea and vomiting (CINV) shows promise when used prior to highly emetogenic, single day regimens. To our knowledge, no data exists to support its prophylactic use in the hematopoietic cell transplant (HCT) population where patients receive multi-day highly emetogenic chemotherapy and CINV may be difficult to control. Uncontrolled CINV can lead to complications and increased hospital stay and is one of the more feared complications of patients. Objectives: Assess the effectiveness of olanzapine to reduce the incidence and severity of CINV among select autologous HCT recipients. The primary objective is to evaluate the impact of olanzapine compared to fosaprepitant on breakthrough antiemetic usage. Secondary objectives are to evaluate the impact of olanzapine compared to fosaprepitant on emesis frequency and length of stay. Methodology: Beginning July 1, 2015, olanzapine replaced fosaprepitant for prevention of CINV in our busulfan, cyclophosphamide, etoposide (BuCyVP) and high-dose melphalan (MEL) autologous HCT protocols. We retrospectively reviewed the charts of patients receiving BuCyVP or MEL from January 1 to June 30, 2015 (fosaprepitant group) and July 1 to December 31, 2015 (olanzapine group). Results: A total of 68 patients receiving MEL (N = 37 fosaprepitant, N = 31 olanzapine) and 47 patients receiving BuCyVP (N = 21 fosaprepitant, N = 26 olanzapine) were included. Breakthrough antiemetic use was significantly lower in the MEL group for patients who received olanzapine compared to fosaprepitant (P < .001). There was no difference in frequency of emesis episodes (P = .07) or hospital length of stay (P = .24) between the two groups. In the BuCyVP group, there was no difference in total breakthrough antiemetic use (P = .08), frequency of emesis episodes (P = .24), or hospital length of stay (P = .78) in patients who received olanzapine compared to fosaprepitant, however; numerically less breakthrough usage was seen in the olanzapine group. Of the patients in either protocol who received olanzapine for the prevention of CINV, 4 (7%) patients discontinued olanzapine early due to adverse events. Conclusions: Olanzapine was associated with significantly lower breakthrough antiemetic usage in patients receiving MEL and numerically lower breakthrough antiemetic usage in patients receiving BuCyVP in this small, retrospective study. Overall, these results encourage a larger trial to determine the safety and efficacy of olanzapine compared to fosaprepitant for prevention of CINV in the setting of HCT.