Stratified administration of serotonin 5-HT3 receptor antagonists (setrons) for chemotherapy-induced emesis - Economic implications

The serotonin 5-HT3 receptor antagonists or 'setrons' have become the stand ard of care for the prevention of chemotherapy-induced emesis (CIE) and are first-line therapy for acute CIE in healthcare organisations worldwide. Ho wever, their superior efficacy versus standard antiemetics comes at a signi ficant cost. Currently, 3 agents are available in the US: ondansetron, gran isetron and dolasetron. The most important treatment-related factor contributing to CIE is the emet ogenicity of chemotherapy. The ability to customise, or stratify, the setro n dose to match the emetogenic challenge of the chemotherapy administered h as potential benefits, both clinically and economically. In adults, there i s an appreciable amount of clinical literature addressing stratified admini stration: however, the amount of 'hard' economic data is rather limited. In tuitively, if clinical outcomes are equivalent, then stratified administrat ion should be associated with economic benefits, as it generally promotes t he use of doses lower than those recommended by the manufacturer. The liter ature strongly substantiates this for ondansetron, but is not as favourable for granisetron or dolasetron. As the rationale and justification for dose stratification is contained in the clinical literature, the authors have reviewed the pertinent literature supporting the clinical and economic benefits of dose stratification in bo th adult and paediatric patients. The authors also provide a discussion of various additional strategies that can be employed to ensure the appropriat e and cost-effective use of setrons in real-world practice settings. These strategies include the use of lower doses than recommended by manufacturers , use for acute versus delayed phase emesis, enhancing the antiemetic effic acy by the addition of a corticosteroid, use of oral versus injectable form ulations (when appropriate) and the implementation and use of local, nation al and international drug use guidelines.