Effectiveness of antiemetic regimens in controlling chemotherapy induced nausea and vomiting during hematopoietic stem cell transplantation

Abstract

This study aimed to evaluate the efficacy of antiemetic regimens in controlling chemotherapy-induced nausea and vomiting (CINV) among patients with haematological malignancies undergoing highly (HEC) or moderately emetogenic chemotherapy (MEC) as part of conditioning for hematopoietic stem cell transplantation (HSCT). A prospective cohort study was conducted from November 2022 to July 2024 at University Hospital Virgen del Rocío, Seville (Spain). Adult patients receiving HEC or MEC conditioning regimens were assessed for CINV control using a symptom questionnaire adapted from the validated questionnaire Pro-CTCAE. Effectiveness was measured by complete response (CR) and complete protection (CP) from nausea/emesis across acute (chemotherapy days) and delayed (five days post-chemotherapy) phases. Bitherapy (5HT3 receptor antagonists + corticosteroids) and monotherapy regimens were compared. 112 patients were included. Of 102 analysed patients, CR and CP were achieved in 42.1% and 34.3% of patients in the acute phase, and 33.3% and 30.4% in the delayed phase, respectively. Patients receiving bitherapy (who received myeloablative conditioning regimens and high-emetogenic regimens) achieved better CINV control compared to those treated with monotherapy (who received reduced-intensity and moderate emetogenic treatments). With significant improvements in acute CR (p = 0.0003) and CP (p = 0.001). Additionally, Rescue antiemetic use was lower in the bitherapy group (p = 0.230). This study reinforces the importance of assessment of antiemetic response in these patients and highlights the effectiveness of bitherapy with 5HT3 receptor antagonists and corticosteroids. However, our findings also suggest that antiemetic regimens could be optimised with strategies possibly involving triple therapy or the integration of other agents.

Supplementary Information

The online version contains supplementary material available at 10.1038/s41598-025-23612-9.

Introduction

Chemotherapy-induced nausea and vomiting (CINV) are among the most disrupting events of cancer treatment, affecting approximately 70–80% of adults receiving highly emetogenic chemotherapy (HEC) or moderately emetogenic chemotherapy (MEC)¹. CINV negatively impacts patients’ nutritional status, adherence to treatment, and can lead to cognitive and physical impairments, ultimately deteriorating their quality of life². Moreover, numerous pathways and neurotransmitters are involved in the complex development of CINV³, so adequate antiemetic prophylaxis is essential to help patients preventing these toxicities⁴.

Several guidelines have remarked on the necessity of optimizing the management of CINV in patients with cancer^5,6. In 2017, The National Cancer Comprehensive Network (NCCN) and the American Society of Clinical Oncology (ASCO) guidelines agree on the use of the standard triple antiemetic therapy (NK1 receptor antagonists (RA) + 5-hydroxy-tryptamine type (5-HT3)–RA + dexamethasone) in patients undergoing HEC⁷. Moreover, there is an update incorporating olanzapine to the triple standard regimen, in terms of CINV control of both acute and delayed phases, in patients with malignant diseases receiving HEC⁸. In fact, NCCN also endorses the incorporation of olanzapine in some antiemetic strategies to prevent MEC, whereas recent updates of the Multinational Association of Supportive Care in Cancer and the European Society of Medical Oncology (MASCC/ESMO)⁹ support the use of a standard triple antiemetic therapy + olanzapine in patients undergoing HEC with a multiple-day cisplatin regimen or stem cell transplants. However, in the study of the efficacy of these antiemetic regimens, the HSCT setting has been inadequately considered, even though HEC and MEC regimens are used^10,11.

In recent years, the management of CINV prevention in patients with haematological malignancies throughout the HSCT period has become a challenge for healthcare professionals^12–14. Some authors recommend individualised management taking into account the patient’s status or condition, potential drug interactions and the emetogenic potential of chemotherapeutic agents used during the HSCT period³. Some recent studies stated that it must be a priority to establish an antiemetic plan appropriate for this complex population, with a high risk of drug side effects due to multi-day CINV prophylaxis regimens¹⁵. Moreover, there are still no specific recommendations issued by the main guidelines for the management of CINV in these patients. The high number of drugs commonly used in the HSCT period contributes to the high variability in the prevention and management of CINV and the use of different antiemetic prophylaxis in these patients. For these reasons, further research to design new strategies to improve CINV control in these patients is required, but it should be noted that this setting has been still understudied.

Thus, the aim of this study was to evaluate the effectiveness of antiemetic prophylaxis in adult patients with haematological malignancies receiving HEC or MEC regimens within conditioning protocols for HSCT.

Methods

Study design

A prospective cohort study was conducted from 1 November 2022 to 31 July 2024 at University Hospital Virgen del Rocio (Seville, Spain) to evaluate the effectiveness of antiemetic prophylaxis in adults with haematological malignancies undergoing HEC or MEC chemotherapy as a part of the conditioning regimen for HSCT.

Population

The study included adult patients (≥ 18 years) who received HEC or MEC as part of conditioning regimens for either allogeneic or autologous HSCT, with adequate language skills in Spanish. Patients were evaluated within 24 h prior to enrollment to ensure the absence of nausea or vomiting due to causes other than chemotherapy (e.g., other medications, gastrointestinal disorders such as obstructions or constipation, electrolyte imbalances, or other medical conditions).

Survey design

To perform the study, we conducted a prior literature search to identify an appropriate questionnaire that could be used in this scenario. However no validated tool focused on the specific characteristics of chemotherapy administration in patients undergoing HSCT was found. Therefore, we designed an adapted questionnaire taking as a basis the Pro-CTCAE tool, which is validated for assessing specific symptoms in cancer patients¹⁶. Since the questionnaires were administered in Spanish, we used the previously validated Spanish translation of the Pro-CTCAE as the source for our adaptation¹⁷.For this study, we notified the NCI about the modification of the recall period and respondent instructions for this specific study Our questionnaire allows both qualitative and quantitative assessment of nausea and vomiting, providing a comprehensive approach to evaluate patient experience and antiemetic treatment effectiveness. Additionally, variables from the Phase III FOND-O clinical trial were included to obtain a more robust approach to symptom assessment related to CINV in HSCT patients¹⁸ to quantitatively determine the number of acute and delayed nausea and emesis in patients undergoing HSCT. The 6 items selected were: frequency and intensity of nausea/emesis, number of vomiting and number of rescues required with anti-emetic medication. For every item, a Likert scale with 5 possible responses was incorporated, where 0 corresponds to “never” or “none” and 4 to “very often” or “very intense”. Finally, variables that defined the baseline characteristics of the patients (demographics, diagnosis, type of HSCT, chemotherapy regimen, emetogenic potential and antiemetic regimen) were collected in the form. The final version of the questionnaire is included in Supplementary file 1.

Intervention

The designed survey was provided and explained by the pharmacy resident or pharmacist of the haematology area on the admission of patients undergoing HSCT or before initiation of conditioning chemotherapy. Patients were required to complete the questionnaire from the first day of the conditioning regimen until 5 days after the end of chemotherapy to evaluate CINV, that is, during both acute and delayed phases. Pharmacists conducted daily follow-ups to answer any questions and ensure accurate data collection. For patients referred to other hospitals, follow-ups were completed by telephone, with calls lasting 5–10 min to ensure data consistency. Although TBI-induced nausea and vomiting is generally classified as radiation-induced (RINV), in this study, regimens containing TBI were included as part of the conditioning chemotherapy. This decision aligns with NCCN guidelines, which recommend antiemetic prophylaxis with ondansetron ± dexamethasone for patients receiving TBI, and reflects common clinical practice in HSCT settings¹⁵.

Effectiveness measures

Primary endpoints

Effectiveness was assessed using two primary measures: complete response (CR), defined as no emesis or significant nausea, and complete protection (CP), defined as no emesis, no breakthrough antiemetic use, and no significant nausea. Outcomes were evaluated across the acute phase (chemotherapy days), delayed phase (five days post-chemotherapy), and the combined overall phase. CR and CP were analysed according to sex, type of HSCT (allogeneic/autologous), conditioning regimen (myeloablative/reduced intensity), and antiemetic regimens based on the number of drugs involved/prescribed, emetogenic potential (HEC/MEC).

Secondary endpoint

As secondary outcomes, we collected the necessity of breakthrough antiemetics use and the number of rescues, which were evaluated separately in each phase and analysed according to the type of HSCT, conditioning chemotherapy and emetogenic potential. We also compared the number of rescues required according to whether they had received monotherapy or bitherapy antiemetic regimens.

Statistical analysis

Frequency measures were used for the analysis of qualitative variables. For quantitative continuous variables, normality was assessed; normally distributed data were presented as mean ± standard deviation, and non-normally distributed data as median and interquartile range (IQR).

The analysis of qualitative variables was performed using the chi-square test/Fisher’s exact statistic or chi-square of independence of k groups test with Yates correction if necessary. We used a Student’s t-test for independent samples for the comparative analysis between the means of groups and the Kolmogorov–Smirnov test for the analysis of normality.

The threshold for statistical significance was established a P Value of 0.05 (P values reported have not been adjusted for multiple comparisons because this was not an exploratory approach involving numerous independent comparisons). The IBM-SPSS StatisticsV25 software was used to analyse the data and a bivariate analysis were performed to relate the effectiveness variables with the type of antiemetic response (Chi-square test).

Ethics

This study was approved by the Committee of Ethics in Research with Medicaments of Seville on April 11, 2024 (Approval No. 07/2024). The research adhered to established ethical principles and standards for research involving human subjects; accordingly, all methods were performed in accordance with relevant guidelines and regulations, including the Declaration of Helsinki. All participants were informed about the study with comprehensive language and provided with informed consent to participate in the project. The complete informed consent is provided in Supplementary file 2.

Results

One hundred twelve patients were included in the study. Table 1 presents demographic characteristics. Median age was 59 years (range: 16–72), 58% were males. The most prevalent diseases were Multiple Myeloma (MM) in 32.1%, followed by Acute Myeloid Leukemia (AML) in 18.8%, Diffuse Large B-Cell Lymphoma (DLBCL) in 10.7%, and Hodgkin Lymphoma (LH) in 7.1%. Autologous transplants were performed in 53.6% of cases. The most common conditioning regimens were thiotepa/busulfan/fludarabine regimen (TBF) (34.8%) and melphalan 200 mg/m² (23.2%). 54.5% of patients received combination therapy with 5HT3 receptor antagonists and corticosteroids, while 45.5% received monotherapy with the first. In addition, 64.3% of the regimens had high emetogenic potential.

Table 1.

Demographic variables (N = 112).

	N = 112
Median age (IQR)	59 (49–64)
Sex male,	65 (58)
Disease
Amyloid	1(0.9)
Bone marrow aplasia	3(2.7)
Mixed-Phenotype Acute Leukemia	1(0.9)
LH	8(7.1)
DLBCL	12(10.7)
Mantle cell lymphoma	5(4.5)
T-cell Lymphoma	3(2.7)
ALL	7(6.3)
AML	21(18.8)
CML	1(0.9)
MF	1(0.9)
Myelofibrosis	5(4.5)
MM	36(32.1)
MDS	7(6.3)
Germ cell tumours	1(0.9)
Type TPH
Alo	52(46.4)
Auto	60(53.6)
Conditioning for HSCT
BEA (myeloablative)	1(0.9)
BEAM (myeloablative)	17(15.2)
BuCy (myeloablative)	5(4.5)
Carboplatin + etoposide (myeloablative)	1(0.9)
TT-BCNU (myeloablative)	4(3.6)
FluCy (myeloablative)	2(1.8)
Cy + TBI (myeloablative)	5(4.5)
FluBu (myeloablative)	1(0.9)
Melphalan 140 mg/m2 (myeloablative)	11(9.8)
Melphalan 200 mg/m2 (myeloablative)	23(23.2)
TBF (reduced intensity)	39(34.8)
Antiemetic regimens
Monotherapy: 5HT3 receptor antagonists	51(45.5)
Bitherapy: 5HT3 receptor antagonists  + corticosteroids	61(54.5)
Emetogenic potential
High	72(64.3)
Moderate	40(35.7)

Data are presented as n (%) unless indicated otherwise. Abbreviation: IQR – interquartile range.

LH: Hodgkin Lymphoma; DLBCL: Diffuse Large B-Cell Lymphoma; ALL: Acute Lymphoblastic Leukemia; AML: Acute Myeloid Leukemia; CML: Chronic Myeloid Leukemia; MF: Myelofibrosis; MM: Multiple Myeloma; MDS: Myelodysplastic Syndromes; TPH: Type of Transplant Hematopoiesis; Alo: Allogeneic Transplant; Auto: Autologous Transplant; HSCT: hematopoietic stem cell transplantation; BEA: BCNU, Etoposide, and Ara-C; BEAM: BCNU, Etoposide, Ara-C, and Melphalan; BuCy: Busulfan and Cyclophosphamide; TT-BCNU: Thiotepa and BCNU; FluCy: Fludarabine and Cyclophosphamide; FluBu: Fludarabine and Busulfan; TBI: Total Body Irradiation; TBF: Thiotepa, Busulfan, and Fludarabine.

Of the 112 enrolled, 102 patients have been included in the analysis presented herein. Of the excluded patients, in six cases there was a loss to follow-up, and four patients were admitted to intensive care, resulting in insufficient data for analysis. Eight patients were transferred to their origin hospitals without completing full follow-up and were contacted by telephone to conclude the study. Among the 102 patients analyzed, 58 (56.9%) were male. Sixty-eight (66.7%) received myeloablative conditioning, and 34 (33.3%) received reduced-intensity regimens. Forty-five (44.1%) underwent allogeneic transplantation and 57 (55.9%) autologous. Sixty-seven (65.7%) received HEC and 35 (34.3%) MEC. Forty patients (39.2%) received monotherapy for antiemetic prophylaxis, while 62 (60.8%) received combination therapy, with no statistically significant difference in age between the two groups (p = 0.653). In the HEC group (n = 67), all patients received myeloablative conditioning, 56 (83.6%) underwent autologous transplantation and 62 (92.5%) received combination antiemetic therapy. In the MEC group (n = 35), 34 (97.1%) received reduced-intensity conditioning and underwent allogeneic transplantation, and all received monotherapy for antiemetic prophylaxis.

The survey results from these 102 patients are summarized in the Fig. 1. The mean number of vomiting episodes was 1.05 (SD ± 1.49) in the acute phase and 1.03 (SD ± 1.40) in the delayed phase. In the acute phase, the most poorly controlled symptom (rated 3 or 4) was the frequency of nausea (35.3%), followed by the intensity of nausea (21.6%). In the delayed phase, the worst controlled aspect was the intensity of nausea (30.4%), followed by the frequency of nausea (27.5%).

Fig. 1.

Results of the Questionnaire on Chemotherapy-Induced Nausea and Vomiting in Patients Undergoing Hematopoietic Stem Cell Transplantation

Overall effectiveness results

Primary endpoints

In the acute phase, 42.2% (CI95% 32.4–51.9) of patients achieved CR, and 34.3% (CI95% 25.5–43.1) achieved CP. In the delayed phase, CR and CP rates were 33.3%(CI95% 24.5–42.2) and 30.4%(CI95% 21.6–40.2), respectively. In both phases 21.6% (CI95% 13.7-30.4) of patientes achieved CR and 16.7% (CI95% 10.8-25.5) achieved CP. Better outcomes were observed in patients who received autologous as compared to allogeneic transplants, with significant differences in acute CR (p = 0.0002) and acute CP (p = 0.0004).

Patients who received myeloablative conditionings also showed better control than those treated with reduced-intensity regimens, particularly in acute CR (p = 0.002) and acute CP (p = 0.003). Bitherapy (5HT3 receptor antagonists + corticosteroids) was more effective than monotherapy in all phases, especially in acute CR (p = 0.0003) and acute CP (p = 0.001). For regimens with moderate emetogenic potential it was observed a lower control in CINV than those patients who were treated with high emetogenic potential, with significant differences in the acute CR and CP phases (p = 0.001 and p = 0.002, respectively) (Table 2).

Table 2.

CINV Outcomes.

N = 102	CR global		CR acute		CR delayed		CP global		CP acute		CP delayed
	N (%)	p	N (%)	p	N (%)	p	N (%)	p	N (%)	p	N (%)	p
Sex
Female n = 44	13 (29.5)	0.088	19 (43.2)	0.855	17 (38.6)	0.322	9 (20.5)	0.517	13 (29.5)	0.377	15 (34.1)	0.479
Male n = 58	9 (15.5)		24 (41.4)		17 (29.3)		9 (15.5)		22 (37.9)		16 (27.6)
Type TPH
Alo n = 45	6 (13.3)	0.072	10 (22.2)	0.0002	12 (26.7)	0.204	4 (8.9)	0.039	7 (15.6)	0.0004	11 (24.4)	0.246
Auto n = 57	16 (28.1)		33 (57.9)		22 (38.6)		14 (24.6)		28 (49.1)		20 (35.1)
Conditioning for HSCT
Myeloablative	19 (27.9)	0.027	36 (52.9)	0.002	27 (39.7)	0.054	16 (23.5)	0.028	30 (44.1)	0.003	24 (35.3)	0.128
n = 68 Reduced intensity n = 34	3 (8.8)		7 (20.6)		7 (20.6)		2 (5.9)		5 (14.7)		7 (20.6)
Antiemetic regimens
Monotherapy: 5HT3 receptor antagonists	4 (10)	0.023	8 (20)	0.0003	8 (20)	0.022	3 (7.5)	0.031	6 (15)	0.001	31 (30. 4)	0.067
n = 40 Bitherapy: 5HT3 receptor antagonists  + corticosteroids n = 62	48.(77.4)		35 (56.5)		26 (41.9)		15 (24.2)		29 (46.8)		23 (37.1)
Emetogenic potential
High n = 67	19 (28.4)	0.21	36 (53.7)	0.001	27 (40.3)	0.039	16 (23.9)	0.022	30 (44.8)	0.002	24 (35.8)	0.099
Moderate n = 35	3 (8.6)		7 (20.0)		7 (20.0)		2 (5.7)		5 (14.3)		7 (20.0)

Values are n (%). Acute indicates within 24 h of chemotherapy initiation; delayed, From 24 h after initiation of chemotherapy through 5 days after last day of chemotherapy. CINV: chemotherapy-induced nausea and vomiting; CP: complete protection; CR: complete response; TPH: type of transplant hematopoiesis; HSCT: hematopoietic stem cell transplantation. Analysis via chi-square test.

Secondary endpoints

In the acute phase, breakthrough antiemetic use was more necessary in the following subgroups: allogenic vs autologous (60% vs 35.6%, p = 0.046), reduced intensity vs myeloablative (64.7% vs 39.7%, p = 0.021) and MEC versus HEC (62.9% vs 40.3%, p = 0.038). No significant differences were detected in the delayed phase between the different subgroups.

Breakthrough antiemetic metoclopramide was used in all cases. The mean number of rescue antiemetic was 2.47 (SD ± 3.70) and 3.32 (SD ± 4.43) in the acute and delayed phases respectively. In the acute phase, the use of rescue antiemetics was significantly lower for patients receiving bitherapy therapy (1.58; SD ± 3.07) compared to monotherapy (3.85; SD ± 4.19, p = 0.002). In the delayed phase, the mean rescue doses were 3.95 (SD ± 5.10) for monotherapy and 2.87 (SD ± 3.90) for bitherapy, although differences between these subgroups were not statistically significant (p = 0.230).

Discussion

This study evaluated the effectiveness of antiemetic prophylaxis in adult patients with haematological malignancies receiving HEC or MEC as part of conditioning regimens for HSCT. Additionally, a questionnaire adapted from the PRO-CTCAE tool was developed to monitor CINV in this setting, specifically tailored to the characteristics of this patient population and the objectives of the study.

CR and CP rates indicate that monotherapy may be insufficient for CINV control in high-risk patients, underscoring the need for robust multi-agent regimens. The results showed that more patients achieved CR in the acute phase than in the delayed phase. CP was similar in both phases, at around 30%. Patients receiving bitherapy were associated with better control of CINV. The results suggest the inadequacy of monotherapy and that the addition of corticosteroids, especially in the acute phase, should improve CINV, even in patients undergoing emetogenic regimens with less emetogenic potential (MEC), and highlight the need to establish more robust antiemetic strategies.

In the context of autologous transplants, myeloablative conditioning regimens that are highly emetogenic are used. To address this, we used bitherapy, combining 5HT3 receptor antagonists with corticosteroids, which resulted in better control of CINV, particularly in the acute phase, versus allogeneic transplantation, where reduced-intensity chemotherapy regimens with lower emetogenicity are usually prescribed. So, the addition of corticosteroids was key to the improved outcomes, as they have a well-established role in enhancing the efficacy of antiemetic regimens^5,7,24.

Results of other studies^20–22 are aligned with our findings, suggesting that multi-agent antiemetic strategies are necessary to prevent breakthrough CINV in high-emetogenic settings. Agura et al.²⁰ demonstrated that while ondansetron was beneficial in reducing CINV during chemotherapy conditioning for HSCT, it showed limitations in extremely high-emetogenic scenarios, suggesting that a single-agent approach may be insufficient. Similarly, Lacerda et al.'s²¹ comparison of ondansetron, granisetron and tropisetron in the prevention of acute CINV highlighted the variability in the patient response, suggesting the potential benefits of combination regimens. Giralt et al.²² further supported this approach by studying palonosetron regimens in patients undergoing high-dose melphalan conditioning and found that additional agents were often required for sustained efficacy. Although clinical guidelines clearly recommend three- or four-drug antiemetic combinations for HEC and two- or three-drug regimens for MEC^5,9, our study revealed that monotherapy is still being used in certain clinical settings. This deviation from established standards is concerning and highlights a critical gap between evidence-based recommendations and real-world practice. The inadequate outcomes associated with single-agent prophylaxis, as demonstrated by our findings and previous studies, underscore the urgent need to reinforce adherence to antiemetic guidelines, particularly for vulnerable populations, such as patients undergoing HSCT. Strengthening institutional protocols and clinician education could help reduce this gap and improve patient care.

Despite the favourable results in the subgroup of subjects treated with bitherapy, a significant number of patients still did not achieve complete response, indicating that there is room for further optimization in CINV management. Several studies have shown that a combination of three or more agents may be essential for optimal management, particularly in high-risk populations. Clark et al.²³ found that the addition of fosaprepitant to standard antiemetic therapy resulted in a significant reduction in CINV, with CR increasing from 60% in the control group to 80% in the fosaprepitant group in patients receiving BEAM or high-dose melphalan prior to HSCT. In 2023, the systematic review carried out by the group of Báez et al.²⁴ was published, which analysed a total of 8 studies that aimed to compare antiemetic prophylaxis regimens in patients with haematologic malignancies undergoing HSCT. The four trials that compared triple and bitherapy antiemetic therapy showed that using an NK1RA resulted in a significant improvement in complete control of CINV compared to not using an NK1RA, ranging from 40 to 81.9%^25–28. In conjunction with our own results, these data strongly support the urgent need to adopt triple antiemetic therapy as the standard of care for HEC regimens. Failure to do so may subject patients to unnecessary suffering and treatment-related complications resulting from unmanaged nausea and vomiting.

Besides, olanzapine, a newer agent incorporated into antiemetic regimens, has shown promising results in further enhancing CINV control in combination with standard antiemetic therapies. The benefits of olanzapine as prophylaxis have been demonstrated in 3 phase III trials in solid malignancies^29,30. Clemmons et al.¹⁹ showed that adding olanzapine to the FOND regimen (quadruple therapy) in the HSCT and haematologic malignancy setting resulted in a significant reduction in CR in the overall assessment period (55% versus 26%) as well as the delayed assessment period (60.8% versus 30%). However, no significant improvement was observed in the acute phase. In addition, Trifilio et al.¹⁴ conducted a retrospective study in myeloma patients receiving high-dose melphalan and showed that olanzapine significantly improved delayed CINV control, with efficacy extending beyond 5 days post-transplant. These findings suggest that incorporating olanzapine into antiemetic regimens could be a potential avenue for improving outcomes in patients undergoing HEC or MEC.

This study has some limitations including its single-center design, which may affect the extrapolation of the results, especially taking into account the possible variability that may exist between the protocols in different hospitals. It should also be considered the possible subjectivity of patients when completing the questionnaire. Future multicenter randomised studies could help validate these findings, explore optimal antiemetic combinations and unify protocols in the context offer diverse HSCT patient populations. Finally, the exclusion of patients who were admitted to the intensive care unit or lost to follow-up may have led to a selection bias that could affect the overall results. However, lost patients represented a quite low proportion the total.

Despite these limitations, this study provides valuable insights into the ongoing challenges of managing CINV in HSCT patients, a population for which existing recommendations remains sparse. In addition, a questionnaire adapted to this type of patient has been designed based on the Pro-CTCAE tool, which could be useful for monitoring CINV in these patients. By focusing on haematological malignancies and examining the effectiveness of different antiemetic regimens specifically within the HSCT setting, this study reveals the need to address a critical gap in the literature and offers a foundation for developing more targeted and unified antiemetic strategies.

Conclusion

This study reinforces the need to assess antiemetic response in patients undergoing transplantation and highlights the importance of the addition of corticosteroids to antiemetic therapy. However, our findings clearly demonstrate the insufficiency of the antiemetic strategies currently used, particularly single-agent or biotherapy, to achieve optimal control of CINV in this high-risk population, highlighting the necessity for enhanced approaches, including triple therapy or the integration of newer agents such as olanzapine. Future research should prioritize optimizing antiemetic regimens for HSCT patients, with an emphasis on multicenter studies to enhance the generalizability of these findings.

Author contributions

Paloma Suárez-Casillas, Pablo Ciudad-Gutiérrez, María Pérez-Moreno designed the data collection instruments, collected the data, carried out the analyses and drafted the manuscript. Cristina Blázquez-Goñi, Francisco Manuel Martín-Domínguez, José Antonio Pérez-Simón, and Laila Abdel-Kader critically reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Funding

This study was not supported by any sponsor or funder.

Data availability

Data is provided within the manuscript or supplementary information files.

Declarations

Competing interests

Non-financial benefits have been received or will be received from any party related directly or indirectly to the subject of this article.