Palonosetron to Prevent Nausea and Vomiting After Chemotherapy
Effective prevention of acute and delayed nausea and vomiting from chemotherapy using palonosetron, a second-generation 5-HT3 antagonist.
Authored by a pharmacist for NHS medicines information on Palonosetron
- About palonosetron
- Key facts about palonosetron
- Who can and cannot take palonosetron
- How and when to take palonosetron
- Dosage for palonosetron
- How to take or administer palonosetron
- Taking palonosetron with other medicines and herbal supplements
- Common questions about palonosetron
About palonosetron
Palonosetron is used to prevent nausea and vomiting that can happen after having chemotherapy treatment for cancer.
It does not treat nausea and vomiting if these symptoms have already started.
Palonosetron only comes as an injection that is given by a healthcare professional. There are 2 strengths of injection: 50 micrograms in 1 ml (0.05 mg/ml) and 250 micrograms in 5 ml (0.05 mg/ml).
In adults, palonosetron is given as a single injection over 30 seconds. The injection is usually given 30 minutes before treatment with chemotherapy starts.
In children aged 1 month to 17 years, palonosetron is also given as a single injection over 30 seconds, 30 minutes before chemotherapy.
Palonosetron is a type of medicine known as an antiemetic. It belongs to a group of medicines called 5HT3 antagonists or 5HT3 receptor antagonists.
Palonosetron works by blocking 5HT3 receptors which are found in the bowel and in the vagus nerve. When chemotherapy is given, it can stimulate these receptors to send signals to the vomiting centre in the brain. This causes the sensation of nausea and triggers the vomiting reflex. Palonosetron blocks these signals and so helps to prevent nausea and vomiting.
Key facts about palonosetron
- Palonosetron starts to work within 30 minutes of being given.
- The effects of palonosetron can last up to 5 days.
- Palonosetron is a second-generation 5-HT3 receptor antagonist with unique pharmacology, providing superior control of both acute and delayed CINV compared to first-generation agents.
- A single dose is highly effective; repeat dosing is not typically required for standard regimens.
Who can and cannot take palonosetron
Palonosetron can be taken by adults and children aged 1 month or older.
Palonosetron is not suitable for everyone. Tell your doctor or nurse before having palonosetron if you:
- have a severe allergy to palonosetron or any of the other ingredients
- have moderate or severe liver problems
- have any heart problems such as a prolonged QT interval on an ECG, heart block, severe heart failure, or disturbances in heart rhythm
- have any problems with your body’s electrolyte balance such as low potassium or magnesium levels
- are taking any other medicines that can cause heart rhythm changes
Pregnancy and breastfeeding
Palonosetron is not usually recommended during pregnancy. Tell your doctor if you are pregnant or trying to get pregnant before having palonosetron.
Palonosetron may get into breast milk in small amounts. Talk to your doctor about breastfeeding before having palonosetron.
How and when to take palonosetron
Palonosetron is given as a single injection into a vein (intravenously) by a doctor or nurse. It is given 30 minutes before you start chemotherapy.
You will only be given palonosetron once per chemotherapy cycle. Do not take more than one dose in 24 hours.
Dosage for palonosetron
The dose of palonosetron depends on your age and body weight.
| Age group | Dose |
|---|---|
| Adults (18 years and over) | 250 micrograms (0.25 mg) given as a single injection |
| Children aged 1 month to 17 years | 20 micrograms/kg body weight (maximum 1,500 micrograms or 1.5 mg) given as a single injection |
Your doctor will work out the dose required for your child based on their weight.
How to take or administer palonosetron
Palonosetron is given by a healthcare professional. The injection is given slowly into a vein over at least 30 seconds.
Palonosetron can be given undiluted or diluted in glucose 5% or sodium chloride 0.9%.
Do not use palonosetron if it is cloudy or discoloured. Do not mix with other medicines.
Taking palonosetron with other medicines and herbal supplements
Palonosetron is commonly used with other antiemetics like dexamethasone and NK-1 receptor antagonists (e.g., aprepitant) for optimal CINV control, particularly in highly emetogenic chemotherapy.
Tell your cancer doctor or pharmacist if you are taking:
- any other medicines including those bought without a prescription and herbal remedies
- medicines that can affect your heart rhythm such as certain antibiotics (e.g., erythromycin), antifungals (e.g., ketoconazole), antidepressants (e.g., citalopram)
There is a small risk that palonosetron may change the way your heart beats (QT prolongation). Your doctor may monitor your heart with an ECG.
Side effects of palonosetron
Like all medicines, palonosetron can cause side effects in some people, although not many people have problems.
Serious side effects
Get medical help immediately if you develop:
- an allergic reaction (rash, swelling, difficulty breathing)
- changes in heartbeat (fast, slow, irregular)
- severe dizziness or fainting
Common side effects
These side effects affect between 1 and 10 in every 100 people:
- headache
- constipation or diarrhoea
- feeling tired or dizzy
- pain, redness or swelling at injection site
Palonosetron has a favorable safety profile compared to first-generation 5-HT3 antagonists, with lower rates of dizziness and similar incidences of headache and constipation.
Side effects in children
Side effects are similar to adults. Palonosetron was non-inferior to ondansetron in pediatric trials with good tolerability.
How palonosetron works for chemotherapy nausea and vomiting
Chemotherapy-induced nausea and vomiting (CINV) is categorized as acute (within 24 hours) or delayed (days 2-5 post-chemotherapy). Palonosetron is particularly effective for both phases, especially delayed CINV with moderately emetogenic chemotherapy (MEC).
A meta-analysis confirmed palonosetron significantly improves control of emesis and nausea in acute and delayed phases after HEC or MEC.
In triple therapy with dexamethasone and NK-1 antagonists, palonosetron enhances delayed nausea control in high-risk regimens like anthracycline + cyclophosphamide.
Pregnancy, breastfeeding and fertility while taking palonosetron
Pregnancy: Limited data; use only if benefit outweighs risk.
Breastfeeding: Unknown if excreted in milk; consider interrupting breastfeeding.
Fertility: No evidence of impairment.
Palonosetron and alcohol
Avoid alcohol as it may worsen nausea.
Frequently Asked Questions (FAQs)
How quickly does palonosetron work?
Palonosetron starts working within 30 minutes and effects last up to 5 days, effectively covering acute and delayed CINV.
Can palonosetron be used in children?
Yes, approved for children from 1 month old at 20 μg/kg (max 1.5 mg). Non-inferior to ondansetron in pediatric trials.
Does palonosetron prevent delayed nausea?
Yes, uniquely indicated for delayed CINV with MEC; meta-analyses confirm efficacy in pediatrics too.
What if I still feel sick after palonosetron?
Contact your healthcare team; additional antiemetics like olanzapine or metoclopramide may be added per guidelines.
Is palonosetron better than ondansetron?
Palonosetron shows superior efficacy for delayed CINV and longer half-life due to higher receptor affinity.
Efficacy in Specific Populations
Adults with HEC/MEC: Meta-analysis shows better control of nausea and emesis vs. older 5-HT3 RAs.
Pediatrics: Effective for HD-MTX in ALL (86.8% complete response acute phase). Recent meta-analysis supports delayed CINV prophylaxis.
High-risk regimens: Triple combination excels in AC regimens.
Guidelines and Place in Therapy
MASCC/ESMO and NCCN guidelines recommend palonosetron in preference for CINV prevention due to evidence of superior efficacy.
References
- Palonosetron in the prevention of chemotherapy-induced nausea and vomiting: an evidence-based review of safety, efficacy, and place in therapy — Luigi Celio, Core Evidence. 2015-08-26. https://pmc.ncbi.nlm.nih.gov/articles/PMC4554402/
- Palonosetron versus ondansetron for prevention of chemotherapy-induced nausea and vomiting in paediatric patients with cancer — The Lancet Oncology. 2016-03-01. https://pubmed.ncbi.nlm.nih.gov/26795844/
- Palonosetron in the prevention of chemotherapy-induced nausea and vomiting in children with acute lymphoblastic leukemia treated with high-dose methotrexate — Journal of Clinical Oncology. 2011-05-20. https://ascopubs.org/doi/10.1200/jco.2011.29.15_suppl.9535
- Palonosetron for prevention of delayed chemotherapy-induced nausea and vomiting in pediatric patients: a meta-analysis — Supportive Care in Cancer. 2023-12-22. https://pubmed.ncbi.nlm.nih.gov/38145979/
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