TABLE 98.10 MANAGEMENT OF CHEMOTHERAPY-INDUCED NAUSEA AND VOMITING (CINV) Agents with a high therapeutic index Drug class Specific drug Serotonin -S3 receptor antagonists Ondansetron Pediatric dosage and frequency ( usual adult maximum ) 0.15 mg/kg ( mg ) q h or 0.45 mg/ kg ( 24 mg ) q24h 10-40|ig/kg ( mg ) q24h 10 mg/m ( 10 mg ) ql 2-24 h Route Comment IV/PO Ondansetron max IV dose: 16 mg Steroid Granisetron Dexamethasone NK receptor Aprepitant 125 mg on day 1, followed by 80 mg once daily on days and PO Scopolamine 1.5-mg fixed -dose transdermal TDP antagonist IV/PO IV/PO Should not be used in patients with steroid -sensitive malignancies without consultation with oncologist ( e.g., ALL, lymphoma ) Use should be avoided/minimized in patients at high risk of infection or if at increased risk of mucosal toxicity from chemotherapy ( e.g., AML, advanced lymphomas, ALL during induction ) For patients >20 kg May be combined with serotonin receptor antagonists Other patch For patients >40 kg Avoid concurrent use of anticholinergic drugs such as diphenhydramine Agents with a low therapeutic index Pediatric dosage and frequency Drug class Specific drug ( usual adult maximum ) Route Comment Benzodiazepine Lorazepam 0.05 mg/kg ( mg ) q h IV/PO Dopamine antagonist Metoclopramide 0.5 mg/kg q h IV/PO Other Dronabinol Olanzapine mg/m2 2.5-10 mg PO PO Overdosage may be common with weight -based dosing strategies Thus, also consider 0.25 mg for 25-50 kg, and mg for >50 kg More potent as an anxiolytic than as an antiemetic Children are at high risk of ext r a py mi dal r ea ctions Must be given with diphenhydramine prophylaxis No data in use younger than yrs Limited data in younger patients IV, intravenous; PO, per os; ALL, acute lymphoblastic leukemia ; AML, acute myeloid leukemia ; NK , neurokinin ; TDP, transdermal patch Transaminitis with elevations in AST and/or ALT is common in pediatric cancer patients Many chemotherapy agents cause a mild reversible transaminitis Treatment-related transaminitis is usually a laboratory-only finding without any clinical correlate Transfusion-associated viral transaminitis can also occur in the frequently transfused oncology population, but the direct and indirect screening of donor blood has reduced the incidence of viral transmission Immunosuppression from treatment can also increase the risk of CMV and EBV Isolated transaminitis may be noted during an evaluation in the ED but rarely is an indication for further laboratory evaluation Hyperbilirubinemia is common during cancer treatment, is usually mild and reversible and rarely requires any further ED evaluation Such elevations are likely