A randomized, double-blind, placebo-controlled phase II study of olanzapine-based prophylactic antiemetic therapy for delayed and persistent nausea and vomiting in patients with HER2-positive or HER2-low breast cancer treated with trastuzumab deruxtecan: ERICA study (WJOG14320B)

Abstract

Nausea and vomiting are common adverse events associated with trastuzumab deruxtecan (T-DXd). We evaluated the efficacy of an olanzapine-based triplet regimen for preventing nausea and vomiting in patients receiving first cycle T-DXd. This multi-institutional, randomized, double-blind, placebo-controlled (ERICA) phase II study enrolled patients with HER2-positive/HER2-low metastatic breast cancer receiving their first cycle of T-DXd. Patients were randomized to olanzapine 5 mg or placebo once daily (1:1 ratio) from Day 1 to 6, plus a 5-hydroxytryptamine type 3-receptor antagonist (5-HT3RA) and dexamethasone 6.6 mg intravenously or 8 mg orally on Day 1. The total observation period was 504 hours (21 days) from the first T-DXd administration. The primary endpoint was complete response (CR), defined as no emetic events and no rescue medications, in the delayed phase (24-120 hours post-T-DXd), with the type I error rate of 0.2 (one-sided) for the comparison. Secondary endpoints included no nausea rate in the delayed and persistent phases (120-504 hours), adverse event by CTCAE and PRO-CTCAE. In total, 168 patients were enrolled at 43 sites in Japan (Nov 2021-Sep 2023) with 162 patients (olanzapine, n = 80; placebo, n = 82) included in the per protocol set. The primary endpoint was met as the delayed phase CR rate was significantly greater with olanzapine than placebo (70.0% versus 56.1%, P = 0.047). Efficacy was maintained in the persistent phase (63.9% versus 44.4%). No nausea rate was also greater with olanzapine (delayed phase: 57.5% versus 37.8%; persistent phase: 51.4% versus 31.9%). CR rates in the delayed phase favored olanzapine across subgroups. Appetite loss was also decreased with olanzapine. Hyperglycemia and somnolence were mostly of low-grade severity. Olanzapine 5mg for 6 days with 5-HT3RA and dexamethasone appears effective for T-DXd-treated patients to prevent delayed and persistent nausea and vomiting.