Waikato DHB Palliative Care Guidelines
3. Nausea and vomiting
Chart antiemetics regularly.
Combinations are often required. | |
Consider the underlying cause(s) which may include:
- hypercalcaemia, uraemia
- drugs – antibiotics, opioids, cytotoxics
- hepatomegaly, gastric stasis, constipation, intestinal obstruction
- abdominal radiotherapy
- raised intracranial pressure, vestibular syndromes
- fear and anxiety.
Investigate and treat cause(s) if possible.
Consider the mechanisms of action of the individual antiemetics.
Review if unresponsive to standard therapy – consider unrecognised physical causes or psychological distress.
The following sections contain examples of agents commonly used.3.1 First-line antiemetics
3.1.1 Metoclopramide
Upper GI prokinetic plus weak central effects via dopamine receptors.
Indicated for GI gastroparesis and functional bowel obstruction (commonly caused by opioids) and for GORD.
10-20mg tds/qid PO or subcut (or IV 4-6 hourly).
Important to give A/C – 20-30 minutes before meals.
Contraindicated in complete proximal bowel obstruction and Parkinsons Disease.
Watch for agitation, particularly higher doses and in young women.
3.1.2 Haloperidol
Dopamine (D2) Receptor Antagonist.
A potent centrally acting antiemetic – VERY useful for opioid induced nausea and vomiting, hypercalcaemia and renal failure.
1.5 - 3mg nocte PO.
Can be given as a subcut bolus (0.5-1mg Q8H) or infusion (1-5mg/ 24hrs).
Available in 0.5mg and 1.5mg tabs.
If concerned about side effects start at 0.5mg 6- 8 hourly PRN.
Contraindicated in Parkinsons Disease.
3.1.3 Cyclizine
Antihistaminic, antimuscarinic
Indicated for motion sickness, pharyngeal stimulation, mechanical bowel obstruction and raised intracranial pressure.
25-50mg tds PO.
Can be given as a subcut infusion (NOT bolus injection as this can cause severe skin irritation and abscess formation) - 50-150mg = total daily dose.
If concerned about sedation, start at 25mg bd.
Note: Cyclizine tablets incur a part charge at community pharmacies but if used in “terminal care”, a special authority number can be applied for. Forms available from your pharmacist or see Pharmac website.
3.2 Second-line antiemetics
3.2.1 Domperidone
Upper GI prokinetic – low side effect profile - no significant central effects.
10 - 20mg qid PO A/C.
No parenteral or rectal preparation.
Note: Domperidone tablets incur a part charge at community pharmacies but if used in “terminal care” a special authority number can be applied for. Forms available from your pharmacist or see Pharmac website.
3.2.2 Methotrimeprazine (Levomepromazine)
Known as Nozinan™
Phenothiazine anti-psychotic used for management of nausea (acting at multiple receptor sites) and can also be useful for pain and terminal restlessness.
Starting dose = 6.25mg – 12.5mg PO/subcut nocte – lower doses may be effective also.
Can either be given once daily at night or up to TDS depending on response or alternatively as a subcut infusion. (Doses above 50mg/24hours are unusual).
Postural hypotension and drowsiness occur commonly and are increasingly likely at higher doses.
3.2.3 Dexamethasone
Centrally acting antiemetic.
2 - 4mg daily PO or subcut. (higher doses may be used e.g. vomiting associated with raised intracranial pressure).
Especially useful in liver metastases and raised intracranial pressure.
3.2.4 Prochlorperazine
Phenothiazine with antiemetic properties.
5-10mg PO tds - must NOT be given subcut.
3mg buccal tabs are usually ineffective.
The rectal route (25mg suppositories up to 8hrly) is valuable on occasions but requires a special authority application.
Overall has LIMITED use in palliative care and there is good evidence that Haloperidol is more effective with less side-effects.
3.2.5 Hyoscine (Scopoderm TTS™)
Rarely used in palliative care.
Marked antimuscarinic effects.
Should NOT be used concurrently with metoclopramide.
Apply patch to skin every 3 days (check availability).
Note: Scopoderm TTS™ patches incur a part charge at community pharmacies but if used in “terminal care”, a special authority number can be applied for. Forms available from your pharmacist or see Pharmac website.
3.2.6 Lorazepam
Benzodiazepine effective for nausea exacerbated by fear/anxiety.
The sedative side effect may often be helpful.
0.5mg – 1mg tds PO.
3.2.7 Ondansetron
The serotonin (5HT3) antagonists, e.g. ondansetron have proven benefit in chemotherapy and radiation induced emesis BUT are not generally prescribed in the treatment of vomiting in Palliative Care patients due to low efficacy, limited availability and high cost.
Causes constipation.
Information last reviewed: June 2009
| Please foward any enquiries about this document to
haggars@waikatodhb.govt.nz |
| Next review date: July 2010 | For Palliative Care advice, please call 8691 or the specialist on-call. |
