Management of Nausea and Vomiting John A. Mulder, MD Vice President, Medical Services Faith Hospice.

Management of

Nausea and Vomiting

John A. Mulder, MDVice President, Medical Services

Faith Hospice

Assessment• Onset• Frequency• Relationship to eating• Relationship to medications• Current nausea medications

• Chronic or progressing• Alleviating factors• Severity• Scale: 1-10• Goal

Assess cause:• Chemoreceptor trigger zone (CTZ)• Gastrointestinal/bowel• Vestibular• Cortical/anxiety• Vomiting center

NAUSEA

Opioids (and metabolites)

Bowel obstruction

Metabolic problemsIntracranial pressure

Other drugs

Autonomic failure

Peptic ulcer disease

Constipation

Driver, L, and Bruera, E., The MD Anderson Palliative Care Handbook

Common Causes in Cancer Patients• Treatment-related factors

– Chemotherapy– Radiation Therapy– Opioid Therapy– Other drugs (antibiotics, NSAIDs,

SSRIs, etc.)

Common Causes in Cancer Patients• Pathophysiologic/metabolic/

biochemical– Constipation– Autonomic dysfunction (gatroparesis,

stasis)– Gastric/duodenal ulcer– GERD/gastritis– Liver failure/hepatomegaly/ascites– Infection/sepsis/fever– Coughing– Increased intracranial pressure

Common Causes in Cancer Patients• Pathophysiologic/metabolic/

biochemical– Oral/esophageal infection/lesions– Pain– Dehydration– Electrolyte imbalance– Hypercalcemia– Uremia– Endocrine dysfunction

Common Causes in Cancer Patients• CNS/psychophysiologic problems

– Vestibular disturbance– Cerebrocortical mechanisms

(anticipatory N/V)– Limbic mechanisms (hypersensitivity

to taste and smell)– Anxiety

Most patients have multifactoral causes

Treatment Considerations• Constipation regimen• Decompress obstruction; disimpact• If no nausea and tolerated, support

only• Oral hygiene• Small stomach: small portions,

frequent meals, cold foods tolerated better

• Odors• Avoid odors of cooking (ventilation)• Perfumes, scents, etc.

• Opioid rotation• Steroids or RT for increased ICP• Reassurance/relaxation for

anticipatory nausea/high anxiety• Correct electrolyte imbalance• Volume repletion for dehydration• Hypercalcemia treatment with

hydration, steroids, bisphosphonates

• Adjustment of nutritional supplements

Review medication list• a. Digitalis • b. Theophylline • c. Chemotherapy• d. Antibiotics

–1. Erythromycin–2. Tetracycline–3. Metronidazole (Flagyl)–4. Ciprofloxacin (Cipro)

Pharmacologic treatmentConventional antiemetics :• metoclopramide (Reglan) – po, pr, iv, sc• prochlorperazine (Compazine) - po, pr,

iv, sc• droperidol (Inapsine) - im, iv, sc• promethazine (Phenergan) - po, pr, iv,

sc• scopolomine (Transderm Scop, Scopace)

– td, po• meclizine (Antivert) - po

Pharmacologic treatmentSelective serotonin 5-HT3 antagonists:• ondansetron (Zofran, Zuplenz) - po, iv,

sc, sl• granisetron (Kytril, Granisol, Sancuso) -

po, iv, sc, td • polonosetron (Aloxi) – iv• dolasetron (Anzemet) – iv

Pharmacologic treatmentCannabinoid receptor agonists:• nabilone (Cesamet) – PO• dronabinol (Marinol) – PO

Pharmacologic treatmentOthers:• aprepitant (Emend) – PO, IV

– Selective human substance P/neurokinin 1 receptor antagonist

Anticholinergic agents• Hyoscyamine (Levsin)

Motility Problem• a. Metoclopramide (Reglan) 5-20mg a.c.• b. Cisapride (Propulsid) 10-20mg QID

Movement induced; initiation of opioids• a. Scopolamine (Transderm Scop Patch) Q

72hrs• b. Meclizine (Antivert) 12.5-25mg Q 6hrs

Alternative antiemetics (cont.)• d. Combination suppositories: BRD

– 1. Benadryl 25 mg– 2 .Reglan 10 mg 1-2 PR Q

4hr– 3. Dexamethasone 2 mg

• e. ABHR– 1. Ativan 0.5 mg– 2. Benedryl 12.5 mg 1 Q 6hr– 3. Haldol 0.5 mg– 4. Reglan 10 mg

Unconventional antiemetics :• Haloperidol (Haldol)• Lorazepam (Ativan)• Diphenhydramine (Benadryl)• Corticosteroids (Decadron)• Sea Bands• Cannabinoids (Marinol)

BAD Drip• 50 cc D5W• 200 mg Benedryl• 8 mg Ativan• 20 mg Decadron• 0.2 – 2.0 ml/h

RBD Drip• 50 cc 0.9% sodium chloride• 80 mg Reglan• 100 mg Benadryl• 8 mg Decadron• 0.5 – 1.5 ml/h

Random thoughts . . .• Metoclopramide 1st drug of choice

because of peripheral (GI) effects and central effects (CTZ)

• Antihistamines have no antidopaminergic effect (not 1st line in treating opioid-related nausea)

• Phenothiazines very sedating, can cause other side effects

• NG tube may be necessary for mgmt of copious vomiting, abd distention, obstruction, etc.

• Combining drugs of different mechanisms may yield positive results in addressing multifactoral etiology

Random thoughts . . .• Anticipatory, PO, RTC dosing most likely

to provide greatest benefit• Corticosteroids often exert excellent

antiemetic effects• Always R/O constipation/impaction in

terminally ill patient presenting with chronic N/V

• 5-HT3 antagonists among most effective for chemotherapy induced N/V, but have minial effects on opioid-induced emesis and have no promotility effects

Costs

Drug PO Inj PRPhenergan .02/mg .09/mg .16/mg

Compazine .08/mg ---- .12/mg

Haldol .14/mg $1.80/mg

----

Emend $275.50/kit

---- ----

Hyoscyamine

$2.48/mg ---- ----

Zofran $4.73/mg $6.00/mg

----

Costs

Drug PO Inj PR

Reglan .02/mg .36/mg ----

Antivert .004/mg ---- ----

Marinol $1.68/mg ---- ----

Costs

Drug

ABHR $1.25/doseCream

$3.95/supp

Sea bands $6.20/pair

Scope patch $5.48/each

John Mulder, MDVP of Medical Services

Faith Hospice616-293-3615

[email protected]