Management ofNausea & Vomiting
Dr Iain LawrieSpecialist Registrar
in Palliative Medicine
Vomit
Vomiting Centre
Cortical Structures
Gut Mucosa
Vestibular Apparatus
D2 5-HT3 ACh
H1 5-HT2 ACh
Chemoreceptor Trigger Zone
D2 5-HT3 Ach
H1, ACh
Vomit
Vomiting Centre
Cortical Structures
Gut Mucosa
Vestibular Apparatus
D2 5-HT3 ACh
H1 5-HT2 ACh
H1 AChMotion
Emotions, sights, smells,
raised ICP
GI obstruction, bowel colic, tumour mass,
constipation
Chemoreceptor Trigger Zone
D2 5-HT3 AChDrugs, toxins,
uraemia, hypercalcaemia
Vomit
Vomiting Centre
Cortical Structures
Gut Mucosa
Vestibular Apparatus
D2 5-HT3 ACh
H1 5-HT2 ACh
H1 AChMotion
Emotions, sights, smells,
raised ICP
GI obstruction, bowel colic, tumour mass,
constipation
Chemoreceptor Trigger Zone
D2 5-HT3 AChDrugs, toxins,
uraemia, hypercalcaemia
Metoclopramide, Levomepromazine
Granisetron
Haloperidol Metoclopramide
Levomepromazine Granisetron
Dexamethasone
Cyclizine, Hyoscine HBr
Cyclizine, Levomepromazine, Hyoscine HBr
Factors to consider
Mechanism of action of anti-emetic drugs
Response to anti-emetics already given Combinations of drugs should have
different actions Levomepromazine has multiple
receptor affinities
Factors to consider
Effects of anti-emetics on GI motility (prokinetic / antikinetic)
Adjuvant use of anti-secretory drugs Adjuvant use of corticosteroids Adverse effects of drugs Cost of drugs
Management
Correct reversible causes stop gastric irritant drugs treat gastritis
• PPIs / antacids treat cough
• antitussive treat constipation
• laxatives
Management
Raised ICP- steroids / radiotherapy
Anxiety Hypercalcaemia
- rehydration +/- bisphosphonates
Causes of drug-induced N&V Gastric irritation
Gastric stasis
CTZ stimulation
5HT3-receptor stimulation
Antibiotics, iron, NSAIDs
Antimuscarinics, opioids, TCA
Antibiotics, cytotoxics, digoxin
Antibiotics, cytotoxics, SSRIs
What if it’s not working?
Is it being absorbed? Is the dose optimum? Do you have the correct cause? Most anti-emetics can be given SC Doses usually the same PO, SC and IV
Prescribing an anti-emetic
Choice depends on cause of N&V Give regularly Alternative to oral route if unable to
absorb- subcutaneous stat doses- continuous subcutaneous infusion (driver)- rectal route
Anti-emetics – dopamine antagonists Haloperidol (D2)
Metoclopramide (D2, 5-HT3, 5-HT4 agonist) Prochlorperazine (D2) Domperidone (D2) Levomepromazine (D2, ACh, H1, 5-HT3)
Side effects- EPSE- sedation in higher doses- reduce seizure threshold
Anti-emetics – histamine antagonists Cyclizine (H1, ACh) Levomepromazine (D2, ACh, H1, 5-HT3)
Side effects- drowsiness- anticholinergic effects- postural hypotension
Anti-emetics - anticholinergics Hyoscine butylbromide (ACh) Hyoscine hydrobromide (ACh) Cyclizine (ACh) Levomepromazine (D2, ACh, H1, 5-HT3)
Side effects- sedation- anticholinergic effects
Anti-emetics - prokinetics
Metoclopramide (D2, 5-HT3, 5-HT4 agonist)
Domperidone (D2)
Side effects:- colic- EPSE (not domperidone – doesn’t cross BBB)
Anti-emetics – serotonin antagonists Ondansetron, granisetron, tropisetron
Side effects- constipation
Place in palliative care- obstruction / stretch- resistant N&V
Anti-emetics - steroids
Dexamethasone Reduce permeability of BBB & area postrema
to emetogenic substances Reduce neuronal content of GABA in the
brain stem Reduce leuenkephalin release Reduce oedema around lesion or tumour
Gastric stasis & irritation
Nausea made worse by eating Large volume vomits Early fullness & bloating Belching & reflux Hiccups Epigastric fullness & tenderness
Gastric stasis & irritation
1st line metoclopramide
Adjuncts- antiflatulent- PPI- stop irritant drugs
Bowel obstruction without colic Variable nausea Vomiting dependent on site of
obstruction Abdominal distension Background aching pain Constipation Absent or ‘hyperactive’ bowel sounds
Bowel obstruction without colic 1st line metoclopramide 2nd line cyclizine or haloperidol
(substitute)
Adjuvants- diamorphine- octreotide- docusate- steroids
Bowel obstruction with colic
Symptoms as before, but with colicky pains
1st line cyclizine OR haloperidol PLUS buscopan
2nd line cyclizine AND haloperidol OR levomepromazine
Adjuvants- diamorphine, octreotide, docusate
Chemical induced N&V
Significant nausea Variable vomiting Few other GI symptoms Evidence of presence
i.e. new drug started, biochemistry results
1st line haloperidol / metoclopramide 2nd line ADD cyclizine OR substitute
levomepromazine
Raised intracranial pressure
Known intracerebral tumour Early morning headaches Predominant nausea Intermittent vomiting Papilloedema Neurological deficit Seizures
Raised intracranial pressure
1st line dexamethasone & cyclizine
2nd line ADD haloperidol
3rd line 5-HT3 antagonist (substitute)
Motion / movement related N&V Nausea & vomiting worse on movement Can be associated with cranial nerve
lesions and base of skull metastases
1st line cyclizine
2nd line hyoscine hydrobromide
Indeterminate N&V
1st line haloperidol OR cyclizine
2nd line haloperidol AND cyclizine
3rd line levomepromazine (substitute)
4th line consider metoclopramide, dexamethasone, 5HT3 antagonist
Summary
Try to determine the cause wherever possible
1/3 of patients will need more than one anti-emetic
Eliminate reversible causes
Continue anti-emetic indefinitely if cause is not self-limiting