General approach for treatment of nausea and vomiting
Overview
Nausea is inclination to vomit; feeling in throat or epigastric region alerting individual that vomiting imminent. Vomiting in ejection or expulsion of gastric contents through mouth, often requiring forceful event. Get our note, "Nausea and Vomiting in general practice".
Management
Non-pharmacological therapy
Behavioral interventions include relaxation, biofeedback, self-hypnosis, cognitive distraction, guided imagery and systematic desensitization. Psychogenic vomiting may benefit from psychological interventions.
Pharmacotherapy
Treatment of simple nausea or vomiting usually requires minimal therapy. Management of complex nausea and vomiting. For example, in patients who are receiving cytotoxic chemotherapy, may require combination therapy. "See table 1" contains information concerning commonly available antiemetic preparations.
| Table (1). Common antiemetic preparations and adult dosage regimens | ||
|---|---|---|
| Drug | Adult Dosage Regimen | Dosage Form/Route |
| Antacids | ||
| Antacids (Maalox, Gaviscon) | 15–30 mL every 2–4 hr PRN | Liquid/oral |
| Antihistaminic–anticholinergic agents | ||
| Cyclizine | 50 mg before departure; may repeat in 4–6 hr PRN | Tab |
| Dimenhydrinate | 50–100 mg every 4–6 hr PRN | Tab, chew tab, cap |
| Diphenhydramine | 25–50 mg every 4–6 hr PRN | Tab, cap, liquid |
| 10–50 mg every 2–4 hr PRN | IM, IV | |
| Meclizine | 12.5–25 mg 1 hr before travel; repeat every 12–24 hr PRN | Tab, chew tab |
| Scopolamine | 1.5 mg every 72 hr | Transdermal patch |
| 200 mg 3–4 times daily | IM | |
| Benzodiazepines | ||
| Alprazolam (Xanax) | 0.5–2 mg 3 times daily prior to chemotherapy | Tab |
| Lorazepam | 0.5–2 mg on night before and morning of chemotherapy | Tab |
| Butyrophenones | ||
| Haloperidol | 1–5 mg every 12 hr PRN | Tab, liquid, IM, IV |
| Droperidol | 2.5 mg; additional 1.25 mg may be given | IM, IV |
| Cannabinoids | ||
| Dronabinol | 5–15 mg/m2 every 2–4 hr PRN | Cap |
| Nabilone | 1–2 mg twice daily | Cap |
| Histamine (H2) antagonists | ||
| Cimetidine | 200 mg twice daily PRN | Tab |
| Famotidine | 10 mg twice daily PRN | Tab |
| Nizatidine | 75 mg twice daily PRN | Tab |
| Ranitidine (Zantac 75) | 75 mg twice daily PRN | Tab |
| Miscellaneous agents | ||
| Metoclopramide, for delayed CINV | 20–40 mg 3–4 daily | Tab |
| Olanzapine (Zyprexa) | 2.5–5 mg twice daily | Tab |
| Phenothiazines | ||
| Chlorpromazine | 10–25 mg every 4–6 hr PRN | Tab, liquid |
| 25–50 mg every 4–6 hr PRN | IM, IV | |
| Prochlorperazine | 5–10 mg 3–4 daily PRN | Tab, liquid |
| 5–10 mg every 3–4 hr PRN | IM | |
| 2.5–10 mg every 3–4 hr PRN | IV | |
| 25 mg twice daily PRN | Supp | |
| Promethazine | 12.5–25 mg every 4–6 hr PRN | Tab, liquid, IM, IV, supp |
| Abbreviations: Cap, capsule; chew tab, chewable tablet; CINV, chemotherapy-induced nausea and vomiting; liquid, oral syrup, concentrate, or suspension; PONV, postoperative nausea and vomiting; supp, rectal suppository; tab, tablet. | ||
Antacids provide relief from simple nausea and vomiting through gastric acid neutralization. Histamine 2-receptor antagonists may be used in low doses to manage simple nausea and vomiting associated with heartburn or gastroesophageal reflux. Simple nausea and vomiting may also be treated with drugs from the antihistaminic-anticholinergic and phenothiazine categories. Potential adverse drug reactions with antihistaminic-anticholinergic products may be problematic for elderly (drowsiness or confusion, blurred vision, dry mouth and urinary retention). Dexamethasone has been used successfully in the management of chemotherapy-induced nausea and vomiting (CINV) and postoperative nausea and vomiting (PONV), either as a single agent or in combination with 5-hydroxytriptamine-3 receptor antagonists (5-HT3-RAs). Cannabinoids should be considered for treatment of refractory nausea and vomiting in patients receiving chemotherapy. Aprepitant is indicated for prophylaxis of nausea and vomiting associated with chemotherapy.
Special cosiderations
- Chemotherapy-induced nausea and vomiting (CINV)
- Emetogenic potential of chemotherapeutic agent or regimen primary factor to consider when selecting antiemetic for prophylaxis of CINV.
- Recommendations for antiemetics in patients receiving chemotherapy, "see table 2".
- Postoperative nausea and vomiting (PONV)
- Most patients undergoing operative procedure do not require preoperative prophylactic antiemetic therapy.
- Patients at high risk of PONV should receive prophylactic antiemetics.
- Patients at moderate risk of PONV should receive 1 or 2 prophylactic antiemetics, and those at high risk should receive 2 prophylactic antiemetics from different classes.
- Radiation-induced nausea and vomiting
- Patients receiving single-exposure, high-dose radiation therapy to the upper abdomen or total- or hemibody irradiation should receive prophylactic antiemetics like 5-HT3-RA and dexamethasone.
- Disorders of balance: Use antihistaminic-anticholinergic agents or transdermal scopolamine.
- Pregnancy
- Pyridoxine B6 (10–25 mg 1–4 times daily) recommended as first-line therapy with or without meclizine or cyclizine (50 mg 4 times daily).
- If symptoms persist, addition of histamine-1 receptor antagonist—such as dimenhydrinate, diphenhydramine is recommended.
- Pediatrics: Chemotherapy of high or moderate risk, corticosteroid plus 5-HT3-RAs. For gastroenteritis, emphasis on rehydration measures rather than on pharmacologic intervention.
| Table (2). Dosage recommendations for CINV for adult patients | ||
|---|---|---|
| Emetic Risk | Prophylaxis of Acute Phase of CINV (One Dose Administered Prior to Chemotherapy) | Prophylaxis of Delayed Phase of CINV |
| High | 5-HT3 receptor antagonists (5-HT3-RA) | |
| Dolasetron 100 mg PO or 100 mg IV or 1.8 mg/kg IV | ||
| Granisetron 2 mg PO or 1 mg IV or 0.01 mg/kg IV or 34.3 mg transdermal patch | ||
| Ondansetron 16–24 mg PO or 8–12 mg IV (maximum 32 mg) | ||
| Palonosetron 0.25 mg IV | ||
| and Dexamethasone 12 mg PO or IV | Dexamethasone 8–12 mg PO days 2–4 | |
| and Aprepitant 125 mg PO or Fosaprepitant 115 mg IV | Aprepitant 80 mg PO days 2 and 3 after chemotherapy | |
| Moderate |
5-HT3 receptor antagonists (5-HT3-RA) | |
| Dolasetron 100 mg PO or 100 mg IV or 1.8 mg/kg IV | 5-HT3-RA : Dolasetron 100 mg PO daily, for 2–3 days following chemotherapy. | |
| Granisetron 2 mg PO or 1 mg IV or 0.01 mg/kg IV or 34.3 mg transdermal patch | Granisetron 1–2 mg PO daily, for 2–3 days following chemotherapy. | |
| Ondansetron 16–24 mg PO or 8–12 mg IV (max. 32 mg) | Ondansetron 8 mg PO daily or twice daily, for 2–3 days following chemotherapy. | |
| Palonosetron 0.25 mg IV | None | |
| Palonosetron 0.5 mg PO | ||
| and Dexamethasone 8–12 mg PO or IV | Dexamethasone 8–12 mg PO daily, for 2–3 days following chemotherapy. | |
| and in select patients | Aprepitant 80 mg PO days 2 and 3 if used on day 1 | |
| Aprepitant 125 mg PO or | ||
| Fosaprepitant 115 mg IV | ||
| Low | Dexamethasone 8–12 mg PO or IV | None |
| Minimal | None | None |
References
- Wells BG, DiPiro JT, Schwinghammer TL, Pharmacotherapy Handbook. 8th ed. New York: McGraw-Hill, 2012
- Bhakta, A. and Goel, R. (2017). Causes and treatment of nausea and vomiting. Prescriber, 28(7), pp.17–23.
