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

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Presentation on theme: "Management of Nausea and Vomiting John A. Mulder, MD Vice President, Medical Services Faith Hospice."— Presentation transcript:

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

2 Assessment Onset Frequency Relationship to eating Relationship to medications Current nausea medications Chronic or progressing Alleviating factors Severity Scale: 1-10 Goal

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

4 NAUSEA Opioids (and metabolites) Bowel obstruction Metabolic problems Intracranial pressure Other drugs Autonomic failure Peptic ulcer disease Constipation Driver, L, and Bruera, E., The MD Anderson Palliative Care Handbook

5 Common Causes in Cancer Patients Treatment-related factors –Chemotherapy –Radiation Therapy –Opioid Therapy –Other drugs (antibiotics, NSAIDs, SSRIs, etc.)

6 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

7 Common Causes in Cancer Patients Pathophysiologic/metabolic/biochemical –Oral/esophageal infection/lesions –Pain –Dehydration –Electrolyte imbalance –Hypercalcemia –Uremia –Endocrine dysfunction

8 Common Causes in Cancer Patients CNS/psychophysiologic problems –Vestibular disturbance –Cerebrocortical mechanisms (anticipatory N/V) –Limbic mechanisms (hypersensitivity to taste and smell) –Anxiety

9 Most patients have multifactoral causes

10 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.

11 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

12 Review medication list a. Digitalis b. Theophylline c. Chemotherapy d. Antibiotics –1. Erythromycin –2. Tetracycline –3. Metronidazole (Flagyl) –4. Ciprofloxacin (Cipro)

13 Pharmacologic treatment Conventional 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

14 Pharmacologic treatment Selective 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

15 Pharmacologic treatment Cannabinoid receptor agonists: nabilone (Cesamet) – PO dronabinol (Marinol) – PO

16 Pharmacologic treatment Others: aprepitant (Emend) – PO, IV –Selective human substance P/neurokinin 1 receptor antagonist

17 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) mg Q 6hrs

18 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. Ativan0.5 mg –2. Benedryl12.5 mg 1 Q 6hr –3. Haldol0.5 mg –4. Reglan10 mg

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

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

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

22 Random thoughts... Metoclopramide 1 st drug of choice because of peripheral (GI) effects and central effects (CTZ) Antihistamines have no antidopaminergic effect (not 1 st 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

23 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

24 Costs Drug POInjPR Phenergan.02/mg.09/mg.16/mg Compazine.08/mg /mg Haldol.14/mg$1.80/mg---- Emend$275.50/kit---- Hyoscyamine$2.48/mg---- Zofran$4.73/mg$6.00/mg----

25 Costs DrugPOInjPR Reglan.02/mg.36/mg---- Antivert.004/mg---- Marinol$1.68/mg----

26 Costs Drug ABHR$1.25/dose Cream $3.95/supp Sea bands$6.20/pair Scope patch$5.48/each

27 John Mulder, MD VP of Medical Services Faith Hospice

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