1. Vice President, Medical Services
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) Intracranial pressure
Metabolic problems
NAUSEA
Other drugs
Constipation
Bowel obstruction
Peptic ulcer disease
Autonomic failure
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 Motility Problem
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 mg
2 .Reglan mg PR Q 4hr
3. Dexamethasone 2 mg
e. ABHR
1. Ativan 0.5 mg
2. Benedryl 12.5 mg Q 6hr
3. Haldol 0.5 mg
4. Reglan 10 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 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

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 PO Inj PR Phenergan .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

25. Costs Drug PO Inj PR 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