Presentation on theme: "Treatment for Nausea and Vomiting: Filling up your Toolbox"— Presentation transcript:
1 Treatment for Nausea and Vomiting: Filling up your Toolbox Tod A. Wyn, MD FAAHPMAssociate Medical DirectorHospice of Holland
2 Disclosures No relevant financial disclosures Off-label use of medications will be discussed
3 Objectives1) Be able to identify the mechanisms involved in nausea and the various triggers that induce nausea and vomiting.2) Identify the various treatments and remedies for nausea and the indications for their use.
4 Notable Quotes"One of the best temporary cures for pride and affectation is seasickness; a man who wants to vomit never puts on airs.” Josh Billings 1860"The act of vomiting deserves your respect. It’s an orchestral event of the gut.”Mary Roach, Packing for Mars: The Curious Science of Life in the Void"Oh, my God! I'm gagging and vomiting at the same time. I'm... I'm gavomiting!"Dr. Cox, Scrubs
10 Bloodletting Ginger Mint Frankincense Historical RemediesBloodletting Ginger Mint FrankincenseQ: What's the best food to eat when you're vomiting?A: Bananas...because they taste the best coming back up!
11 Case study84 year-old woman diagnosed with ovarian cancer 3 years ago and is s/p surgery and chemo. Has diffuse abdominal metastasis which have caused partial bowel obstruction.Chief issues have been nausea/vomiting, odynophagia/dysphasia, and GERD.Wants to keep eating.
12 Etiology of Nausea1) Chemoreceptor Trigger Zone 2) Vestibular 3) Cortex 4) GI/peripheral pathways
13 Assessment Onset Frequency Relationship to eating Relationship to medsCurrent anti-emeticsChronic vs. ProgressingAlleviating factorsSeverity (scale: 1-10)Goal
27 Dosing Appropriate doses... scheduled around-the-clock "Go hard or go home"Appropriate doses...scheduled around-the-clock
28 Case study revisitedPatient was placed on Reglan (10 mg BID), Zofran (4 mg QID), and a PPI.Initially seemed to respond well, but then had worsening nausea. No emesis, and symptom description complicated by confusion between nausea and GERD.Added Phenergan (25 mg q6 hrs) and an H2 blocker, but had minimal improvement.
30 Poly-Drug Regimens and Routes of Delivery General guidelines:* Don't use more than one drug from each class* Consider less traditional medications: Decadron, Ativan* May need to consider alternate routes: topical, rectal, SQ* Be alert for drug interactions* May need to consider "palliative sedation" (eg Propofol)
31 ABHR (Ativan, Benadryl, Haldol, Reglan) Can be given topically or rectallyBut does it work?
32 Continuous InfusionsHave the potential to provide very quick and effective relief of intractable nauseaCan be transitioned over to an oral regimenBenadryl/Ativan/Decadron (BAD drip): ( ml/hr)(50 cc D5W, 200 mg Benadryl, 8 mg Ativan, 20 mg Decadron)Reglan/Benadryl/Decadron (RBD drip): ( ml/hr)(50 cc NS, 80 mg Reglan, 100 mg Benadryl, 8 mg Decadron)Could consider Haldol/Ativan/Decadron, or Reglan/Ativan/Decadron
38 Non-traditional Meds Bendectin (pyridoxine/doxylamine) Anti-histamine, sedatingNO evidence of causing birth defects (thank you William McBride)Propulsid (cisapride)5HT4 AgonistProlonged QTAvailable only for "compassionate use"Ginger lollipops
39 Marijuana Active ingredient: Nine-delta-tetrahydrocannabinol (THC) Demonstrated effectiveness in:Amelioration of nausea and vomitingInducement of hunger in settings of chemotherapy and AIDSAnalgesiaLowering intra-occular pressure? Multiple Sclerosis? Depression
40 Legal Issues: Michigan Law vs. FDA On Dec.4, 2008, the Michigan Medical Marihuana Act was enacted into law allowing patients with debilitating medical conditions such as HIV,cancer, and Hepatitis C to legally possess and use marijuana. The patient can have up to two and a half ounces of usable marijuana and twelve plants that are kept in an enclosed and locked facility.Cannabis is classified as a Schedule I drug under the federal Controlled Substances Act of 1970 and is deemed to have a high potential for abuse and no legitimate medical uses
41 Administration and Dosing Smoking – associated with exposure to CO and tar, similar to smoking nicotine. Peaks at 2.5 minutes and then declines over 30 minutesVaporizing – no elevation of CO or tar. Safer, more predictableIngesting – peaks at 2.5 hours (and at a much lower level) and then declines over 25 hours. Can still produce psycho-active metabolite.
42 Tetrahydrocannabinol Principal psychoactive component of cannabisDronabinol (Marinol) - a Schedule III drugNabilone (Casemet) - a Schedule II drug available in CanadaSativex (THC + canabidiol) mouth spray for M.S. patients
43 Who does it Help? Those with symptoms un-relieved by traditional meds Those with history of recreational use of marijuana
44 Thoughts on MJ May offer some benefit for nausea, appetite, and pain Other drugs probably at least as good or betterMJ does have side effects and drug interactionsThose most likely to benefit are those who’ve done poorly on traditional meds and have prior experienceThose least likely to benefit are the elderly with no prior experience
45 Research data is poorHigh risk for diversion and abuseMichigan’s Medical marijuana law is not based on current science, is confusing , and is in opposition to Federal Law
47 Case study conclusionPatient was placed on subcutaneous BAD drip which was gradually increased to 1.2 ml per hour with 0.4ml bolus prn.She continued her H2 blocker and PPI, but seemed to get her best GERD relief from a GI cocktail.Patient responded well with nearly complete resolution of both symptoms. Within a couple of weeks, she stopped eating and gradually became less responsive. She passed away comfortably.
48 Random Thoughts* Reglan (metoclpramide) 1st drug of choice: has GI effects and CTZ effects* Haldol is a great anti-emetic* Steroids too* NG tube may be necessary* Combination drugs of different mechanisms may be helpful* Anticipatory dosing most beneficial* Use of 5-HT3 antagonists of questionable benefit in non-chemotherapy-induce N/V
49 Successful Strategies Attempt to identify the most likely etiology and mechanism involvedChoose the medication based on that mechanismDose appropriately and on a scheduled basisIf ineffective, consider multi-drug regimensConsider continuous infusions (RBD, BAD)Consider less traditional interventions/medications