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Treatment for Nausea and Vomiting: Filling up your Toolbox Tod A. Wyn, MD FAAHPM Associate Medical Director Hospice of Holland.

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Presentation on theme: "Treatment for Nausea and Vomiting: Filling up your Toolbox Tod A. Wyn, MD FAAHPM Associate Medical Director Hospice of Holland."— Presentation transcript:

1 Treatment for Nausea and Vomiting: Filling up your Toolbox Tod A. Wyn, MD FAAHPM Associate Medical Director Hospice of Holland

2 Disclosures No relevant financial disclosures Off-label use of medications will be discussed

3 Objectives 1) 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 " "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 Notable Quotes

5 History

6 Famous Vomiting with the Ancients

7 Famous Vomiting in Politics

8 Famous Vomiting in Sports

9 Vomiting in Pop Culture

10 Bloodletting Ginger Mint Frankincense Q: What's the best food to eat when you're vomiting? A: Bananas...because they taste the best coming back up! Historical Remedies

11 Case study 84 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 1) Chemoreceptor Trigger Zone 2) Vestibular 3) Cortex 4) GI/peripheral pathways Etiology of Nausea

13 Assessment Onset Frequency Relationship to eating Relationship to meds Current anti-emetics Chronic vs. Progressing Alleviating factors Severity (scale: 1-10) Goal

14 Identify Potential Reversible Causes * Drugs (chemo, opioids, abx, NSAIDS, SSRIs) * Constipation * Gastroparesis * GERD * Uremia * Infection * Pain * Dehydration * Electrolyte imbalance (high Ca) * Endocrine dysfunction * Increased ICP * Anxiety

15 Other Causes * Pregnancy * Cyclic Vomiting Syndrome * Hepatic disease * Migraine headaches * Following surgery * Myocardial infarction * Violent coughing * Hangover * Meniere's disease

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17 Most patients have multi-factorial causes

18 Non Pharmacologic Treatment Reassurance/relaxation Correct dehydration, correct electrolyte distrubances Decompress, correct constipation Oral hygeine Reduce portions and use cold food Reduce or eliminate tube feedings Avoid odors

19 Matching Etiology with Mechanism 1) Chemoreceptor Trigger Zone 2) Vestibular 3) Cortex 4) GI/peripheral pathways 1) D2 and 5HT3 antagonists 2) Antihistamines and Anti-muscarinics 3) Antihistamines and Anxiolytics 4) D2 and 5HT3 antagonists

20 Matching Medication to Mechanism D2 Antagonists: Haldol, Reglan, Compazine, Thorazine 5HT3 Antagonists: Zofran, Emend, Remeron Anti-histamines: Benadryl, Phenergan, Antivert, Cyclizine Anti-cholinergics/anti-muscarinics : Hyoscyamine, Scopolamine Others: Decadron, Ativan Pro-motility: Reglan, Propulsid

21 Opioid-Induced Primarily hits CTZ Think D2 Antagonist: Reglan, Haldol, Compazine, Thorazine Consider opioid-rotation

22 Chemotherapy-Induced Primarily from 5HT3 stimulating gut/peripheral pathways Think 5HT3 antagonists: Zofran, Emend, Remeron

23 Malignant Bowel Obstruction Primarily from stimulation of CTZ Think D2-antagonists: Reglan, Compazine, Haldol Consider Octreotide Remember Decadron Don’t forget to decompress

24 Motion-Induced Primarily from stimulation of vestibular system Think anti-muscarinics: Scopolamine, Hyoscyamine Think anti-histamines: Antivert, Phenergan

25 Increased ICP Steroids act to decrease pressure Directly stimulates the Vomiting Center Think anti-histamines

26 Most patients have multi-factorial causes

27 Dosing "Go hard or go home" Appropriate doses... scheduled around-the-clock

28 Case study revisited Patient 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.

29 Intractable Vomiting

30 Poly-Drug Regimens and Routes of Delivery General guidelines: * Don't use more than one drug from each class * Don't use more than one drug from each class * Consider less traditional medications: Decadron, Ativan * Consider less traditional medications: Decadron, Ativan * May need to consider alternate routes: topical, rectal, SQ * May need to consider alternate routes: topical, rectal, SQ * Be alert for drug interactions * Be alert for drug interactions * May need to consider "palliative sedation" (eg Propofol) * May need to consider "palliative sedation" (eg Propofol)

31 ABHR (Ativan, Benadryl, Haldol, Reglan) Can be given topically or rectally But does it work?

32 Continuous Infusions Have the potential to provide very quick and effective relief of intractable nausea Benadryl/Ativan/Decadron (BAD drip): ( ml/hr) (50 cc D5W, 200 mg Benadryl, 8 mg Ativan, 20 mg Decadron) Can be transitioned over to an oral regimen Could consider Haldol/Ativan/Decadron, or Reglan/Ativan/Decadron Reglan/Benadryl/Decadron (RBD drip): ( ml/hr) (50 cc NS, 80 mg Reglan, 100 mg Benadryl, 8 mg Decadron)

33 Alternative Therapies

34 Acupressure Thought to work at the P6 (Neiguan) point. Examples include "sea bands" Five Phases (Wu Xing) Theory

35 Acupuncture In nausea, stimulation of point P6 (forearm) is believed to offer relief. Generally believed to be more helpful in setting of chemotherapy and post-op nausea

36 Korean Hand Therapy

37 Aromatherapy Oil of Mint

38 Non-traditional Meds 5HT4 Agonist Prolonged QT Available only for "compassionate use" Anti-histamine, sedating NO evidence of causing birth defects (thank you William McBride) Bendectin (pyridoxine/doxylamine) Propulsid (cisapride) Ginger lollipops

39 Marijuana Active ingredient: Nine-delta-tetrahydrocannabinol (THC) Demonstrated effectiveness in: Amelioration of nausea and vomiting Amelioration of nausea and vomiting Inducement of hunger in settings of chemotherapy and AIDS Inducement of hunger in settings of chemotherapy and AIDS Analgesia Analgesia Lowering intra-occular pressure Lowering intra-occular pressure ? Multiple Sclerosis ? Multiple Sclerosis ? Depression ? 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 minutes Vaporizing – no elevation of CO or tar. Safer, more predictable Ingesting – peaks at 2.5 hours (and at a much lower level) and then declines over 25 hours. Can still produce psycho-active metabolite.

42 Principal psychoactive component of cannabis Tetrahydrocannabinol Dronabinol (Marinol) - a Schedule III drug Nabilone (Casemet) - a Schedule II drug available in Canada Sativex (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 better MJ does have side effects and drug interactions Those most likely to benefit are those who’ve done poorly on traditional meds and have prior experience Those least likely to benefit are the elderly with no prior experience

45 Research data is poor High risk for diversion and abuse Michigan’s Medical marijuana law is not based on current science, is confusing, and is in opposition to Federal Law

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47 Case study conclusion Patient 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 involved Choose the medication based on that mechanism Dose appropriately and on a scheduled basis If ineffective, consider multi-drug regimens Consider continuous infusions (RBD, BAD) Consider less traditional interventions/medications

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