Nausea & Vomiting ‘made easy’

First steps What is the cause? Non-medical treatment Medical treatment 1st line Other options

Scale of the problem Occurs in 40-70% patients with advanced cancer 1/3 will have more than 1 contributing factor 1/3 will need more than 1 anti-emetic

Non-medical treatment Calm environment & good ventilation Frequent small snacks Avoid sight & smell of food eg cooking

Gastric stasis - causes Drugs Opioids ‘Squashed stomach syndrome’ tumour, enlarged liver, ascites Outflow obstruction tumour

Gastric stasis - symptoms Epigastic discomfort Fullness Early satiety Exacerbated by eating / relieved by vomiting Large volume vomits (undigested food)

Gastric stasis - management Prokinetic agent metoclopramide 10-20mg tds (oral) 40-80/24hrs sc infusion Also consider Domperidone (less side effects but not sc) PPI to reduce acidity Steroids 8-12mg dexamethasone for 7 days 2nd line Cyclizine 50mg tds po/sc (150mg/24hrs sc infusion) bowel distension

Chemically-induced nausea - causes Drugs (10-30% on inititation of opioid) antibiotics, anticonvulsants, antidepressants, cytotoxics, steroids, digoxin, NSAID’s Metabolic renal or hepatic failure, hypercalcaemia, hyponatraemia, ketoacidosis Toxins ischaemic/obstructed bowel, tumour effect, infection

Chemically-induced nausea - symptoms Constant nausea Vomiting is variable in volume & timing May be other features of drug toxicity

Chemically-induced nausea - management Haloperidol po/sc 1.5-3mg od/bd 2.5-10 mg/24hrs sc infusion Also consider Correct the correctable Metoclopramide (gastric stasis) 10mg tds

Raised intracranial pressure – causes Intracranial tumour Cerebral oedema Intracranial bleed Meningeal infiltration by tumour Skull metastases Cerebral infection

Raised intracranial pressure – symptoms Nausea worse in the morning Headache Nausea and/or vomiting provoked by head movement

Raised intracranial pressure – management Cyclizine 50mg tds (oral) 150mg/24hr sc infusion Also consider High dose steroid: dexamethasone 16mg od Hyoscine hydrobromide Kwells 300mcg qds 0.8-3.6mg/24hr sc infusion

If at first you don’t succeed… Consider adding a second agent Different mechanisms of action eg haloperidol with cyclizine Avoid antagonistic action cyclizine counteracts the prokinetic affect of metoclopramide Consider levomepromazine ‘broad spectrum’ antiemetic 6.25-12mg (1/4 -1/2 tablet)po or 5-25 mg sc/sc infusion over 24hrs

Summary Gastric stasis Chemically-induced Raised intracranial pressure metoclopramide Chemically-induced haloperidol Raised intracranial pressure cyclizine Consider additional or 2nd line treatment Don’t forget the effect of anxiety & pain