Nausea & Vomiting

Overview

Determine potential cause(s) of the nausea and vomiting and treat any reversible causes. Treat the patient's nausea/vomiting if it is affecting their quality of life and be aware that nausea and vomiting can impact nutritional intake.

Always rule out sepsis, constipation and dehydration and treat them if they are present
Always consider the emetogenic pathways of the nausea/vomiting and choose therapies or pharmacologic agents accordingly
If the symptom is constant or persistent, use an agent regularly, add a second PRN agent if needed

Step 1 Consider the Underlying Causes of Nausea & Vomiting

Assess for possible modifiable factors contributing to nausea and vomiting and address:

Gastrointestinal disturbances (e.g. candidiasis oral or esophageal, esophagitis/gastritis, gastroparesis, constipation, bowel obstruction/ileus)
Metabolic disorders (e.g. hyponatremia, hypo/hypercalcemia, uremia)
Medications (e.g. SSRI antidepressants, antidiabetic medications, opioids, beta-blockers)
Infection (e.g. gastrointestinal or other)
CNS (e.g. vestibular dysfunction, brain or leptomeningeal metastases)
Anxiety
Cancer treatments (e.g. chemotherapy & radiotherapy induced nausea/vomiting, malignant bowel obstruction)
Miscellaneous (e.g. ascites, illicit substances)

Step 2 Non-Pharmacological Management

General Principles

Non-pharmacological measures should be considered in all patients experiencing nausea and/or vomiting
Nutritional intake may be impacted by chronic nausea and vomiting
Provide patients with the Nausea/Vomiting Patient Handout

Encourage the following behaviours

Ensure good oral hygiene
Encourage fluids 30-60 min before or after meals instead of with meals (to avoid early satiety)
Avoid foods that are greasy, spicy, or excessively sweet
Eat small amounts of food more frequently and adjust timing of meals as necessary
Eat slowly
Relax in an upright position after eating to facilitate digestion
Limit/avoid alcohol
Manage constipation Constipation Patient Handout

Consider environmental Factors

Minimize triggering aromas (cooking odors, perfumes, smoke, etc.)
Wear loose fitting clothing
Apply a cool damp cloth to forehead or nape of neck

Complimentary Treatments

Consider complementary alternative therapies such as relaxation, imagery, acupressure or acupuncture
Ginger: has been shown to be a promising therapy across clinical studies though the target dose remains unclear. Tablets or real ginger can be used
Aromatherapy peppermint or ginger oil have sometimes been successful in reducing nausea symptoms

Step 3 Pharmacological Management

General Principles

These medications should be considered in patients with chronic, persistent nausea, especially where the symptom is having a significant impact on quality of life or ability to function
The primary goal of therapy is to balance symptom control with the careful protection of physical function, cognition, and overall well-being
When choosing an anti-emetic consider the following:

Etiology of the nausea (GI versus opioid/centrally induced)
Side effect profile (choosing the medication that won’t worsen already present conditions such as constipation or QTc prolongation)
Use only ONE of below medications at a time (stop if ineffective, and progress to next line medication)
Consider cost and health insurance coverage

Metoclopramide First-line Agent

5-10 mg 4 times daily (30 min before meals and nightly)
Maximum dose: should not exceed 40 mg in 24 hours

2.5 mg - 5 mg 4 times daily (30 min before meals and nightly)
With eGFR between 10-60 mL/min, use 50% of total dose, if eGFR <10 mL/min, use 33% of total dose
Child Pugh B/C max dose 20 mg/day.
Maximum Dose: 20 mg in 24 hr period

Contraindicated in patients with bowel obstruction, convulsions, epilepsy, GI hemorrhage, mechanical obstruction or perforation, history of tardive dyskinesia and pheochromocytoma. Avoid prescribing with other dopamine antagonists

Metoclopramide crosses the blood-brain barrier: watch for extrapyramidal side effects, potential for QTc prolongation. Use with caution in Parkinson’s disease

Watch for tardive dyskinesia (with long term use) QTc prolongation, extrapyramidal symptoms, tardive dyskinesia

Can exacerbate Restless Legs Syndrome

Prokinetic

Domperidone First-line Agent

Maximum Dose: 80 mg in 24 hr period

10 mg orally 2 to 3 times daily
Maximum Dose: 30 mg in 24 hours

Avoid prescribing with other dopamine antagonists

Contraindicated in arrhythmia, GI hemorrhage, mechanical obstruction or perforation; significant electrolyte disturbances, hepatic impairment, renal impairment, congestive heart failure

Contraindicated in patients who are Child Pugh C

In patients with severe renal insufficiency the dosing frequency should be reduced to once or twice daily, depending on the severity of the impairment, and the dose may need to be reduced

Higher risk prolonged QTc than metoclopramide, especially combined with CYP3A4 inhibitors. Does not readily cross the blood brain barrier therefore less likely to extrapyramidal side effects or sedation than metoclopramide

Use with caution in hepatic insufficiency

Prokinetic
Higher doses often needed to treat nausea and vomiting than gastrointestinal motility disorders

Haloperidol Second-line Agent

0.5-1mg PO/SC/IM/IV q4h prn

Avoid prescribing with other dopamine antagonists

Also avoid in Lewy body disease, Parkinsons' disease and thyrotoxicosis

Dose dependent QTc prolongation. Higher risk of extrapyramidal side effects and sedation than metoclopramide and olanzapine

Antipsychotic
No prokinetic effect - preferred in high grade GI tract obstruction

Dimenhydrinate Second-line Agent

25-50 mg orally/IV/IM every 4 to 6hrs as needed
Titrate to effect or a maximum dose of 400 mg daily

Antihistamine

Increased risk of constipation and sedation with higher doses

Ondansetron Third-line Agent

8 mg PO/SC 2 to 3 times daily

Starting dose 4 mg PO/SC 3 times daily
May titrate to 8 mg PO/SC 3 times daily

4-8 mg PO every 8 hours as needed
Maximum Dose: 16 mg in a 24 hr period

Can be constipating. Potential for QTc prolongation

Child Pugh B/C . Max dose 8mg/day

Selective 5HT3 receptor antagonist

Olanzapine Second-line Agent

Initial dose 2.5 mg PO 2 times daily
For severe, persistent nausea, can dose every 8 to 12 hours around the clock and every 4 hours as needed

Avoid prescribing with other dopamine antagonists

Can exacerbate Restless Legs Syndrome

Lowers seizure threshold. Risk of QT prolongation, anticholinergic effects, and sedation. Use only if sedation acceptable/preferred by patient

Heart failure (increased risk of fluid retention), Acute myocardial Infarction (risk of myocardial rupture), Cirrhosis (risk of fluid retention), GI ulcer (increased risk of bleeding), Diverticulitis (increased risk of GI perforation), Acute angle glaucoma (increase IOP)