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CDHB

Nausea and Vomiting

Hypercalcaemia, electrolyte imbalance, opioid use, constipation, bowel obstruction and increased intracranial pressure can all be associated with nausea and vomiting and it is important to screen for these problems before commencing treatment. See Causes of Vomiting.

Check that Ca, creatinine, Na and K have been measured recently. Recent onset of renal impairment will cause or exacerbate morphine-related nausea due to retention of toxic morphine metabolites - dose reduction may be needed. Give intravenous fluids if dehydrated. Use specific treatment if cause identified, e.g., dexamethasone for cerebral metastases, hydration for hypercalcaemia.

Chemotherapy - Associated Nausea and Vomiting

• Pre-chemotherapy: antiemetics are individually tailored to the emetogenicity of the regimen, and vary between domperidone10 mg PO, or dexamethasone 4-8 mg PO for mildly emetogenic regimens, to a combination of ondansetron 16 mg PO/IV, aprepitant 125 mg PO, and dexamethasone 12 mg IV in 100 mL sodium chloride 0.9% for highly emetogenic regimens.
• Post-chemotherapy: again treatment is tailored according to chemotherapy regimen.
  • Mildly emetogenic regimens - domperidone 10-20 mg PO QID or metoclopramide 10 mg PO QID.
  • Moderately emetogenic regimens - dexamethasone 4-8 PO mg mane for 3 days after chemotherapy.
  • Highly emetogenic regimens - dexamethasone 8 mg mane and aprepitant 80 mg on days 2 and 3 after chemotherapy.

For persisting emesis, more than 24 hours after chemotherapy:

• Give regular domperidone or metoclopramide, consider adding cyclizine 50 mg PO TDS.
• Within the first 3 or 4 days of chemotherapy increase dexamethasone to a maximum of 8 mg BD (8 mg mane only in patients on aprepitant), and adding ondansetron 8 mg BD may also be effective.

  Note: Constipation may be severe with ondansetron, and may worsen nausea.

Antiemetics for Oncology, Haematology, and Palliative Care Patients

• Domperidone: 10-20 mg PO QID before food and nocte
• Metoclopramide: 10 mg PO, IV, or subcut 4-6 hourly (commonly given QID before food)
• Haloperidol: 0.5-3 mg PO, subcut or IV 6-12 hourly, or single nocte dose (max 5 mg/day)
• Cyclizine: 25-50 mg PO or slow IV BD or TDS (max 150 mg/day)
• Prochlorperazine: 5-10 mg PO 6 hourly or 25 mg PR 8 hourly
• Dexamethasone: 2-4 mg PO daily
• Lorazepam: 0.5-1 mg PO 6-8 hourly

Notes:

• Avoid metoclopramide and domperidone in bowel obstruction; haloperidol or cyclizine are preferred and can be given subcutaneously.
• Domperidone is an alternative prokinetic agent (oral only) that can be used if dystonic reactions or other side-effects are encountered with metoclopramide.
• Combinations of 2 or 3 agents may be more successful than a single agent.
• Haloperidol is very effective for opioid-related nausea.
• Dexamethasone can be useful for liver metastases.
• Avoid ondansetron in patients with constipation, bowel obstruction, or in patients on opioids.
• Subcutaneous injections of metoclopramide and haloperidol can be effective given regularly or in varying combinations in a continuous infusion. Refer to the Syringe Driver Compatibility Chart in the Palliative Care Handbook (online at http://handbook.palliativecare.org.nz), which details drug compatibilities for continuous subcutaneous infusions (note - a maximum of 3 drugs can be mixed together in an infusion).
• Methotrimeprazine is a broad-spectrum antiemetic and can be very effective in advanced disease. Refer to the Palliative Care Guidelines (online at http://cdhb.palliativecare.org.nz), or refer to the Palliative Care service.
• If nausea and vomiting remain a problem, consult Oncology or the Palliative Care Service  81473 for further advice.

Topic Code: 1564