From the Guidelines
The treatment of intractable vomiting should begin with a stepwise approach, prioritizing the most recent and highest quality evidence, which recommends titrating dopamine receptor antagonists, such as prochlorperazine, haloperidol, metoclopramide, or olanzapine, to maximum benefit and tolerance 1.
Key Considerations
- The approach should include intravenous fluid resuscitation to correct dehydration and electrolyte abnormalities.
- First-line antiemetic therapy may include ondansetron, metoclopramide, or prochlorperazine, with dosages adjusted according to the patient's response and tolerance.
- For refractory cases, consider adding a 5-HT3 antagonist, such as ondansetron, or other agents like dexamethasone, haloperidol, or olanzapine, as suggested by the guidelines 1.
Treatment Strategies
- Titrate dopamine receptor antagonists to maximum benefit and tolerance 1.
- Consider adding a 5-HT3 antagonist, such as ondansetron, for refractory cases.
- Use of corticosteroids, such as dexamethasone, may be beneficial in reducing nausea and vomiting, especially when combined with other antiemetic agents 1.
- Alternative agents like scopolamine, dronabinol, or olanzapine may be considered for management of nausea, as suggested by the guidelines 1.
Underlying Cause Identification
- Identifying and treating the underlying cause of intractable vomiting is crucial, whether it's medication-induced, pregnancy-related, vestibular disorders, or other conditions.
- Proton pump inhibitors, like pantoprazole, may help if gastritis or GERD contributes to symptoms.
- Nutritional support through enteral feeding may be necessary if vomiting persists beyond 3-5 days.
From the FDA Drug Label
In single-arm trials, 148 patients receiving cyclophosphamide-based chemotherapy were re-treated with ondansetron tablets 8 mg three times daily during subsequent chemotherapy for a total of 396 re-treatment courses No emetic episodes occurred in 314 (79%) of the re-treatment courses, and only 1 to 2 emetic episodes occurred in 43 (11%) of the re-treatment courses.
The treatment approach for intractable vomiting is to administer ondansetron tablets 8 mg three times daily. This regimen has been shown to be effective in preventing emetic episodes in patients receiving chemotherapy, with 79% of re-treatment courses resulting in no emetic episodes and 11% resulting in only 1 to 2 emetic episodes 2.
- Key points:
- Ondansetron dosage: 8 mg three times daily
- Efficacy: 79% of re-treatment courses had no emetic episodes, and 11% had only 1 to 2 emetic episodes
- Patient population: Patients receiving cyclophosphamide-based chemotherapy
From the Research
Intractable Vomiting Treatment Approach
- The treatment approach for intractable vomiting depends on the underlying cause, which can range from gastrointestinal issues to neurological disorders 3.
- In children, the initial evaluation is directed at assessing airway, breathing, and circulation, as well as hydration status and red flag signs, to guide the approach to treatment 4.
- Antiemetic medications, such as ondansetron, can be used to treat vomiting in children who are unable to take oral fluids due to persistent vomiting 4.
- Dopamine receptor antagonists are a class of antiemetic agents that can be used to treat intractable nausea and vomiting, although they may have varying degrees of effectiveness and side effects 5, 6.
- In adults, the evaluation and treatment of nausea and vomiting depend on the duration and presence of alarm symptoms, with chronic symptoms often requiring a more comprehensive evaluation and treatment approach 7.
- Nonpharmacologic management options, such as fluid and electrolyte replacement and avoidance of trigger foods, can be used in conjunction with antiemetic medications to manage symptoms 7.
- The choice of antiemetic medication depends on the suspected cause of symptoms and the neurotransmitters involved in central and peripheral pathways of nausea and vomiting, with serotonin antagonists and dopamine antagonists being commonly used options 7, 6.