What are the options for nausea control in a patient with seizure disorder?

From the Guidelines

For nausea control in patients with seizures, ondansetron (Zofran) 4-8mg orally every 8 hours as needed is generally the safest first-line option, as it works by blocking serotonin receptors in the brain and gut without significantly lowering seizure threshold 1. When considering nausea control, it's essential to assess other potential causes of nausea, such as constipation, CNS pathology, or other medications, as outlined in the guidelines for managing nausea and vomiting 1. Key points to consider when managing nausea in patients with seizures include:

• Avoiding phenothiazines like prochlorperazine (Compazine) when possible, as they substantially increase seizure risk
• Considering alternative options like promethazine (Phenergan) 12.5-25mg orally or rectally every 4-6 hours, or metoclopramide (Reglan) 5-10mg orally every 6 hours, though these carry slightly higher seizure risks
• Implementing non-pharmacological approaches, including small frequent meals, avoiding trigger foods, adequate hydration, and ginger supplements (250mg four times daily)
• Monitoring for drug interactions between anti-nausea medications and the patient's existing anti-seizure regimen, as some combinations may affect seizure control or medication levels 1. Additionally, for patients on anti-seizure medications causing nausea, taking these with food or splitting doses can help reduce gastrointestinal side effects, and corticosteroids can also be quite beneficial for reducing opioid-induced nausea and vomiting, particularly in combination with metoclopramide and ondansetron 1.

From the FDA Drug Label

To Control Severe Nausea and Vomiting: Adjust dosage to the response of the individual. Begin with the lowest recommended dosage. Oral Dosage-Tablets: Usually one 5mg or 10mg tablet 3 or 4 times daily. Severe Nausea and Vomiting in Children: Prochlorperazine should not be used in pediatric patients under 20 pounds in weight or 2 years of age. Weight Usual Dosage Not to Exceed under 20 lbs not recommended 20 to 29 lbs 2½ mg 1 or 2 times a day 7. 5 mg per day 30 to 39 lbs 2½ mg 2 or 3 times a day 10 mg per day 40 to 85 lbs 2½ mg 3 times a day or 5 mg 2 times a day 15 mg per day

For a patient with seizures, prochlorperazine can be used to control severe nausea and vomiting. The dosage should be adjusted according to the response of the individual and the severity of the symptoms.

• For adults, the usual dosage is 5mg or 10mg tablet 3 or 4 times daily.
• For children, the dosage varies by weight:
  • 20 to 29 lbs: 2½ mg 1 or 2 times a day, not to exceed 7.5 mg per day
  • 30 to 39 lbs: 2½ mg 2 or 3 times a day, not to exceed 10 mg per day
  • 40 to 85 lbs: 2½ mg 3 times a day or 5 mg 2 times a day, not to exceed 15 mg per day 2

From the Research

Nausea Control in Patients with Seizures

• There is limited direct evidence on nausea control in patients with seizures, as the provided studies primarily focus on seizure management and anti-epileptic drugs.
• However, a study on the efficacy of a scheduled IV cocktail of antiemetics for nausea and vomiting in a hospice population 3 may provide some insights into nausea management, although it is not specifically tailored to patients with seizures.
• The study found that a combination of metoclopramide, diphenhydramine, and dexamethasone was effective in relieving nausea and vomiting in 90% of patients, with symptom relief usually noted within 2 days.

Seizure Management and Anti-Epileptic Drugs

• Several studies examined the efficacy of various anti-epileptic drugs, including levetiracetam, lamotrigine, and sodium valproate, in managing seizures 4, 5, 6, 7.
• A systematic review and meta-analysis on levetiracetam for seizure prophylaxis in neurocritical care found that levetiracetam may be preferred post supratentorial neurosurgery, but its efficacy in other conditions, such as traumatic brain injury, subarachnoid hemorrhage, and intracerebral hemorrhage, is unclear 7.
• Another study compared the efficacy of levetiracetam, lamotrigine, and sodium valproate in patients with juvenile myoclonic epilepsy and found that levetiracetam and sodium valproate had similar efficacy, while lamotrigine had a higher rate of failure and adverse reactions 5.

Gaps in Evidence

• There is a lack of direct evidence on nausea control in patients with seizures, highlighting the need for further research in this area.
• The available studies on anti-epileptic drugs and seizure management may provide some indirect insights into nausea control, but more specific research is needed to address this topic.