From the Guidelines
For intractable nausea and vomiting, a stepwise approach is recommended starting with first-line antiemetics such as ondansetron 4-8mg orally or IV every 8 hours, metoclopramide 10mg orally or IV every 6 hours, or prochlorperazine 5-10mg orally or IV every 6 hours, as supported by the most recent evidence from 1. If these are ineffective, second-line options include promethazine 12.5-25mg orally, IV, or rectally every 6 hours, or scopolamine transdermal patch 1.5mg applied behind the ear every 72 hours. For refractory cases, consider dexamethasone 4-8mg orally or IV daily for short-term use, aprepitant 125mg orally on day 1 followed by 80mg on days 2-3 for chemotherapy-induced nausea, or haloperidol 0.5-2mg orally or IV every 8 hours, as suggested by 1 and 1. Combination therapy using medications with different mechanisms of action often works better than monotherapy, as noted in 1. Hydration should be maintained with IV fluids if oral intake is compromised. The underlying cause of nausea should always be identified and treated when possible, as medications provide symptomatic relief but may not address the root cause. These medications work by blocking various receptors involved in the vomiting reflex, including dopamine, serotonin, histamine, and neurokinin receptors in both the chemoreceptor trigger zone and the vomiting center in the brain, as explained in 1 and 1.
Some key points to consider:
- The choice of antiemetic should be based on the underlying cause of nausea and vomiting, as well as the patient's medical history and current medications, as recommended by 1.
- Combination therapy may be more effective than monotherapy in refractory cases, as suggested by 1.
- Hydration and nutrition should be maintained to prevent dehydration and malnutrition, as noted in 1.
- The patient's symptoms and response to treatment should be closely monitored and adjusted as needed, as recommended by 1.
In terms of specific medications, the following may be considered:
- Ondansetron 4-8mg orally or IV every 8 hours, as supported by 1
- Metoclopramide 10mg orally or IV every 6 hours, as suggested by 1 and 1
- Prochlorperazine 5-10mg orally or IV every 6 hours, as recommended by 1 and 1
- Promethazine 12.5-25mg orally, IV, or rectally every 6 hours, as noted in 1
- Scopolamine transdermal patch 1.5mg applied behind the ear every 72 hours, as suggested by 1
- Dexamethasone 4-8mg orally or IV daily for short-term use, as recommended by 1 and 1
- Aprepitant 125mg orally on day 1 followed by 80mg on days 2-3 for chemotherapy-induced nausea, as suggested by 1 and 1
- Haloperidol 0.5-2mg orally or IV every 8 hours, as noted in 1 and 1.
It is essential to prioritize the patient's quality of life, morbidity, and mortality when managing intractable nausea and vomiting, as emphasized by 1 and 1.
From the FDA Drug Label
14 CLINICAL STUDIES 14. 1 Prevention of Chemotherapy-Induced Nausea and Vomiting
Highly Emetogenic Chemotherapy In 2 randomized, double-blind, monotherapy trials, a single 24 mg oral dose of ondansetron tablets was superior to a relevant historical placebo control in the prevention of nausea and vomiting associated with highly emetogenic cancer chemotherapy, including cisplatin greater than or equal to 50 mg/m 2
HIGHLIGHTS OF PRESCRIBING INFORMATION These highlights do not include all the information needed to use APREPITANT CAPSULES safely and effectively. See full prescribing information for APREPITANT CAPSULES. APREPITANT capsules, for oral use Initial U. S. Approval: 2003 INDICATIONS AND USAGE Aprepitant is a substance P/neurokinin 1 (NK1) receptor antagonist Aprepitant capsules are indicated • in combination with other antiemetic agents, in patients 12 years of age and older for prevention of: • acute and delayed nausea and vomiting associated with initial and repeat courses of highly emetogenic cancer chemotherapy (HEC) including high-dose cisplatin (1. 1)
- Medications for intractable nausea and vomiting include:
- Key points:
- Ondansetron is effective in preventing nausea and vomiting associated with highly emetogenic cancer chemotherapy.
- Aprepitant is indicated for prevention of acute and delayed nausea and vomiting associated with highly emetogenic cancer chemotherapy, including high-dose cisplatin.
- Dosage:
From the Research
Medications for Intractable Nausea and Vomiting
- The treatment of nausea and vomiting can be challenging, especially in cases where the cause is unknown or the symptoms are chronic 4.
- Antiemetic drugs can be effective in reducing symptoms of acute nausea and vomiting, but chronic symptoms are often more difficult to treat 4.
- In some cases, medications such as serotonin antagonists or dopamine antagonists can be used to target the suspected cause of symptoms and the neurotransmitters involved in central and peripheral pathways of nausea and vomiting 4.
Specific Medications
- Ondansetron, metoclopramide, and droperidol have been compared to placebo in the treatment of nausea and vomiting in adult emergency department patients, with varying results 5, 6.
- Olanzapine 5 mg has been shown to be effective in preventing chemotherapy-induced nausea and vomiting when combined with standard antiemetic therapy 7.
- Other medications, such as aprepitant, palonosetron, and dexamethasone, are also used in the management of nausea and vomiting, particularly in the context of chemotherapy 7.
Treatment Approaches
- Nonpharmacologic management options, such as fluid and electrolyte replacement, small frequent meals, and avoidance of trigger foods, can be effective in managing nausea and vomiting 4.
- Pharmacologic therapy should be used for the shortest time necessary to control symptoms, and the choice of medication may depend on factors such as the patient's preference, adverse effect profile, and cost 4, 5.
- Emerging treatments, such as bioelectrical neuromodulation and behavioral therapies, may offer new options for patients with intractable nausea and vomiting 8.