What are the treatment options for chronic nausea?

From the Guidelines

Treatment for chronic nausea should prioritize antiemetic medications, such as ondansetron (4-8mg every 8 hours) and metoclopramide (10mg before meals and at bedtime), as first-line treatment, according to the most recent evidence 1. When considering treatment options for chronic nausea, it's essential to evaluate the underlying cause of the condition, as it may stem from various disorders like gastroparesis, migraine, vestibular disorders, or medication side effects.

• Medications for nausea and vomiting, including ondansetron, granisetron, and prochlorperazine, can be effective in managing symptoms, as reported in a study published in Clinical Gastroenterology and Hepatology 1.
• Non-medication approaches, such as dietary modifications (eating smaller, more frequent meals, avoiding trigger foods), ginger supplements (250-1000mg daily), acupressure or acupuncture, and cognitive behavioral therapy, can also help alleviate symptoms.
• Identifying and treating the underlying cause of chronic nausea is crucial, and lifestyle changes like staying hydrated, avoiding strong odors, and managing stress can help reduce symptom frequency and severity.
• In cases where nausea is severe or persistent despite treatment, further evaluation by a gastroenterologist may be necessary to explore additional options like neuromodulators or specialized therapies, as suggested in a study published in the same journal 1.
• The use of medications like domperidone, a dopamine D2-receptor antagonist, may be considered for patients who fail metoclopramide, although its availability is limited in the United States and requires an FDA investigational drug application 1.
• Neurokinin (NK-1) receptor antagonists, such as aprepitant, may also be effective in improving nausea and vomiting, especially in patients with idiopathic gastroparesis, as reported in a study published in Clinical Gastroenterology and Hepatology 1.

From the FDA Drug Label

Treatment with metoclopramide can cause tardive dyskinesia (TD), a potentially irreversible and disfiguring disorder characterized by involuntary movements of the face, tongue, or extremities. The risk of tardive dyskinesia increases with the duration of treatment and the total cumulative dose An analysis of utilization patterns showed that about 20% of patients who used metoclopramide took it longer than 12 weeks. Treatment with metoclopramide for longer than the recommended 12 weeks should be avoided in all but rare cases where therapeutic benefit is thought to outweigh the risk of developing TD

Chronic Nausea Treatment Options are not explicitly stated in the provided drug label for metoclopramide. However, based on the information provided, metoclopramide can be used to treat nausea, but its use is recommended for a limited duration of 12 weeks due to the risk of developing tardive dyskinesia.

• The label does not provide a clear answer to the question of what are the treatment options for chronic nausea.
• Metoclopramide may be considered for short-term use, but the risk of tardive dyskinesia and other side effects should be carefully weighed against the potential benefits 2.

From the Research

Treatment Options for Chronic Nausea

• Nonpharmacologic management options include fluid and electrolyte replacement, small, frequent meals, and avoidance of trigger foods 3
• Antiemetic drugs can be used to reduce symptoms of nausea and vomiting, with serotonin antagonists or dopamine antagonists being potential options when a specific etiology is not identified 3
• Pharmacologic therapy should be used for the shortest time necessary to control symptoms 3
• A 5-step approach to the clinical evaluation and treatment of nausea and vomiting can be applied, including defining the patient's symptoms, determining whether symptoms are acute or chronic, considering medication or toxin adverse effects, and directing treatment based on knowledge of neurotransmitters and receptors involved in the emetic pathways 4

Management of Chronic Nausea

• Management of symptoms that are chronic or moderate-severe may involve testing for an underlying cause and considering medication adverse effects, neurologic causes, gastrointestinal diseases, metabolic or endocrine conditions, and psychogenic disorders 4
• Gastroparesis, a disorder characterized by delayed gastric emptying, can be treated with prokinetic agents such as metoclopramide and domperidone, as well as antiemetic agents such as promethazine and ondansetron, although potential drug-drug interactions should be considered 5
• Treatment of chronic nausea and vomiting should be based on a thoughtful discussion of benefits, side effects, and costs, as a validated treatment algorithm does not exist 6

Specific Conditions

• Nausea and vomiting in early pregnancy can be treated with various interventions, including acupressure, acupuncture, corticosteroids, ginger, metoclopramide, ondansetron, prochlorperazine, promethazine, and pyridoxine (vitamin B6) 7
• Gastroparesis and cyclic vomiting syndrome are specific conditions that can cause chronic nausea and vomiting, and require targeted treatment approaches 6