What is the best medication for nausea and vomiting in pregnancy?

From the Guidelines

The best medication for nausea and vomiting in pregnancy is typically a combination of pyridoxine (Vitamin B6) and doxylamine, often available as a prescription medication called Diclegis or Diclectin, as recommended by the American College of Obstetricians and Gynecologists (ACOG) 1.

Key Considerations

• The recommended dosage is usually two tablets at bedtime, which can be increased to a maximum of four tablets daily (one in the morning, one in the afternoon, and two at bedtime) if needed, starting with the lowest effective dose and increasing gradually under a doctor's guidance.
• In addition to medication, eating small, frequent meals and avoiding strong odors or foods that trigger nausea can help alleviate symptoms.
• Ginger in various forms (tea, candies, capsules) can also help alleviate symptoms, and staying hydrated and considering acupressure wristbands may be beneficial.

Safety and Efficacy

• This combination is considered safe and effective because pyridoxine helps with nausea, while doxylamine, an antihistamine, reduces vomiting, with nighttime dosing helping manage morning sickness 1.
• If symptoms persist or worsen, consulting a healthcare provider is necessary, as more severe cases may require additional interventions, and informing the doctor of any other medications or supplements being taken is crucial to avoid potential interactions.

Alternative Options

• Other medications like ondansetron, metoclopramide, and promethazine may be considered in moderate to severe cases, but their use should be guided by a healthcare provider, considering the potential risks and benefits, as noted in studies 1.

From the FDA Drug Label

The first trial compared oral doses of ondansetron 24 mg as a single dose, 8 mg every 8 hours for 2 doses, and 32 mg as a single dose in 357 adult cancer patients receiving chemotherapy regimens containing cisplatin greater than or equal to 50 mg/m 2. In a double-blind US trial in 336 patients receiving a cyclophosphamide-based chemotherapy regimen containing either methotrexate or doxorubicin, ondansetron tablets 8 mg administered twice a day, was as effective as ondansetron tablets 8 mg administered 3 times a day in preventing nausea and vomiting

The best medication for nausea and vomiting in pregnancy is not explicitly stated in the provided drug labels. The labels discuss the use of ondansetron for nausea and vomiting in various contexts, including chemotherapy and radiation therapy, but do not specifically address its use in pregnancy. Therefore, no conclusion can be drawn about the best medication for nausea and vomiting in pregnancy based on the provided information 2 2.

From the Research

Medications for Nausea and Vomiting in Pregnancy

• The combination of doxylamine succinate and pyridoxine hydrochloride, known as Diclegis, is currently the only FDA-approved medication for the treatment of nausea and vomiting in pregnancy (NVP) 3.
• This combination has been shown to be effective in improving symptoms of NVP, with a substantial amount of safety data accumulated over the years, making it one of the few drugs that qualify for FDA Pregnancy Category A status 3.
• A study published in 2018 found that doxylamine-pyridoxine was associated with a trend towards efficacy for nausea and vomiting symptoms compared with placebo, although the difference was not statistically significant using all approaches to handling missing data 4.
• Other medications that have been found to be effective in treating NVP include ginger, vitamin B6, antihistamines, metoclopramide, and ondansetron 5.
• Vitamin B6 has been shown to be effective in combination with doxylamine, and its harmlessness during pregnancy has been established for doses up to 40-60mg/day 6.
• The pharmacologic management of NVP may involve the use of various medications, including doxylamine succinate/pyridoxine hydrochloride, antihistamines, metoclopramide, ondansetron, phenothiazines, and corticosteroids 7.

Comparison of Medications

• A systematic review published in 2016 found that pyridoxine-doxylamine, promethazine, and metoclopramide were associated with greater benefit than placebo for moderate symptoms of NVP 5.
• Ondansetron was found to be associated with improvement for a range of symptom severity, and corticosteroids may be associated with benefit in severe cases 5.
• A study published in 2020 suggested that vitamin B6 could be integrated into the therapeutic arsenal of mild to moderate nausea and vomiting during pregnancy, alone or in combination with doxylamine 6.

Recommendations

• The combination of doxylamine succinate and pyridoxine hydrochloride is recommended as first-line pharmacologic treatment for NVP 3, 7.
• Other medications, such as ginger, vitamin B6, antihistamines, metoclopramide, and ondansetron, may be considered for the treatment of NVP, depending on the severity of symptoms and individual patient needs 5, 6, 7.