From the Guidelines
For managing nausea in inpatients, first-line antiemetic medications include ondansetron, prochlorperazine, and metoclopramide, with the most recent guidelines 1 recommending their use. The choice of medication depends on the suspected cause of nausea, with consideration of the patient's comorbidities, potential drug interactions, and side effect profiles. Some key points to consider when managing nausea in inpatients include:
- Assessing for other causes of nausea, such as constipation, central nervous system pathology, chemotherapy, radiation therapy, and hypercalcemia 1
- Using antiemetic agents prophylactically in patients with a prior history of opioid-induced nausea 1
- Considering the use of serotonin receptor antagonists, such as granisetron or ondansetron, for managing opioid-induced persistent nausea 1
- Using corticosteroids, such as dexamethasone, for reducing opioid-induced nausea and vomiting 1
- Regular reassessment of symptom control and medication side effects is essential, with adjustments made as needed 1
In terms of specific medications,
- Ondansetron (4-8mg IV/PO every 8 hours) is effective for chemotherapy-induced and postoperative nausea 1
- Prochlorperazine (5-10mg IV/PO every 6 hours) blocks dopamine receptors in the chemoreceptor trigger zone 1
- Metoclopramide (10mg IV/PO every 6 hours) both blocks dopamine receptors and enhances gastric emptying, making it useful when gastroparesis contributes to nausea 1
- For persistent symptoms, second-line options include promethazine (12.5-25mg IV/PO/PR every 6 hours) or dexamethasone (4-8mg IV/PO daily) 1
- In specific cases, such as opioid-induced nausea, haloperidol (0.5-2mg IV/PO every 8 hours) may be beneficial 1
- For anticipatory or anxiety-related nausea, lorazepam (0.5-2mg IV/PO every 6 hours) can be added 1
From the FDA Drug Label
In two placebo-controlled, double-blind trials (one conducted in the US and the other outside the US) in 865 females undergoing inpatient surgical procedures, ondansetron tablets 16 mg as a single dose or placebo was administered one hour before the induction of general balanced anesthesia (barbiturate, opioid, nitrous oxide, neuromuscular blockade, and supplemental isoflurane or enflurane), ondansetron tablets were significantly more effective than placebo in preventing postoperative nausea and vomiting.
- Ondansetron is a recommended medication for managing nausea in inpatients, specifically for postoperative nausea and/or vomiting.
- The recommended dose is 16 mg as a single dose, administered one hour before the induction of general balanced anesthesia 2.
From the Research
Medications for Nausea in Inpatients
- The following medications are recommended for managing nausea in inpatients:
- Ondansetron, which has a favorable ratio between side effects and price 3
- Metoclopramide, which is effective in reducing nausea and vertigo symptoms 4
- Dimenhydrinate, which has similar efficacy to metoclopramide in treating nausea and vertigo 4
- Droperidol, which is effective but has a potential for QT prolongation and is limited to refractory cases 5
- Promethazine, which is more sedating than other comparative agents and may be suitable when sedation is desirable 5
- Prochlorperazine, which must be monitored for akathisia that can develop at any time over 48 hours post-administration 5
Non-Pharmacologic Management
- Non-pharmacologic management options include:
Pharmacologic Therapy
- Pharmacologic therapy should be used for the shortest time necessary to control symptoms 6
- When a specific etiology is not identified, a serotonin antagonist or dopamine antagonist can be used 6
- Medications may also target the suspected cause of symptoms and the neurotransmitters involved in central and peripheral pathways of nausea and vomiting 6