What is the evaluation and management approach for intractable nausea and vomiting?

From the Guidelines

The evaluation and management of intractable nausea and vomiting requires a systematic approach, starting with identifying the underlying cause and providing symptomatic relief, and the most effective approach is to use a combination of antiemetic agents, such as ondansetron, dexamethasone, and haloperidol, as recommended by the most recent guidelines 1. The management of intractable nausea and vomiting involves a thorough history and physical examination, focusing on medication use, recent dietary changes, and associated symptoms. Some key points to consider in the management of intractable nausea and vomiting include:

• Laboratory testing, including basic metabolic panel, liver function tests, pregnancy test in women of childbearing age, and imaging studies such as abdominal ultrasound or CT scan if indicated.
• Ensuring adequate hydration with IV fluids containing appropriate electrolytes.
• First-line antiemetics, such as ondansetron 4-8 mg IV/PO every 8 hours, prochlorperazine 5-10 mg IV/PO every 6 hours, or metoclopramide 10 mg IV/PO every 6 hours.
• For refractory cases, consider combination therapy with different antiemetic classes, such as adding dexamethasone 4-8 mg IV/PO daily, haloperidol 0.5-2 mg IV/PO every 8 hours, or a scopolamine patch 1.5 mg applied behind the ear every 72 hours, as recommended by the guidelines 1.
• Benzodiazepines, such as lorazepam 0.5-1 mg IV/PO every 6 hours, can help with anticipatory nausea.
• Targeted therapy for specific causes, such as proton pump inhibitors for gastritis, antibiotics for infections, or discontinuation of offending medications.
• Non-pharmacological approaches, including small, frequent meals, avoiding trigger foods, and acupressure or acupuncture, can provide additional relief. These interventions work by targeting different pathways in the chemoreceptor trigger zone, vestibular system, and gastrointestinal tract that contribute to the complex pathophysiology of nausea and vomiting, and the most recent guidelines recommend a combination of these approaches for optimal management 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Evaluation Approach

• The evaluation of intractable nausea and vomiting involves a thorough history and physical examination to determine the underlying cause 2, 3, 4.
• A 5-step approach can be used, including defining the patient's symptoms, determining whether symptoms are acute or chronic, considering medication or toxin adverse effects, formulating a differential diagnosis, and directing treatment based on knowledge of neurotransmitters and receptors involved in the emetic pathways 2.
• The history should include associated symptoms, timing of onset and duration of symptoms, exacerbating or relieving factors, alarm symptoms, medication and substance use, relationship with recent food ingestion, and comorbidities 3, 4.

Differential Diagnosis

• The differential diagnosis for intractable nausea and vomiting is broad and includes gastrointestinal, infectious, metabolic, neurologic, psychiatric, and medication-related causes 2, 3, 4, 5.
• Gastrointestinal causes include gastroparesis, cyclic vomiting syndrome, and other disorders 5.
• Non-gastrointestinal causes include medications, vestibular and neurologic disorders, endocrine conditions, and psychiatric causes 3, 4, 5.

Diagnostic Testing

• Diagnostic testing may include laboratory studies such as urinalysis, urine pregnancy testing, complete blood count, comprehensive metabolic panel, amylase and lipase levels, thyroid-stimulating hormone level, and stool studies with cultures 4.
• Imaging studies such as abdominal radiography, ultrasonography, and computed tomography may also be used 4.
• Esophagogastroduodenoscopy and gastric emptying studies may be recommended in certain cases 4, 5.

Treatment Approach

• Treatment of intractable nausea and vomiting depends on the underlying cause and may involve antiemetic medications, fluid and electrolyte replacement, and small, frequent meals 2, 3, 6.
• Antiemetic medications such as serotonin antagonists, dopamine antagonists, and neurokinin antagonists may be used 2, 3, 6.
• Treatment should be based on a thoughtful discussion of benefits, side effects, and costs, and a validated treatment algorithm for chronic nausea and vomiting does not exist 5.