What is the best approach for managing nausea and vomiting?

From the Guidelines

The most effective approach for managing nausea and vomiting involves a combination of medications and supportive measures, with olanzapine being a recommended addition to the standard antiemetic regimen for adults who experience nausea or vomiting despite optimal prophylaxis. This approach is based on the most recent and highest quality study available, which suggests that olanzapine can be beneficial in reducing nausea and vomiting in patients who have not responded to initial treatment 1.

Key Considerations

• For patients with a prior history of opioid-induced nausea, prophylactic treatment with antiemetic agents is highly recommended, with options including phenothiazines, dopamine receptor antagonists, and serotonin receptor antagonists 1.
• If nausea persists despite an as-needed regimen, administering antiemetics around the clock for 1 week and then changing dosing as needed may be helpful, with the addition of therapies that target different mechanisms of action resulting in a synergistic effect 1.
• Corticosteroids can also be beneficial for reducing opioid-induced nausea and vomiting, particularly in combination with metoclopramide and ondansetron 1.

Medication Options

• Olanzapine is recommended as an addition to the standard antiemetic regimen for adults who experience nausea or vomiting despite optimal prophylaxis 1.
• Other options for managing nausea and vomiting include NK1 receptor antagonists, lorazepam or alprazolam, dopamine receptor antagonists, dronabinol, and nabilone 1.
• Ginger supplements and peppermint tea may provide natural relief for nausea and vomiting.

Supportive Measures

• Staying hydrated with small sips of clear fluids and avoiding large volumes at once is important for managing nausea and vomiting.
• Eating small, bland meals and avoiding spicy, greasy foods can also help alleviate symptoms.
• Resting in a cool, well-ventilated environment and trying not to move suddenly can also be beneficial.

When to Seek Medical Attention

• If symptoms persist beyond 24-48 hours, are accompanied by severe abdominal pain, high fever, or signs of dehydration, seeking medical attention is recommended as this may indicate a more serious condition requiring different treatment.

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

(For children’s dosage and administration, see below.) Dosage should be increased more gradually in debilitated or emaciated patients.

1. To Control Severe Nausea and Vomiting: Adjust dosage to the response of the individual. Begin with the lowest recommended dosage. Oral Dosage-Tablets: Usually one 5mg or 10mg tablet 3 or 4 times daily.

The best approach for managing nausea and vomiting is to use ondansetron or prochlorperazine.

• Ondansetron is effective in preventing nausea and vomiting associated with highly emetogenic cancer chemotherapy, with a single 24 mg oral dose being superior to a historical placebo control 2.
• Prochlorperazine can be used to control severe nausea and vomiting, with oral dosage usually being one 5mg or 10mg tablet 3 or 4 times daily 3. Key considerations:
• Dosage should be adjusted according to the response of the individual and the severity of the condition.
• Elderly patients and debilitated or emaciated patients should be observed closely and have their dosage increased more gradually.

From the Research

Management of Nausea and Vomiting

The management of nausea and vomiting involves a combination of nonpharmacologic and pharmacologic approaches.

• Nonpharmacologic management options include fluid and electrolyte replacement, small, frequent meals, and avoidance of trigger foods 4.
• A careful history of related factors is essential to guide the initial evaluation and narrow the differential diagnosis, including 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 4, 5.

Pharmacologic Management

Pharmacologic therapy should be used for the shortest time necessary to control symptoms.

• Antiemetic drugs effectively reduce symptoms of acute nausea and vomiting, but chronic symptoms are often more challenging to treat 4.
• The main antiemetic classes include antagonists of the serotonin, dopamine, histamine, muscarinic and neurokinin systems, corticosteroids and benzodiazepines 6.
• Serotonin and neurokinin antagonists, such as ondansetron and aprepitant, are highly effective in treating chemotherapy-induced nausea and vomiting 6.
• Metoclopramide and antihistamines are first-line options for nausea and vomiting in pregnancy 6.

Treatment Approaches

The treatment approach may vary depending on the underlying cause of nausea and vomiting.

• A 5-step approach to the clinical evaluation and treatment of nausea and vomiting includes defining what the patient means by nausea and vomiting, determining whether symptoms are acute or chronic, considering medication or toxin adverse effects, using the patient's presentation, severity of symptoms, and physical examination findings to formulate a differential diagnosis and to guide evaluation, and directing treatment on the basis of knowledge of neurotransmitters and receptors involved in the emetic pathways 5.
• Management of symptoms that are acute in onset or mild in severity may involve an empirical trial of antiemetics without extensive testing 5.
• Studies have compared the efficacy of ondansetron, metoclopramide, and promethazine in adults with nausea and vomiting, with mixed results 7, 8.