What is the treatment for nausea?

Treatment of Nausea

Medications that target dopaminergic pathways (such as haloperidol, metoclopramide, or prochlorperazine) should be used as first-line agents for the treatment of nausea and vomiting. 1

First-Line Treatment Options

The treatment approach to nausea depends on the underlying cause and severity of symptoms. Based on current guidelines, the following medications are recommended:

Dopamine Antagonists

• Metoclopramide: 10-20 mg PO or IV every 4-6 hours 1
• Prochlorperazine: 5-10 mg PO or IV every 4-6 hours, or 25 mg suppository every 12 hours 1
• Haloperidol: 0.5-2 mg PO or IV every 4-6 hours 1

Serotonin (5-HT3) Antagonists

• Ondansetron: 4-8 mg PO or IV twice or three times daily 1, 2
• Granisetron: 1-2 mg PO daily or 1 mg PO twice daily 1

Other Antiemetic Options

• Promethazine: 12.5-25 mg PO or IV every 4 hours (IV through central line only) 1
• Scopolamine: 1.5-3 mg patch every 72 hours 1
• Lorazepam: 0.5-2 mg PO or IV every 4-6 hours (particularly useful for anticipatory nausea) 1
• Dexamethasone: 2-8 mg PO or IV daily (especially helpful in bowel obstruction) 1

Treatment Algorithm

1. Assess for underlying cause: Rule out serious conditions like bowel obstruction, CNS pathology, metabolic disorders

2. Initial therapy:

   • For mild to moderate nausea: Start with a dopamine antagonist (metoclopramide 10 mg or prochlorperazine 5-10 mg)
   • For severe nausea or vomiting: Consider ondansetron 4-8 mg or granisetron 1 mg

3. If initial therapy fails:

   • Add a medication from a different drug class
   • Consider scheduled rather than as-needed dosing 1

4. For refractory nausea:

   • Combine multiple agents with different mechanisms of action
   • Consider alternative routes of administration if oral route not feasible 1

Special Considerations

• Chemotherapy-induced nausea: 5-HT3 antagonists like ondansetron are particularly effective 2

• Radiation-induced nausea: Ondansetron 8 mg 2-3 times daily with or without dexamethasone 1

• Anticipatory nausea: Lorazepam 0.5-2 mg or behavioral therapy techniques 1

• Gastroparesis-related nausea: Metoclopramide is preferred due to its prokinetic effects 1

Monitoring and Cautions

• Monitor for side effects:

  • Extrapyramidal symptoms with dopamine antagonists (use diphenhydramine 25-50 mg for treatment) 1
  • QT prolongation with ondansetron and droperidol
  • Sedation with promethazine and antihistamines

• For prolonged use: Consider rotating antiemetics to prevent tachyphylaxis and minimize side effects

• Avoid metoclopramide in patients with Parkinson's disease or history of tardive dyskinesia

The evidence suggests that while many antiemetics are effective, no single agent has demonstrated clear superiority over others for undifferentiated nausea 3. The choice of agent should be guided by the suspected cause, patient comorbidities, and side effect profile of the medication.