What are the management options for nausea and vomiting?

Management Options for Nausea and Vomiting

The most effective management of nausea and vomiting requires identifying the underlying cause and selecting targeted therapy, with dopamine receptor antagonists (such as metoclopramide, prochlorperazine, or haloperidol) serving as first-line agents for most non-specific cases. 1

Step 1: Identify the Cause

First, determine the likely etiology of nausea and vomiting:

• Chemotherapy/Radiation-induced: Follow specific antiemetic guidelines based on emetogenic potential 1
• Medication-related: Check blood levels of possible culprits (digoxin, phenytoin, carbamazepine, tricyclic antidepressants) 1
• GI-related:
  • Gastritis/GERD: Use proton pump inhibitors or H2 receptor antagonists 1
  • Gastric outlet obstruction: Consider corticosteroids, endoscopic stenting, or G-tube 1
  • Bowel obstruction: Manage according to cause and severity 1
• Metabolic: Correct hypercalcemia or other metabolic abnormalities 1
• Anxiety-related: Consider benzodiazepines 1

Step 2: Select Appropriate Therapy

First-Line Agents for Non-Specific Nausea and Vomiting:

• Dopamine receptor antagonists: 1
  • Metoclopramide: Most evidence-supported option for non-chemotherapy nausea
  • Prochlorperazine
  • Haloperidol
  • Olanzapine (also blocks multiple other receptors)

For Persistent Nausea and Vomiting:

1. Titrate dopamine receptor antagonists to maximum benefit and tolerance 1
2. Add one or more of the following: 1
   • 5-HT3 receptor antagonists (ondansetron, granisetron)
   • Anticholinergic agents (scopolamine)
   • Antihistamines (meclizine)
   • Corticosteroids (dexamethasone)
   • Cannabinoids (dronabinol, nabilone) for refractory cases

For Specific Scenarios:

• Chemotherapy-induced: Use 5-HT3 antagonists with dexamethasone as standard of care 1
• Post-procedure (e.g., TACE): Metoclopramide (80% use) or 5-HT3 antagonists (70.9% use) 1
• Opioid-induced: Consider opioid rotation 1

Step 3: Consider Administration Routes

For patients unable to tolerate oral medications:

• Continuous intravenous or subcutaneous infusions of antiemetics 1
• Rectal administration for dying patients 1

Step 4: Add Non-Pharmacologic Approaches

• Alternative therapies: acupuncture, hypnosis, cognitive behavioral therapy 1
• For anticipatory nausea: behavioral therapies (progressive muscle relaxation, systematic desensitization) 1

Common Pitfalls and Caveats

1. Medication side effects: Monitor for:

   • Akathisia with prochlorperazine or metoclopramide (can develop up to 48 hours after administration) 2
   • QT prolongation with certain antiemetics, especially droperidol 2
   • Sedation with promethazine 2

2. Refractory cases:

   • Combination therapy is more effective than single agents for persistent symptoms 1
   • Consider ondansetron as a first-line agent in emergency settings due to favorable side effect profile 2
   • For intractable symptoms, palliative sedation may be considered as a last resort after specialized palliative care services have been exhausted 1

3. Evidence limitations:

   • Antiemetic recommendations for non-chemotherapy nausea have moderate to weak evidence at best 1
   • Studies of multidrug combination therapies do not consistently support their effectiveness 1

Remember that the goal of treatment is to improve quality of life by effectively managing symptoms while minimizing medication side effects. Treatment should be continued for the shortest time necessary to control symptoms 3.