What is the treatment for nausea and upset stomach?

Treatment for Nausea and Upset Stomach

For nausea and upset stomach, first-line treatment includes dopamine receptor antagonists such as prochlorperazine, metoclopramide, or haloperidol, with serotonin (5-HT3) receptor antagonists like ondansetron added for persistent symptoms. 1

Initial Assessment and Cause Identification

Before initiating treatment, identify potential causes of nausea and upset stomach:

• Medication-induced (opioids, chemotherapy, antibiotics)
• Gastritis or gastroesophageal reflux
• Gastric outlet or bowel obstruction
• Constipation
• Metabolic disorders (hypercalcemia)
• Vestibular disorders

First-Line Treatments

Dopamine Receptor Antagonists

• Prochlorperazine: 5-10 mg 3-4 times daily
• Metoclopramide: 5-10 mg 3-4 times daily (also has prokinetic effects)
• Haloperidol: 0.5-2 mg 1-2 times daily

For Specific Causes

• Gastritis/GERD: Proton pump inhibitors or H2 receptor antagonists 1
• Opioid-induced nausea: Consider opioid rotation or prophylactic antiemetics 1
• Constipation-related: Treat underlying constipation with stimulant laxatives 1

For Persistent Nausea (Step-Up Approach)

If nausea persists despite first-line treatment:

1. Add 5-HT3 receptor antagonists:

   • Ondansetron: 4-8 mg 2-3 times daily
   • Granisetron: 1 mg twice daily 1

2. Consider combination therapy targeting different mechanisms:

   • Add anticholinergic agents (scopolamine patch every 3 days)
   • Add antihistamines (meclizine 12.5-25 mg three times daily) 1

3. Add corticosteroids:

   • Particularly effective in combination with metoclopramide and ondansetron 1
   • Dexamethasone 4-8 mg daily

For Refractory Nausea and Vomiting

If symptoms persist beyond one week:

1. Reassess underlying cause 1

2. Consider antipsychotics:

   • Olanzapine: 2.5-5 mg daily (especially helpful for patients with bowel obstruction) 1

3. Consider cannabinoids (for truly refractory cases):

   • Dronabinol: 2.5-5 mg 1-3 times daily
   • Nabilone: 1-2 mg twice daily 1

Special Considerations

For Elderly Patients

• Start at lower doses and titrate slowly
• Monitor for anticholinergic effects and QT prolongation
• Nortriptyline may be better tolerated than amitriptyline 2

For Gastroparesis

• Metoclopramide is FDA-approved for gastroparesis
• Domperidone (via FDA investigational protocol) may have fewer central side effects 1
• Consider 5-HT4 receptor agonists for gastric emptying 3

Common Pitfalls to Avoid

1. Prolonged metoclopramide use: Risk of tardive dyskinesia increases with duration; limit to 12 weeks when possible

2. Overlooking constipation: Always assess and treat constipation when managing nausea

3. Medication interactions: Monitor for QT prolongation with combined antiemetics

4. Inadequate dosing: If using as-needed regimen without success, switch to scheduled dosing for one week 1

5. Single-agent fixation: Instead of replacing one antiemetic with another, consider adding agents with different mechanisms of action for synergistic effects 1

For optimal outcomes, adjust treatment based on symptom response and tolerability, with the goal of improving quality of life and reducing morbidity associated with persistent nausea and vomiting.