What is the treatment for nausea?

Treatment of Nausea

For most cases of nausea, first-line treatment should be a dopamine receptor antagonist such as prochlorperazine (5-10 mg 3-4 times daily), metoclopramide (5-10 mg 3-4 times daily), or haloperidol (0.5-2 mg 1-2 times daily). 1

Medication Selection Based on Cause

General Nausea Treatment Algorithm:

1. First-line options:

   • Prochlorperazine 5-10 mg PO/IV 3-4 times daily
   • Metoclopramide 5-10 mg PO/IV 3-4 times daily
   • Haloperidol 0.5-2 mg PO/IV 1-2 times daily

2. For persistent symptoms, add:

   • 5-HT3 receptor antagonist (ondansetron 4-8 mg PO/IV 2-3 times daily or granisetron 1 mg PO twice daily) 1, 2

3. For refractory cases, consider:

   • Olanzapine 2.5-5 mg daily 2
   • Dexamethasone 4-8 mg daily 1
   • Lorazepam 0.5-2 mg PO/IV/sublingual every 4-6 hours (as adjunct only) 2

Cause-Specific Treatments:

Chemotherapy-Induced Nausea

Treatment should be based on the emetic risk of the chemotherapy regimen 2:

• High emetic risk: Combination of 5-HT3 antagonist + NK1 receptor antagonist + dexamethasone 2
• Moderate emetic risk: 5-HT3 antagonist + dexamethasone 2
• Low emetic risk: Single dose of 5-HT3 antagonist OR single 8-mg dose of dexamethasone 2
• Minimal emetic risk: No routine prophylaxis recommended 2

Postoperative Nausea

• Ondansetron 4 mg IV is significantly more effective than placebo 3
• Consider dexamethasone as an adjunct 2

Opioid-Induced Nausea

• Consider opioid rotation or prophylactic antiemetics 1
• Haloperidol 0.5-2 mg 1-2 times daily 1

Constipation-Related Nausea

• Treat underlying constipation with stimulant laxatives 1

GERD-Related Nausea

• Proton pump inhibitors or H2 receptor antagonists 1

Special Considerations

Breakthrough Nausea

For patients experiencing breakthrough nausea despite prophylaxis:

• Re-evaluate emetic risk, disease status, concurrent illnesses, and medications 2
• Add olanzapine if not already being used 2

Anticipatory Nausea

• Lorazepam 0.5-2 mg PO/IV/sublingual every 4-6 hours 2
• Alprazolam 0.25-0.5 mg PO three times daily, beginning the night before treatment 2

Bowel Obstruction

• Octreotide for nausea and vomiting due to bowel obstruction caused by cancer 2
• Consider olanzapine 2.5-5 mg daily 1

Practical Administration Tips

• For IV administration of antiemetics, slower infusion rates can reduce the incidence of adverse effects like akathisia 4
• Oral and IV 5-HT3 antagonists have equivalent efficacy when used at appropriate doses 2
• Start at lower doses and titrate slowly, especially in elderly patients or those with hepatic impairment 5
• Monitor for QT prolongation with certain antiemetics, particularly droperidol 4

Monitoring and Follow-up

• If symptoms persist beyond one week, reassess the underlying cause 1
• For chronic nausea (lasting ≥4 weeks), a more thorough diagnostic evaluation is warranted to identify specific causes 6, 7
• Consider non-pharmacological approaches such as small, frequent meals and avoiding trigger foods 6

The evidence supporting antiemetic therapy is generally of low to moderate quality 8, but the medications mentioned above have demonstrated efficacy in reducing nausea and improving quality of life. Treatment should be continued for the shortest time necessary to control symptoms while addressing the underlying cause when possible.