What are the treatment options for nausea?

Treatment Options for Nausea

5-HT3 receptor antagonists, particularly ondansetron (4-8 mg PO/IV 2-3 times daily) or granisetron (1 mg PO twice daily or 34.3 mg transdermal patch weekly), are the recommended first-line treatments for nausea due to their excellent efficacy and safety profile. 1

First-Line Medication Options

5-HT3 Receptor Antagonists

• Ondansetron: 4-8 mg PO/IV 2-3 times daily 2, 1

  • Excellent safety profile with minimal sedation
  • May cause constipation, headache
  • Potential for QT prolongation at higher doses
  • FDA-approved for chemotherapy-induced nausea and vomiting 3

• Granisetron: 1 mg PO twice daily or 34.3 mg transdermal patch weekly 2, 1

  • Similar efficacy to ondansetron
  • Transdermal patch option beneficial for patients with difficulty swallowing
  • Studies show transdermal granisetron can decrease symptom scores by 50% in refractory gastroparesis 2

Second-Line and Alternative Options

Phenothiazines

• Prochlorperazine: 5-10 mg PO/IV four times daily 2, 1

  • Effective but requires monitoring for akathisia and extrapyramidal symptoms
  • Consider lower doses in elderly patients

• Chlorpromazine: 10-25 mg three or four times daily 2

  • Effective but has more sedating properties

Antihistamines

• Meclizine: 12.5-25 mg three times daily 2, 1

  • Particularly effective for motion-related nausea
  • May cause sedation and dry mouth

• Diphenhydramine: 12.5-25 mg three times daily 2, 1

  • Can be used alone or to counteract extrapyramidal symptoms from other antiemetics
  • Causes sedation and anticholinergic effects

• Dimenhydrinate: 25-50 mg three times daily 2

  • Similar profile to diphenhydramine

Anticholinergics

• Scopolamine: 1.5 mg transdermal patch every 3 days 2
  • Particularly effective for motion sickness and vestibular-related nausea

Other Options

• Trimethobenzamide: 300 mg three times daily 2, 1

  • Less sedating than phenothiazines
  • No known association with SIADH

• Neurokinin-1 (NK-1) receptor antagonists: (e.g., aprepitant 80 mg/day) 2

  • Block substance P in areas involved in nausea and vomiting
  • Particularly effective for chemotherapy-induced nausea
  • Studies show improvement in nausea and vomiting regardless of gastric emptying time

• Metoclopramide: 5-20 mg three to four times daily 2

  • Dual action: antiemetic and prokinetic
  • Monitor for extrapyramidal symptoms

• Ginger: 1 g twice daily 2, 1

  • Can be used as adjunct therapy
  • Minimal side effects

Treatment Algorithm Based on Nausea Etiology

Chemotherapy-Induced Nausea

1. For highly emetogenic chemotherapy: Combination of 5-HT3 antagonist + dexamethasone + NK-1 receptor antagonist 2
2. For moderately emetogenic chemotherapy: 5-HT3 antagonist + dexamethasone 2
3. For breakthrough symptoms: Add one agent from a different drug class 2

Gastroparesis-Related Nausea

1. 5-HT3 antagonist (ondansetron or granisetron) 2
2. Consider adding prokinetic agent (metoclopramide) 2
3. For refractory cases: NK-1 receptor antagonists 2

Motion Sickness/Vestibular Nausea

1. Antihistamines (meclizine, dimenhydrinate) 1
2. Scopolamine transdermal patch 2

General/Undifferentiated Nausea

1. Start with ondansetron 4-8 mg or granisetron 1 mg 1, 4
2. If ineffective, try a medication from a different class (phenothiazine or antihistamine) 1
3. For refractory nausea, consider combination therapy 1

Special Considerations

Elderly Patients

• Start with lower doses of all agents and titrate slowly 1
• Use caution with ondansetron and haloperidol due to potential QT prolongation 1
• Avoid or use reduced doses of medications with anticholinergic properties 1

Pregnancy

• Vitamin B6 (10-25mg) may be a safer first-line option 1
• Consult obstetric provider before using antiemetics

Patients with Cardiac Disease

• Use caution with ondansetron and haloperidol due to potential QT prolongation 1
• Consider granisetron as an alternative 5-HT3 antagonist

Non-Pharmacologic Approaches

• Elevate head of bed 6-8 inches 1
• Avoid meals within 3 hours of bedtime 1
• Small, frequent meals rather than large meals 5
• Avoid trigger foods 1
• Adequate hydration and electrolyte replacement 5
• Consider acupressure wristbands as adjunct therapy 1

Management of Side Effects

• For constipation: Increase fluid intake and consider mild laxatives 1
• For headache: Acetaminophen as needed 1
• For extrapyramidal symptoms: Diphenhydramine 25-50 mg 2, 1

While multiple studies and guidelines support these treatment recommendations, it's important to note that the Cochrane review found limited evidence for superiority of any one antiemetic over others or over placebo in the emergency department setting, suggesting that supportive care with IV fluids may be sufficient for many patients 6.