What are the treatments for nausea?

Treatment Options for Nausea

Antiemetic medications from different pharmacological classes are the primary treatment for nausea, with selection based on the suspected cause and patient-specific factors. 1

First-Line Pharmacological Treatments

Dopamine Receptor Antagonists

• Metoclopramide: 10-20 mg orally or intravenously every 4-6 hours as needed 1
  • Start with 10 mg in elderly patients
  • Monitor for extrapyramidal symptoms, especially in elderly
  • Limit treatment duration to minimize risk of tardive dyskinesia

Serotonin (5-HT3) Receptor Antagonists

• Ondansetron: 8 mg orally or intravenously every 8-12 hours 1, 2
• Granisetron: 1 mg PO twice daily or 1 mg IV daily 1
• Palonosetron: 0.25 mg IV as a single dose 1
• Particularly effective for chemotherapy-induced nausea and vomiting 3
• Dose adjustment needed in severe hepatic impairment 2

Phenothiazines

• Prochlorperazine: 10 mg orally or intravenously every 6 hours 3, 1
• Thiethylperazine: Dosing as directed 3

Corticosteroids

• Dexamethasone: 4-20 mg IV/PO daily 1
• Particularly effective in combination with metoclopramide and ondansetron 3
• Beneficial for reducing opioid-induced nausea and vomiting 3

Second-Line and Adjunctive Treatments

Antihistamines

• Diphenhydramine: 25-50 mg PO/IV every 6 hours 1
  • Useful when sedation is desired or for managing extrapyramidal symptoms
• Meclizine: 12.5-25 mg PO three times daily 1
  • Particularly effective for motion sickness and vertigo-related nausea

Antipsychotics

• Haloperidol: 0.5-2 mg IV every 4-6 hours 1
• Olanzapine: 5-10 mg orally daily 3, 1
  • Especially helpful for patients with bowel obstruction 3

Cannabinoids

• Dronabinol: FDA-approved for chemotherapy-induced nausea and vomiting 3
• Nabilone: For patients who have not responded to conventional antiemetics 3

Treatment Approach Based on Cause

Opioid-Induced Nausea

1. Prophylactic treatment with antiemetics is highly recommended for patients with prior history 3
2. If nausea develops, assess for other causes (constipation, CNS pathology, etc.) 3
3. If nausea persists despite as-needed regimen, administer antiemetics around the clock for 1 week 3
4. Consider adding therapies with different mechanisms of action for synergistic effect 3
5. If nausea persists longer than a week, reassess cause and consider opioid rotation 3

Chemotherapy-Induced Nausea

1. Preventive administration is more effective than treating established symptoms 3, 1
2. For highly emetogenic chemotherapy: 5-HT3 antagonists plus dexamethasone 3
3. For breakthrough symptoms, use an agent from a different drug class 3

General Approach to Nausea

1. Identify and treat underlying cause when possible 4
2. For acute nausea (≤7 days), symptomatic treatment is typically sufficient 4
3. For chronic nausea (≥4 weeks), more extensive evaluation is needed 4, 5

Non-Pharmacological Management

• Fluid and electrolyte replacement 4
• Small, frequent meals 4
• Avoidance of trigger foods 4
• Acupressure may be helpful for some patients 6

Important Considerations

Medication Selection

• IV administration is preferred for breakthrough symptoms 1
• Around-the-clock administration should be considered to prevent emesis, rather than as-needed dosing 3
• When first-line treatment fails, add or switch to an agent from a different class 1

Special Populations

• Elderly: Higher risk for extrapyramidal symptoms with metoclopramide; start with lower doses 1
• Hepatic Impairment: Dose reduction may be necessary, particularly for ondansetron in severe impairment 2

Common Pitfalls

• Failing to recognize that anxiety disorders are strongly associated with nausea (OR 3.42) 7
• Treating symptoms without addressing underlying cause
• Using single agents when combination therapy may be more effective for refractory nausea 3, 1
• Not monitoring for medication side effects, particularly extrapyramidal symptoms with dopamine antagonists 1

By following this evidence-based approach and selecting appropriate antiemetic therapy based on the suspected cause of nausea, most patients can achieve significant symptom relief.