What is the treatment for intractable vomiting (persistent vomiting)?

From the Guidelines

The treatment of intractable vomiting should begin with titrating dopamine receptor antagonists, such as prochlorperazine, haloperidol, metoclopramide, or olanzapine, to maximum benefit and tolerance, as recommended by the most recent guidelines 1.

Initial Management

Initial management includes identifying and addressing the underlying cause while providing supportive care.

• Intravenous fluid therapy with normal saline or lactated Ringer's solution to correct dehydration and electrolyte imbalances is essential.
• Antiemetic medications are the cornerstone of symptomatic treatment.

First-Line Options

First-line options include:

• Dopamine receptor antagonists, such as prochlorperazine, haloperidol, metoclopramide, or olanzapine, as recommended by the guidelines 1.
• If nausea and vomiting persist, adding a 5-HT3 antagonist, such as ondansetron, may be beneficial, as suggested by the guidelines 1.

Combination Approach

For severe cases, a combination approach may be necessary, potentially adding:

• A corticosteroid, such as dexamethasone, as recommended by the guidelines 1.
• Other agents, such as scopolamine, dronabinol, or olanzapine, may also be considered for management of nausea, as suggested by the guidelines 1.

Persistent Vomiting

Persistent vomiting requires investigation for serious underlying conditions, such as:

• Intestinal obstruction
• Pancreatitis
• Increased intracranial pressure If vomiting persists despite these interventions, hospitalization may be necessary for more aggressive management, including nasogastric tube placement for gastric decompression. The most recent guidelines recommend considering a continuous IV/subcut infusion of antiemetics and opioid rotation if the patient is on opioids 1.

From the FDA Drug Label

Ondansetron Injection (three 0. 15-mg/kg doses) was significantly more effective than placebo in preventing nausea and vomiting induced by cisplatin-based chemotherapy. In uncontrolled trials, 127 patients receiving cisplatin (median dose, 100 mg/m2) and ondansetron who had two or fewer emetic episodes were re-treated with ondansetron and chemotherapy, mainly cisplatin, for a total of 269 re-treatment courses (median: 2; range: 1 to 10) No emetic episodes occurred in 160 (59%), and two or fewer emetic episodes occurred in 217 (81%) re-treatment courses.

The treatment for intractable vomiting (persistent vomiting) is not directly addressed in the provided FDA drug label for ondansetron (IV) 2. However, based on the available information, ondansetron may be used to prevent nausea and vomiting induced by chemotherapy. The recommended dose is 0.15 mg/kg administered three times during the course of cancer chemotherapy.

• Key points:
  • Ondansetron is effective in preventing nausea and vomiting induced by cisplatin-based chemotherapy.
  • The recommended dose is 0.15 mg/kg administered three times.
  • Re-treatment with ondansetron and chemotherapy may be effective in patients who have had two or fewer emetic episodes. However, the FDA drug label does not provide direct information on the treatment of intractable vomiting.

From the Research

Treatment for Intractable Vomiting

The treatment for intractable vomiting, also known as persistent vomiting, typically involves the use of antiemetic agents. These agents can help to reduce the frequency and severity of vomiting episodes.

Antiemetic Agents

Some of the commonly used antiemetic agents for the treatment of intractable vomiting include:

• Ondansetron: a serotonin antagonist that is effective in treating chemotherapy-induced nausea and vomiting, as well as vomiting in children with acute gastroenteritis 3, 4, 5, 6
• Metoclopramide: a dopamine antagonist that can be used to treat nausea and vomiting, but may cause extrapyramidal adverse effects, particularly in children 3, 7
• Domperidone: a dopamine antagonist that is commonly used to treat vomiting in children, but its efficacy and safety profile are not well established 4, 5
• Promethazine: a phenothiazine derivative that can be used to treat nausea and vomiting, but may cause sedation and vascular damage upon intravenous administration 3
• Prochlorperazine: a phenothiazine derivative that can be used to treat nausea and vomiting, but may cause akathisia and other extrapyramidal adverse effects 3

Administration and Dosage

The administration and dosage of antiemetic agents may vary depending on the specific agent, the patient's age and weight, and the severity of the vomiting. For example:

• Ondansetron can be administered orally or parenterally, with a typical dose of 0.2 mg/kg oral or 0.15 mg/kg parenteral, up to a maximum of 4 mg 6
• Metoclopramide can be administered orally or intravenously, with a typical dose of 0.1-0.2 mg/kg per dose, up to a maximum of 10 mg per dose 7

Important Considerations

When treating intractable vomiting, it is essential to:

• Assess the patient's hydration status and provide fluid replacement as needed
• Monitor for red flag signs, such as bilious or bloody vomiting, altered sensorium, and severe dehydration
• Use antiemetic agents judiciously, taking into account their potential side effects and interactions with other medications
• Consider the underlying cause of the vomiting and treat it accordingly 3, 4, 7, 5, 6