What are the guidelines for using Levomepromazina (Methotrimeprazine) as a treatment option?

Guidelines for Using Levomepromazina (Methotrimeprazine) as a Treatment Option

Levomepromazina (methotrimeprazine) is recommended as a second-line treatment for nausea and vomiting in advanced cancer patients, particularly when first-line antiemetics have failed. 1

Indications for Use

Primary Indications:

• Refractory nausea and vomiting in advanced cancer patients 2, 1
• Terminal agitation in palliative care settings 3
• Management during the last 48 hours of life 3

Clinical Scenarios:

1. Advanced Cancer with Refractory Emesis

   • When first-line antiemetics (metoclopramide or haloperidol) have failed 1
   • For multifactorial causes of nausea and vomiting (54% of cases) 2
   • When nasogastric tube removal is desired (shown to allow removal in 100% of cases) 4

2. Terminal Phase Care

   • For combined management of psychological and physical symptoms 3
   • When sedation may be beneficial alongside antiemetic effects 3

Dosing Guidelines

For Nausea and Vomiting:

• Starting dose: 6.25 mg daily (oral) or lower 2
• Typical median dose: 6.25 mg daily (range: 3.12-25 mg) 4
• Administration routes:
  • Oral administration
  • Subcutaneous bolus injection
  • Continuous subcutaneous infusion (CSCI) 3

Titration Protocol:

• Begin with lowest effective dose (6.25 mg daily)
• Adjust according to response and side effects
• Maximum recommended dose: 25 mg via 24-hour subcutaneous infusion 2
• Assess response after 2 days of treatment (significant improvement typically seen within this timeframe) 4

Efficacy Data

• Reduces nausea from median 8/10 to 1/10 after two days of treatment 4
• Stops vomiting in 92% of advanced cancer cases 4
• Enables removal of nasogastric tubes in all patients who had one 4
• Shows antiemetic activity in 62% of patients by day 2 and 58% by day 5 2

Side Effect Management

Common Side Effects:

• Sedation: Most frequent side effect (median 2/10 intensity)
  • Not correlated with dose of levomepromazine 4
  • Monitor especially in elderly or debilitated patients

Monitoring Requirements:

• Daily assessment of sedation levels
• Observation for extrapyramidal symptoms
• Monitoring for orthostatic hypotension

Practical Administration Guidelines

Compatibility and Stability:

• Can be safely administered in continuous subcutaneous infusion with most other commonly used drugs in palliative care 3
• When diluted with 0.9% sodium chloride at concentrations of 0.13-6.25 mg/ml and stored in polypropylene syringes, stable for at least 14 days 5

Administration Algorithm:

1. Confirm failure of first-line antiemetics (metoclopramide or haloperidol)
2. Start low-dose levomepromazine (6.25 mg daily)
3. Assess response after 48 hours
4. If inadequate response but tolerable side effects, increase dose incrementally
5. If intolerable side effects, reduce dose or consider alternative therapy

Special Considerations

Important Caveats:

• Low-dose therapy (6.25 mg) is typically sufficient for antiemetic effects 4
• Higher doses may be needed for sedative or antipsychotic effects
• Consider potential drug interactions with other medications commonly used in palliative care

Contraindications:

• Caution in patients with cardiovascular disease due to potential hypotensive effects
• Avoid in patients with severe CNS depression
• Use with caution in patients with seizure disorders

Conclusion

Levomepromazina represents an effective second-line option for managing nausea and vomiting in advanced cancer patients, with evidence supporting its efficacy when first-line treatments fail. Its broad spectrum of activity (antipsychotic, anxiolytic, and sedative effects) makes it particularly valuable in palliative care settings, especially during the terminal phase of illness.