What are the treatment options for nausea?

Treatment Options for Nausea

The most effective treatment approach for nausea involves targeting the underlying cause with specific medications, with 5-HT3 antagonists like ondansetron (4-8 mg) being first-line therapy for most types of nausea, while dopaminergic antagonists like metoclopramide, haloperidol, or prochlorperazine are excellent alternatives. 1

First-Line Medications Based on Cause

Chemotherapy-Induced Nausea and Vomiting

• 5-HT3 receptor antagonists are first-line therapy:
  • Ondansetron 4-8 mg orally or IV every 6-8 hours 1
  • Granisetron 1 mg orally twice daily or 3.1 mg transdermal patch weekly 1
• Add dexamethasone (4 mg daily) to enhance antiemetic effect 1
• For breakthrough symptoms, add a second agent with different mechanism of action 1

Radiation-Induced Nausea and Vomiting

• For upper abdominal radiation: ondansetron (8 mg, 2-3 times daily) or granisetron (2 mg daily) 1
• Consider adding dexamethasone for enhanced effect 1
• For total body irradiation: ondansetron or granisetron with or without dexamethasone 1

Postoperative Nausea and Vomiting

• Ondansetron 4 mg IV is significantly more effective than placebo 2, 3
• Alternatives include droperidol or metoclopramide, though studies show similar efficacy to ondansetron 3

Opioid-Induced Nausea

• Prophylactic treatment recommended for patients with prior history 1
• First-line options:
  • Phenothiazines: prochlorperazine (5-10 mg every 6 hours) or chlorpromazine 1
  • Dopamine antagonists: metoclopramide (10-20 mg) or haloperidol (0.5-1 mg) 1
• For persistent symptoms, add serotonin antagonists (ondansetron, granisetron) 1

Gastroparesis-Related Nausea

• 5-HT3 antagonists: ondansetron (4-8 mg) or granisetron 1
• Prokinetic agents: metoclopramide (5-20 mg three times daily) 1
• Phenothiazines: prochlorperazine (5-10 mg four times daily) 1

Second-Line and Adjunctive Treatments

Anticholinergic Agents

• Scopolamine transdermal patch (1.5 mg every 3 days) - particularly effective for motion sickness and vestibular-related nausea 1, 4
• Apply patch at least 4 hours before anticipated need 4

Benzodiazepines for Anticipatory Nausea

• Lorazepam (0.5-2 mg) or alprazolam (0.25-0.5 mg three times daily) 1
• Particularly useful for anticipatory nausea related to chemotherapy 1
• Start the night before treatment for anticipatory symptoms 1

Neurokinin-1 (NK-1) Receptor Antagonists

• Aprepitant (80 mg daily) for refractory nausea, especially in gastroparesis 1
• Particularly effective when combined with 5-HT3 antagonists 1

Corticosteroids

• Dexamethasone (2-8 mg) for bowel obstruction or as adjunct to other antiemetics 1
• Particularly effective in combination with metoclopramide and ondansetron 1

Other Options

• Olanzapine - especially helpful for patients with bowel obstruction 1
• Cannabinoids (dronabinol, nabilone) - FDA-approved for chemotherapy-induced nausea 1
• Ginger (1 g twice daily) - natural alternative with some evidence of efficacy 1

Non-Pharmacological Approaches

• Behavioral therapy techniques for anticipatory nausea 1
  • Hypnosis with systematic desensitization 1
  • Guided imagery 1
• Small, frequent meals and avoiding trigger foods 5
• Adequate hydration and electrolyte replacement 5

Treatment Algorithm Based on Duration and Severity

Acute Nausea (≤7 days)

1. Identify and treat underlying cause if possible 5
2. For mild symptoms: non-pharmacological approaches first 5
3. For moderate-severe symptoms: select antiemetic based on suspected etiology 5

Chronic Nausea (≥4 weeks)

1. Comprehensive evaluation to determine underlying cause 6
2. Target therapy based on gastric emptying status:
   • Delayed emptying: prokinetic agents (metoclopramide) 1
   • Normal emptying: antiemetics targeting central pathways 6
3. Consider combination therapy for refractory symptoms 1

Common Pitfalls and Caveats

• Failure to identify and address the underlying cause of nausea 5, 6
• First-generation antihistamines (diphenhydramine) and vasopressors should be avoided in infusion reactions as they may exacerbate hypotension and tachycardia 1
• Metoclopramide carries risk of extrapyramidal side effects, especially at higher doses 1
• Ondansetron and other 5-HT3 antagonists can cause constipation as a side effect 7
• For persistent symptoms beyond 1 week, reassess cause and consider opioid rotation if opioid-induced 1