How to manage nausea caused by steroid use?

Management of Steroid-Induced Nausea

For patients experiencing nausea due to steroid use, a combination approach using antiemetics targeting different mechanisms of action is recommended, with dopamine receptor antagonists such as metoclopramide or phenothiazines as first-line agents.

First-Line Management Options

• For acute steroid-induced nausea, phenothiazines (prochlorperazine, thiethylperazine) or dopamine receptor antagonists (metoclopramide, haloperidol) are effective first-line agents 1
• If nausea persists despite as-needed dosing, administer antiemetics around the clock for 1 week, then adjust to as-needed dosing 1
• For patients with a history of steroid-induced nausea, prophylactic treatment with antiemetics is highly recommended before starting steroid therapy 1

Combination Therapy for Persistent Nausea

• Rather than replacing one antiemetic with another, add medications with different mechanisms of action for synergistic effect 1
• Consider adding serotonin receptor antagonists (ondansetron, granisetron) which have lower rates of CNS side effects 1
• Alternative agents to consider include:
  • Scopolamine (anticholinergic) 1
  • Olanzapine (particularly helpful in patients with bowel obstruction) 1
  • Dronabinol (cannabinoid) 1

Dosing Recommendations

• Dopamine antagonists (3-4 times daily):
  • Metoclopramide: 20-30 mg orally 1
  • Prochlorperazine: 10-20 mg orally 1
• Serotonin antagonists (once daily):
  • Ondansetron: 16-24 mg orally 1
  • Granisetron: 2 mg orally 1
• For refractory nausea, consider adding benzodiazepines such as lorazepam 1-2 mg 1-4 times daily 1

Special Considerations

• Always assess for other potential causes of nausea when steroid-induced nausea persists, including constipation, CNS pathology, metabolic disorders, or other medications 1
• If nausea persists for longer than a week despite antiemetic therapy, consider:
  • Reassessing the underlying cause 1
  • Adjusting the steroid dose if clinically appropriate 1
  • Switching to a different steroid formulation 1

Important Caveats

• While corticosteroids themselves are effective antiemetics for chemotherapy-induced nausea, they can paradoxically cause nausea as a side effect 1
• High-dose methylprednisolone has been shown to improve the efficacy of metoclopramide in controlling nausea and emesis in patients receiving chemotherapy 2, but evidence for managing steroid-induced nausea specifically is limited
• A Cochrane review found very low-quality evidence regarding corticosteroid use for nausea unrelated to cancer treatments, highlighting the need for more research in this area 3
• Single high-dose dexamethasone may improve acute nausea control but could potentially worsen delayed symptoms 4, suggesting careful consideration of dosing regimens

Monitoring and Follow-up

• Monitor patients for common side effects of antiemetics, including sedation, extrapyramidal symptoms (with dopamine antagonists), and QT prolongation (with some serotonin antagonists) 1
• If steroid-induced nausea significantly impacts quality of life and persists despite antiemetic therapy, consider consulting with specialists about alternative treatments or steroid-sparing approaches 1

Remember that effective management of steroid-induced nausea is essential for ensuring medication adherence and maintaining quality of life for patients requiring steroid therapy 1.