What is the treatment plan for nausea?

Treatment Plan for Nausea

For patients with nausea, first assess the underlying cause and then implement a stepwise treatment approach with dopamine receptor antagonists as first-line therapy, followed by adding medications with different mechanisms of action for persistent symptoms. 1

Initial Assessment

• Evaluate for specific causes of nausea including constipation, central nervous system pathology, chemotherapy, radiation therapy, hypercalcemia, medications, and gastrointestinal disorders 1
• Check for medication-induced nausea by reviewing current medications, especially opioids, which commonly cause nausea 1
• Consider checking blood levels of medications that can cause nausea (digoxin, phenytoin, carbamazepine, tricyclic antidepressants) 1
• For patients with a prior history of opioid-induced nausea, prophylactic treatment with antiemetic agents is highly recommended 1

First-Line Treatment

• Begin with dopamine receptor antagonists:

  • Prochlorperazine 10 mg PO every 6 hours as needed 1
  • Haloperidol 0.5-1 mg PO every 6-8 hours 1
  • Metoclopramide 10-20 mg PO every 6 hours (also has prokinetic effects) 1
  • Olanzapine 2.5-5 mg PO (especially helpful for patients with bowel obstruction) 1

• For anxiety-related nausea, consider benzodiazepines 1

For Persistent Nausea

• If nausea persists despite as-needed regimen, administer antiemetics around the clock for 1 week and then change to as-needed dosing 1

• Consider adding medications with different mechanisms of action:

  • Serotonin (5-HT3) receptor antagonists:

    • Ondansetron 8 mg PO daily or twice daily 1, 2
    • Granisetron PO daily 1
    • (Note: Use with caution as constipation is a side effect) 1

  • Anticholinergic agents:

    • Scopolamine transdermal patch 1 mg/3 days 1, 3

  • Antihistamines:

    • Meclizine 1

  • Corticosteroids:

    • Dexamethasone 2-8 mg PO or IV (especially beneficial if nausea persists for more than a week) 1
    • Particularly effective in combination with metoclopramide and ondansetron 1

For Refractory Nausea

• Reassess cause and severity of nausea 1
• Consider cannabinoids (dronabinol, nabilone) for chemotherapy-induced nausea and vomiting that is refractory to standard therapies 1
• For opioid-induced nausea, consider opioid rotation if nausea persists after a trial of several opioids and above measures 1
• Alternative therapies such as acupuncture, hypnosis, or cognitive behavioral therapy may be considered 1

Special Considerations

• For gastritis or gastroesophageal reflux causing nausea, use proton pump inhibitors and H2 receptor antagonists 1
• For gastric outlet obstruction, consider corticosteroids, endoscopic stenting, or insertion of a decompressing G-tube 1
• For chronic nausea, neuromodulator agents (tricyclic antidepressants, gabapentin, mirtazapine) may be more effective than conventional antiemetics 4
• For patients with bowel obstruction due to cancer, octreotide should be utilized 1

Common Pitfalls to Avoid

• Failing to identify and treat the underlying cause of nausea 1, 5
• Using only one antiemetic when combination therapy targeting different mechanisms may be more effective 1, 4
• Not distinguishing between acute and chronic nausea, which may require different treatment approaches 5, 4
• Overlooking medication-induced nausea as a common cause 1, 6
• Not administering antiemetics around the clock for persistent nausea 1

By following this systematic approach to treating nausea, you can effectively manage symptoms while addressing the underlying cause, ultimately improving patient comfort and quality of life.