What is the plan for managing nausea in a patient?

Management Plan for Nausea in SOAP Format

Dopamine receptor antagonists are the first-line treatment for non-specific nausea and vomiting, with 5-HT3 receptor antagonists recommended for specific causes like chemotherapy or radiation-induced nausea. 1, 2

Initial Assessment and Cause Identification

• Evaluate for specific causes of nausea including medication-induced, psychogenic, gastrointestinal disorders, and disease-specific causes 2
• Check available blood levels of medications that may cause nausea (digoxin, phenytoin, carbamazepine, tricyclic antidepressants) 1
• Review current medications, especially opioids, which commonly cause nausea 2
• Consider other potential causes: bowel obstruction, vestibular dysfunction, brain metastases, electrolyte imbalances, uremia, gastroparesis, or anxiety 1

First-Line Treatment Based on Cause

Non-Specific Nausea and Vomiting

• Initiate dopamine receptor antagonists:
  • Prochlorperazine 5-10 mg PO/IV every 6 hours 1, 3
  • Haloperidol 0.5-1 mg PO/IV every 6-8 hours 2
  • Metoclopramide 5-20 mg PO/IV every 6 hours 1, 2

Chemotherapy-Induced Nausea and Vomiting

• For high emetic risk chemotherapy:
  • 5-HT3 antagonist (ondansetron 16-24 mg PO or 8-24 mg IV day 1) 1
  • Plus dexamethasone 12 mg PO/IV day 1, then 8 mg daily days 2-4 1
  • Plus neurokinin-1 antagonist (aprepitant 125 mg PO day 1,80 mg PO daily days 2-3) 1

Radiation-Induced Nausea and Vomiting

• For high-risk radiation (total body irradiation):
  • 5-HT3 antagonist (ondansetron 8 mg PO/IV or granisetron 2 mg PO/1 mg IV) 1
  • Plus dexamethasone 4 mg PO/IV 1

Opioid-Induced Nausea

• Prophylactic treatment with antiemetic agents is highly recommended 2
• Consider opioid rotation if nausea persists after trials of several opioids 2

Persistent Nausea Management

• If nausea persists with as-needed regimen, administer antiemetics around the clock 2
• Add a 5-HT3 antagonist (e.g., ondansetron 8 mg PO/IV) 1, 4
• Consider adding an anticholinergic agent (e.g., scopolamine transdermal patch) 1
• Consider adding an antihistamine (e.g., meclizine) 1
• Consider adding a corticosteroid (e.g., dexamethasone 4 mg PO/IV) 1

Refractory Nausea Treatment

• Consider using a continuous IV/SC infusion of antiemetics 1
• Consider cannabinoids for chemotherapy-induced nausea refractory to standard therapies 2
• Consider alternative therapies such as acupuncture 1, 2
• Reassess for cause and severity of nausea if symptoms persist 1

Medication-Specific Dosing

Ondansetron

• 4-8 mg PO/IV every 8 hours as needed 4
• For chemotherapy: 16-24 mg PO or 8-24 mg IV day 1 1
• For radiation: 8 mg PO/IV daily 1

Prochlorperazine

• Adults: 5-10 mg PO/IV every 6 hours, not to exceed 40 mg daily 3
• Elderly: Use lower dosage range and monitor closely for hypotension and neuromuscular reactions 3

Common Pitfalls and Caveats

• Monitor for extrapyramidal side effects with dopamine antagonists, especially at higher doses 5
• Consider using an H2 blocker or proton pump inhibitor to prevent dyspepsia, which can mimic nausea 1
• Be cautious with metoclopramide in elderly patients due to increased risk of extrapyramidal symptoms 5
• For patients receiving multiple-day chemotherapy, extend antiemetic prophylaxis to include the day after each fraction 1
• Recognize that optimal control of acute nausea is essential to achieve good protection from delayed nausea and vomiting 6

Non-Pharmacological Approaches

• Recommend eating small, frequent meals and choosing foods at room temperature 1
• Consider dietary consultation for persistent nausea 1
• For anticipatory nausea, consider behavioral therapy techniques 5