What is the appropriate management plan for a patient experiencing nausea?

Management of Nausea in Clinical Practice

The first-line treatment for nausea should be a dopamine receptor antagonist such as prochlorperazine (5-10 mg PO/IV every 6 hours) or metoclopramide (10-20 mg PO three times daily), with treatment selection based on the underlying cause of nausea. 1, 2

Initial Assessment and Cause Identification

• Begin by evaluating for specific causes of nausea, including medication-induced (especially opioids), psychogenic, gastrointestinal disorders, and disease-specific causes 1
• Review current medications, particularly those commonly associated with nausea such as opioids, digoxin, phenytoin, carbamazepine, and tricyclic antidepressants 1
• Consider other potential causes including bowel obstruction, vestibular dysfunction, brain metastases, electrolyte imbalances, uremia, gastroparesis, or anxiety 1
• Determine if nausea is acute (≤7 days) or chronic (≥4 weeks), as this affects treatment approach 3

First-Line Treatment Based on Cause

Chemotherapy-Induced Nausea and Vomiting

• For high emetic risk chemotherapy: 5-HT3 antagonists such as ondansetron (8 mg oral twice daily or 8 mg IV) 4, 5
• Add dexamethasone (4 mg daily) to enhance antiemetic effect 2

Radiation-Induced Nausea and Vomiting

• For high-risk radiation: 5-HT3 antagonist before each fraction throughout treatment 4
• For minimal emetic risk radiation: rescue therapy with either dopamine receptor antagonist or 5-HT3 antagonist 4

Opioid-Induced Nausea

• Prophylactic treatment with phenothiazines such as prochlorperazine (5-10 mg every 6 hours) 4, 6
• Consider haloperidol (0.5-1 mg PO every 6-8 hours) if nausea persists 4

Non-Specific or General Nausea

• Dopamine receptor antagonists: prochlorperazine (5-10 mg PO/IV every 6 hours) 2, 6
• Promethazine (12.5-25 mg every 4-6 hours) for nausea and vomiting 7

Management of Persistent Nausea

• If nausea persists despite as-needed regimen, administer antiemetics around the clock for one week, then change to as-needed 4
• Consider adding a 5-HT3 antagonist (e.g., ondansetron 8 mg PO/IV) if first-line therapy fails 4, 5
• For motion sickness or vestibular-related nausea, consider scopolamine transdermal patch 2
• For anticipatory nausea related to chemotherapy, consider lorazepam (0.5-2 mg) 2

Refractory Nausea Treatment

• Consider combination therapy for refractory symptoms 2
• For chemotherapy-induced nausea refractory to standard therapies, consider cannabinoids 1
• Consider continuous IV/SC infusion of antiemetics for severe refractory nausea 1
• Reassess cause and consider opioid rotation if opioid-induced nausea persists beyond 1 week 2

Non-Pharmacological Approaches

• Eat small, frequent meals and choose foods at room temperature 1
• Consider dietary consultation for persistent nausea 1
• Behavioral therapy techniques may help with anticipatory nausea 1, 2

Common Pitfalls and Caveats

• Metoclopramide carries risk of extrapyramidal side effects, especially at higher doses and with prolonged use 2
• Ondansetron can cause QT interval prolongation; avoid in patients with congenital long QT syndrome 5
• Promethazine is contraindicated in children under 2 years of age 7
• Nausea may be an atypical presentation of gastroesophageal reflux disease; consider this diagnosis in patients with unexplained nausea 8
• Placebo response in nausea treatment is significant; in one study, 76% of patients receiving placebo reported symptom improvement 9