Can a patient with nausea (N), vomiting (V), fever, and diarrhea, who is on a nothing by mouth (NPO) diet, take their oral medications (PO meds)?

Management of Oral Medications in a Patient on NPO Status with N/V, Fever, and Diarrhea

Oral medications should not be administered until swallowing has been assessed and the patient is no longer NPO, as alternative routes such as intravenous and rectal administration should be considered while a patient is NPO. 1

Assessment and Initial Management

• Patients with nausea, vomiting, fever, and diarrhea who are NPO should have their medications administered via alternative routes (IV, rectal) until oral intake is safe 1
• For patients with acute gastroenteritis symptoms, NPO status is typically recommended during the acute phase of vomiting as even small amounts of water may not be tolerated 2
• The optimal NPO duration for patients with acute vomiting appears to be 4-6 hours, which has shown the lowest rate of refeeding failure (3.7%) compared to other durations 2

Medication Administration Considerations

• Oral medications should not be given until a swallowing assessment has been completed using a validated tool 1
• Patients should remain NPO until swallowing ability has been properly assessed for patient safety 1
• A patient's clinical status can change rapidly in the first hours following admission with these symptoms, requiring close monitoring for changes in swallowing ability 1

Management of Nausea and Vomiting

• Antiemetic therapy may be considered once the patient is adequately hydrated, but this is not a substitute for fluid and electrolyte therapy 1
• For adults with persistent nausea and vomiting, a stepwise approach may be used:
  • Begin with dopamine receptor antagonists (e.g., prochlorperazine, haloperidol, metoclopramide) 1
  • Add a 5-HT3 antagonist (e.g., ondansetron) if needed 1
  • Consider adding corticosteroids (e.g., dexamethasone) for persistent symptoms 1

Reintroduction of Oral Intake and Medications

• Early refeeding may cause re-vomiting in patients, whereas late refeeding may result in dehydration and hypoglycemia 2
• Once the patient can tolerate oral intake, reintroduce medications gradually, starting with essential medications 1
• For patients with infectious diarrhea, early refeeding decreases intestinal permeability, reduces illness duration, and improves nutritional outcomes 1

Special Considerations

• Antimotility drugs (e.g., loperamide) should not be given to children <18 years with acute diarrhea but may be given to immunocompetent adults with acute watery diarrhea 1
• Taking oral medications with food does not consistently reduce nausea and vomiting and may actually increase these adverse events in some cases 3
• Patients with complicated diarrhea (moderate to severe cramping, nausea, vomiting, diminished performance status, fever, sepsis, neutropenia, bleeding or dehydration) require more aggressive management including IV fluids and potentially IV medications 1

Common Pitfalls and Caveats

• Avoid assuming that all oral medications can be safely administered with small sips of water during NPO status 1
• Do not delay alternative routes of administration for critical medications (e.g., antibiotics, anticonvulsants) while waiting for NPO status to be lifted 1
• Be aware that some medications may exacerbate gastrointestinal symptoms and should be evaluated for necessity during acute illness 4
• Recognize that the underlying cause of symptoms (infectious, medication-induced, etc.) may influence the approach to medication administration 1