What is the treatment for vomiting?

Treatment of Vomiting

The first-line treatment for vomiting should include dopamine receptor antagonists such as prochlorperazine, haloperidol, metoclopramide, or olanzapine, which can be combined with 5-HT3 receptor antagonists like ondansetron for persistent cases. 1

Approach to Treatment Based on Cause

Non-specific Vomiting

• Dopamine receptor antagonists (prochlorperazine, haloperidol, metoclopramide, olanzapine) are effective first-line agents 1
• Benzodiazepines can be used for anxiety-related nausea and vomiting 1
• For persistent vomiting, titrate dopamine receptor antagonists to maximum benefit and tolerance 1

Persistent or Refractory Vomiting

• Add 5-HT3 receptor antagonists (ondansetron, granisetron, dolasetron, palonosetron) 1
• Consider adding anticholinergic agents and/or antihistamines 1
• Corticosteroids (dexamethasone) can be added for persistent symptoms 1
• Continuous intravenous or subcutaneous infusion of antiemetics may be necessary for intractable cases 1
• Antipsychotics (olanzapine, haloperidol) can be effective for persistent vomiting 1
• Cannabinoids (dronabinol, nabilone) are FDA-approved for chemotherapy-induced nausea and vomiting refractory to standard therapies 1

Breakthrough Vomiting

• Give an additional agent from a different drug class 1
• Consider routine around-the-clock administration rather than PRN dosing 1
• For ongoing vomiting, rectal or intravenous therapy is often required as oral route may not be feasible 1
• Multiple concurrent agents, perhaps in alternating schedules or routes, may be necessary 1

Special Considerations

Hydration Management

• Ensure adequate hydration and fluid repletion 1
• Check and correct any electrolyte abnormalities 1
• For children with dehydration, rapid IV rehydration (20-30 mL/kg isotonic crystalloid solution over 1-2 hours) can be effective 2
• In recovery phase, focus on consuming electrolyte-rich fluids 1

Medication-Related Vomiting

• Assess for medication-related causes of vomiting 1
• Check blood levels of possible culprits (digoxin, phenytoin, carbamazepine, tricyclic antidepressants) 1
• Consider opioid rotation if opioid-induced nausea and vomiting is suspected 1

Gastrointestinal Causes

• For gastritis or gastroesophageal reflux, 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

Cyclic Vomiting Syndrome (CVS)

• Abortive treatment typically requires combinations of 2 agents 1
• Sumatriptan (nasal spray or subcutaneous) combined with an antiemetic like ondansetron is commonly used 1
• Sedation is often an effective abortive strategy using promethazine, diphenhydramine, or benzodiazepines 1
• For ED management of CVS, IV fluids, IV ketorolac for pain, and sedation in a quiet, darker room are recommended 1

Alternative Approaches

• Consider alternative therapies such as acupuncture, hypnosis, or cognitive behavioral therapy for persistent cases 1
• Palliative sedation can be considered as a last resort if other interventions fail 1

Important Caveats

• Before administering the next cycle of chemotherapy (for chemotherapy-induced vomiting), reassess antiemetic regimens that failed during the current cycle 1
• Rule out non-chemotherapy related causes of breakthrough vomiting (brain metastases, electrolyte abnormalities, tumor infiltration, other comorbidities) 1
• Prevention is more effective than treatment for chemotherapy-induced nausea and vomiting 1
• Patients sometimes have difficulty discriminating heartburn from nausea; consider antacid therapy 1