What is the treatment for refractory vomiting?

Treatment for Refractory Vomiting

For refractory vomiting, the most effective approach is to administer multiple concurrent agents with different mechanisms of action, using non-oral routes when necessary, with routine around-the-clock administration rather than PRN dosing. 1

First-Line Interventions

• Begin with dopamine receptor antagonists titrated to maximum benefit and tolerance, such as:

  • Haloperidol 1
  • Metoclopramide 1
  • Prochlorperazine 1
  • Olanzapine 1

• If vomiting persists, add a 5-HT3 receptor antagonist such as:

  • Ondansetron 1
  • Granisetron 1, 2
  • Palonosetron (for chemotherapy-induced vomiting) 1

Second-Line Interventions

• Add anticholinergic agents and/or antihistamines:

  • Scopolamine (transdermal patch) 1
  • Meclizine 1
  • Diphenhydramine 1

• Consider adding corticosteroids:

  • Dexamethasone 1

• For anxiety-related nausea, add benzodiazepines:

  • Lorazepam 1
  • Alprazolam (available in sublingual form) 1

Route of Administration Considerations

• Oral route is often not feasible due to ongoing vomiting 1
• Consider alternative delivery methods:
  • Intravenous or subcutaneous infusion 1
  • Rectal suppositories (prochlorperazine, promethazine) 1
  • Sublingual tablets (ondansetron, alprazolam) 1
  • Nasal sprays (sumatriptan for cyclic vomiting syndrome) 1

Special Considerations

For Cyclic Vomiting Syndrome (CVS)

• Combination therapy with sumatriptan (nasal spray) and an antiemetic agent is often required 1
• Sedation is an effective abortive strategy using:
  • Promethazine 1
  • Diphenhydramine 1
  • Benzodiazepines 1

For Chemotherapy-Induced Refractory Vomiting

• Consider adding aprepitant if not previously included 1
• For breakthrough emesis, add agents from different drug classes 1
• Cannabinoids (dronabinol, nabilone) are FDA-approved for chemotherapy-induced nausea and vomiting that has not responded to conventional antiemetics 1

Advanced Interventions for Persistent Refractory Vomiting

• Consider gastric electrical stimulation (GES) for medically refractory cases, which has shown efficacy in reducing vomiting frequency in patients with and without gastroparesis 3, 4
• Alternative therapies to consider:
  • Acupuncture 1
  • Hypnosis 1
  • Cognitive behavioral therapy 1

Important Caveats and Monitoring

• Ensure adequate hydration and fluid repletion 1

• Check and correct any electrolyte abnormalities 1

• Before initiating treatment, assess for non-vomiting related causes:

  • Brain metastases 1
  • Bowel obstruction 1
  • Medication side effects 1
  • Metabolic disorders (hypercalcemia, hypokalemia) 1

• Monitor for side effects of antiemetics, particularly:

  • Extrapyramidal symptoms with dopamine antagonists 5
  • QT prolongation with certain antiemetics 1
  • Sedation with antihistamines and benzodiazepines 1

• For persistent symptoms despite optimal medical management, palliative sedation can be considered as a last resort if specialized palliative care or hospice services fail 1