What are the goals of care for managing nausea?

Goals of Care for Managing Nausea

The primary goals of care for managing nausea should focus on adequate symptom control, reduction of patient distress, acceptable sense of control, relief of caregiver burden, strengthened relationships, optimized quality of life, and personal growth and enhanced meaning. 1

Assessment and Identification of Cause

• Initial evaluation should identify 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, 2
• Review current medications, especially opioids, which commonly cause nausea 2
• Consider other potential causes such as bowel obstruction, vestibular dysfunction, brain metastases, electrolyte imbalances, uremia, or gastroparesis 2

Pharmacological Management Based on Cause

First-Line Treatment Options

• Initiate pharmacologic management with dopamine receptor antagonists (e.g., haloperidol, metoclopramide, prochlorperazine) for non-specific nausea and vomiting 1
• 5-HT3 receptor antagonists such as ondansetron (4-8 mg twice or three times daily) are effective first-line treatments that block serotonin receptors in the chemoreceptor trigger zone and inhibit vagal afferents 3, 4
• Granisetron (1 mg twice daily or transdermal patch) offers similar efficacy to ondansetron with different administration options 3, 1

For Persistent Nausea

• Administer antiemetics around the clock if nausea persists with as-needed regimen 2
• Add a 5-HT3 antagonist (ondansetron 8 mg PO/IV) if not already using one 2
• Consider adding an anticholinergic agent, such as scopolamine transdermal patch 1, 2
• Add corticosteroids (e.g., dexamethasone) for persistent nausea 1

For Refractory Nausea

• Consider using a continuous IV/SC infusion of antiemetics 1
• Consider cannabinoids for nausea refractory to standard therapies 1, 2
• Consider alternative therapies such as acupuncture 1, 2

Non-Pharmacological Approaches

• Eat small, frequent meals rather than large meals 3, 2
• Choose foods at room temperature rather than hot foods 3, 2
• Avoid strong odors that may trigger nausea 3
• Ensure adequate hydration throughout the day 3
• Consider dietary consultation for persistent nausea 2
• Consider behavioral therapy techniques for anticipatory nausea 2

Monitoring and Follow-up

• Assess response to antiemetic therapy within 24-48 hours to determine effectiveness 3
• If nausea persists for more than one week despite appropriate management, reassess for other potential causes 3
• Monitor for adverse effects of antiemetic medications, such as sedation with antihistamines or QT prolongation with ondansetron at higher doses 3, 4

Special Considerations

For Chemotherapy-Induced Nausea

• For high emetic risk chemotherapy, use a four-drug combination of a neurokinin 1 receptor antagonist, a 5-HT3 receptor antagonist, dexamethasone, and olanzapine 1
• For moderate emetic risk chemotherapy, use a two-drug combination of a 5-HT3 receptor antagonist and dexamethasone 1

For Radiation-Induced Nausea

• For high emetic risk radiation, use a 5-HT3 antagonist before each fraction throughout radiation therapy; continue for at least 24 hours after completion 1
• For moderate emetic risk radiation, use a 5-HT3 antagonist before each fraction for the entire course of radiotherapy 1
• For low emetic risk radiation, use a 5-HT3 antagonist either as rescue or prophylaxis 1

For Gastroparesis-Related Nausea

• Metoclopramide (10-20 mg every 6 hours) is recommended for gastroparesis-related nausea 1

Cautionary Notes

• Monitor patients on ondansetron for QT interval prolongation, especially those with congenital long QT syndrome, electrolyte abnormalities, cardiac failure, or arrhythmias 4
• In patients with severe hepatic impairment, do not exceed a total daily dose of 8 mg of ondansetron 4
• Be aware of potential serotonin syndrome when using 5-HT3 antagonists, particularly with concomitant use of other serotonergic drugs 4
• Metoclopramide and prochlorperazine can cause akathisia that can develop up to 48 hours post-administration 5