What medications are recommended for treating nausea?

Medications for Treating Nausea

Dopamine receptor antagonists such as haloperidol, metoclopramide, and prochlorperazine should be used as first-line treatment for nausea, with 5-HT3 antagonists like ondansetron added as second-line therapy for refractory symptoms. 1

First-Line Medications

• Dopaminergic pathway antagonists are recommended as first-line therapy for nausea management 1:

  • Haloperidol: 0.5-2 mg IV/PO every 6-8 hours as needed 1
  • Metoclopramide: 10-20 mg PO/IV 3-4 times daily (also has prokinetic effects beneficial for constipation-related nausea) 1
  • Prochlorperazine: 5-10 mg PO/IV 3-4 times daily 1
  • Chlorpromazine: 12.5-25 mg IV or 25-50 mg PO 3-4 times daily 1

• For nausea due to bowel obstruction caused by cancer, octreotide is specifically recommended 1

Second-Line Medications

• For refractory nausea, add a 5-HT3 receptor antagonist when first-line medications are insufficient 1:

  • Ondansetron: 4-8 mg IV/PO every 8 hours 1, 2
  • Granisetron: 1 mg IV or PO daily 1
  • Palonosetron: 0.25 mg IV (available only as IV formulation) 1

• Corticosteroids can be added for persistent nausea 1:

  • Dexamethasone: 2-8 mg IV/PO 3-6 times daily (particularly useful in bowel obstruction or intracranial hypertension) 1

Medication Administration Strategy

• For persistent nausea, switch from as-needed dosing to scheduled around-the-clock administration for at least one week 1

• If nausea persists despite multiple agents, consider:

  • Evaluating for other causes of nausea (constipation, CNS pathology, electrolyte disturbances) 1, 3
  • Rotating to a different agent within the same class 1
  • Using combinations of medications with different mechanisms of action 1, 3

Special Considerations

• For patients with prior history of nausea, prophylactic antiemetic treatment is highly recommended before the precipitating event 1, 3

• For mild infusion reactions causing nausea, ondansetron 4-8 mg IV is recommended 1

• Lorazepam (0.5-2 mg IV/PO every 6 hours) can be helpful specifically for anticipatory nausea 1

• For patients with bowel obstruction or increased intracranial pressure, dexamethasone (2-8 mg IV/PO) is particularly effective 1

• Scopolamine (1.5-3 mg topical patch every 72 hours) is useful for nausea associated with increased oral secretions 1

Common Pitfalls and Caveats

• First-generation antihistamines (e.g., diphenhydramine) should be avoided for nausea as they can potentially exacerbate hypotension, tachycardia, and sedation 1

• High-dose ondansetron (32 mg IV) carries risk of QT prolongation and should be avoided 4

• 5-HT3 antagonists like ondansetron can cause constipation, which may worsen nausea if not addressed 1

• Studies have not shown newer 5-HT3 medications to be superior to older dopaminergic agents in treating nausea at the end of life, supporting the first-line use of dopamine antagonists 1

• For chemotherapy-induced nausea, combination therapy with ondansetron and dexamethasone has been shown to be more effective than ondansetron monotherapy 5