What is the treatment for recurrent vomiting?

Treatment for Recurrent Vomiting

The treatment for recurrent vomiting should follow a stepwise approach, starting with dopamine receptor antagonists (such as prochlorperazine, haloperidol, or metoclopramide) as first-line therapy, titrated to maximum benefit and tolerance. 1

Initial Assessment and Management

• Identify and treat underlying causes of vomiting, such as chemotherapy/radiation-induced vomiting, severe constipation, gastroparesis, bowel obstruction, medication-induced vomiting, and metabolic abnormalities 1
• For gastritis or gastroesophageal reflux, use proton pump inhibitors or H2 receptor antagonists 1
• Ensure adequate hydration or fluid repletion and correct any electrolyte abnormalities 2, 1
• Consider that prevention of nausea and vomiting is more effective than treatment once symptoms are established 3

Pharmacological Treatment Algorithm

First-line options:

• Dopamine receptor antagonists: prochlorperazine, haloperidol, or metoclopramide 1
  • Metoclopramide is FDA-approved for relief of symptoms associated with diabetic gastroparesis and prevention of chemotherapy-induced and postoperative nausea and vomiting 4
  • Monitor for extrapyramidal side effects with dopamine receptor antagonists 1

Second-line options (if vomiting persists):

• Add one or more of the following 1:
  • 5-HT3 receptor antagonists (ondansetron, granisetron, dolasetron)
  • Anticholinergic agents
  • Antihistamines
  • Cannabinoids (dronabinol and nabilone are FDA-approved for patients whose nausea and vomiting have not responded to conventional antiemetics) 2

For refractory symptoms:

• Consider adding corticosteroids like dexamethasone 1, 3
• Consider continuous intravenous or subcutaneous infusion of antiemetics 1
• Consider olanzapine for persistent symptoms 1
• For anxiety-related nausea, add benzodiazepines such as lorazepam 1, 3

Route of Administration Considerations

• The oral route may not be feasible due to ongoing vomiting; therefore, rectal or intravenous therapy is often required 2, 3
• Nasal sprays might be useful for treatment of breakthrough emesis, providing acute delivery of agents 2
• Consider routine around-the-clock administration of antiemetics rather than PRN (as-needed) dosing to prevent emesis 2, 3

Special Considerations

For chemotherapy-induced vomiting:

• For highly emetogenic chemotherapy: combination of aprepitant, dexamethasone, and a 5-HT3 antagonist 2, 3
• For moderately emetogenic chemotherapy: 5-HT3 antagonist on day 1, followed by dexamethasone or aprepitant on days 2-3 2, 3

For radiation-induced vomiting:

• For radiation to upper abdomen: oral ondansetron (8 mg, 2-3 times daily) or granisetron (2 mg daily), with or without oral dexamethasone 2
• For total body irradiation: ondansetron or granisetron with or without dexamethasone 2

For pediatric patients:

• Ondansetron has been shown to reduce the risk of recurrent vomiting, need for intravenous fluids, and hospital admissions in children with acute gastroenteritis 5, 6
• Typical pediatric dosing: ondansetron 0.15-0.2 mg/kg (maximum 4 mg) 7

Important Pitfalls to Avoid

• Avoid antiemetics in patients with suspected mechanical bowel obstruction 1
• Avoid long-term use of benzodiazepines due to risk of dependence 1
• When using combination therapy, target different mechanisms of action for synergistic effect rather than replacing one antiemetic with another 1
• Do not delay diagnosis and treatment of potentially serious underlying causes by focusing only on symptomatic relief 8
• Remember that vomiting may be the presenting symptom of several life-threatening conditions, particularly in children (e.g., intracranial pressure, intestinal obstruction) 7, 8