What is the treatment plan for nausea?

Treatment Plan for Nausea

For nausea treatment, dopamine receptor antagonists should be used as first-line therapy, with the addition of serotonin antagonists for persistent symptoms, and consideration of specialized treatments for specific causes of nausea. 1, 2

Initial Assessment and First-Line Treatment

• Evaluate patients for specific causes of nausea, including constipation, CNS pathology, medications (especially opioids), gastrointestinal disorders, and metabolic disturbances 2
• Begin treatment with dopamine receptor antagonists as first-line therapy:
  • Haloperidol 0.5-2 mg orally every 6 hours 1, 2
  • Prochlorperazine 5-10 mg orally every 3-4 hours 1, 2
  • Metoclopramide 10-20 mg orally every 6 hours 2, 3
  • Chlorpromazine 25-50 mg orally every 3-4 hours 1

Persistent Nausea Management

• If nausea persists despite as-needed regimen, administer antiemetics around the clock for 1 week before changing back to as-needed dosing 2
• Add a second agent with a different mechanism of action:
  • Serotonin (5-HT3) receptor antagonists:
    • Ondansetron 8 mg orally once or twice daily 1, 2
    • Granisetron orally daily 2
  • Anticholinergic agents:
    • Scopolamine transdermal patch 1.5-3 mg every 72 hours 1, 2
  • Corticosteroids:
    • Dexamethasone 2-8 mg orally or IV 1, 2

Specialized Treatment Based on Etiology

• For chemotherapy-induced nausea and vomiting:

  • Treatment should be based on the emetic risk of the chemotherapeutic agent 1
  • For high-emetic-risk agents: 3-drug combination of NK1 receptor antagonist, 5-HT3 receptor antagonist, and dexamethasone 1
  • For low-emetic-risk agents: single dose of 5-HT3 receptor antagonist or 8 mg dexamethasone 1
  • For minimal-emetic-risk agents: no routine prophylaxis needed 1

• For bowel obstruction due to cancer:

  • Octreotide is highly recommended 1, 2
  • Consider surgical intervention, stenting, or decompression procedures in appropriate candidates 1, 2

• For anticipatory nausea:

  • Lorazepam 0.5-2 mg orally or IV every 6 hours 1

Refractory Nausea Treatment

• For refractory nausea, reassess the cause and consider:
  • Adding olanzapine 2.5-5 mg orally if not already used 1, 2
  • Cannabinoids (dronabinol, nabilone) for chemotherapy-induced nausea resistant to other therapies 1, 2
  • For opioid-induced nausea, consider opioid rotation if multiple trials have failed 2

Important Considerations and Precautions

• Droperidol, while effective, should be used with caution due to risk of QT prolongation 3, 4
• Promethazine is more sedating than other antiemetics and has potential for vascular damage with IV administration 3
• Monitor patients receiving prochlorperazine or metoclopramide for akathisia, which can develop within 48 hours 3
• Ondansetron is generally well-tolerated but requires dose adjustment in patients with hepatic impairment 5, 4
• Intravenous fluid replacement should be considered as supportive therapy, as many patients report improvement with hydration alone 6

Treatment Duration

• Antiemetic medications should be used for the shortest time necessary to control symptoms 7
• For acute nausea (lasting up to 7 days), symptomatic treatment is typically sufficient 7
• For chronic nausea (lasting 4+ weeks), a more thorough diagnostic evaluation is warranted 7