What is the treatment plan for nausea and vomiting?

Treatment Plan for Nausea and Vomiting

The optimal treatment for nausea and vomiting should follow a stepwise approach targeting the underlying cause, with dopamine receptor antagonists (such as metoclopramide) as first-line therapy for non-specific nausea and vomiting, followed by 5-HT3 receptor antagonists (such as ondansetron) for persistent symptoms. 1

Initial Assessment and Identification of Cause

• Determine if nausea and vomiting are acute (≤7 days) or chronic (≥4 weeks), as this affects treatment approach 2
• Identify potential causes including:
  • Medication side effects (opioids, antibiotics, antifungals) 1
  • Gastrointestinal disorders (gastritis, reflux, obstruction) 1
  • Metabolic disorders (hypercalcemia, electrolyte disturbances) 1
  • Chemotherapy or radiation therapy 1
  • Psychological factors (anxiety) 1

First-Line Treatment Options

• For non-specific nausea and vomiting:

  • Dopamine receptor antagonists (prochlorperazine, haloperidol, metoclopramide, olanzapine) 1
  • Metoclopramide has the strongest evidence for non-chemotherapy related nausea 1
  • Monitor for akathisia with prochlorperazine or metoclopramide 3

• For anxiety-related nausea:

  • Benzodiazepines can be effective 1

• For gastritis or gastroesophageal reflux:

  • Proton pump inhibitors or H2 receptor antagonists 1

Treatment for Persistent Nausea and Vomiting

• Add 5-HT3 receptor antagonists (ondansetron) 1, 4
• Consider adding anticholinergic agents and/or antihistamines 1
• Add corticosteroids (dexamethasone) for refractory symptoms 1
• Consider continuous or subcutaneous infusion of antiemetics for severe symptoms 1

Special Considerations

Chemotherapy-Induced Nausea and Vomiting

• For highly emetogenic chemotherapy: 5-HT3 receptor antagonist + dexamethasone + NK1 receptor antagonist 1
• For moderately emetogenic chemotherapy: 5-HT3 receptor antagonist + dexamethasone 1, 4
• Administer prophylactically 30-60 minutes before chemotherapy 1

Anticipatory Nausea and Vomiting

• Best managed through optimal control of acute and delayed emesis 1
• Behavioral therapies (progressive muscle relaxation, systematic desensitization, hypnosis) 1
• Benzodiazepines may help but efficacy decreases over time 1

Bowel Obstruction

• Surgical intervention for patients with good performance status 1
• Consider stenting, decompression percutaneous gastrostomy tube, nasogastric tube, or octreotide for inoperable cases 1
• Octreotide has shown efficacy in randomized controlled trials for inoperable bowel obstruction 1

Non-Pharmacologic Approaches

• Fluid and electrolyte replacement for dehydration 2
• Small, frequent meals and avoidance of trigger foods 2
• Alternative therapies such as acupuncture, hypnosis, or cognitive behavioral therapy 1

Treatment Algorithm

1. Identify and treat underlying cause if possible
2. Start with dopamine receptor antagonist (metoclopramide) for non-specific nausea
3. For persistent symptoms, add or switch to 5-HT3 receptor antagonist (ondansetron)
4. For refractory symptoms, consider combination therapy with multiple agents targeting different receptors
5. For severe cases unresponsive to standard therapy, consider specialized palliative care consultation 1

Pitfalls and Caveats

• Avoid prolonged use of antiemetics to prevent side effects; use for shortest time necessary 2
• Monitor for extrapyramidal side effects with dopamine antagonists, especially in elderly 3
• Consider medication interactions when selecting antiemetic therapy 1
• Reassess treatment efficacy within 48 hours for inpatients and within 1 month for outpatients 1