What is the recommended dose and usage of Stemitil MD (prochlorperazine) for nausea and vomiting?

Stemitil MD (Prochlorperazine) Dosing and Usage

For nausea and vomiting, prochlorperazine is dosed at 5-10 mg orally 3-4 times daily, with a maximum of 40 mg per day in resistant cases. 1

Standard Dosing for Adults

Oral Administration

• Initial dose: 5-10 mg orally 3-4 times daily 2, 1
• Maximum daily dose: 40 mg per day (only in resistant cases) 1
• Frequency: Every 3-4 hours as needed 3
• Begin with the lowest recommended dosage and adjust based on individual response 1

Intravenous Administration

• Emergency department use: 2.5-5 mg IV given slowly over one minute 4, 5
• Repeat dosing: If no response within 20 minutes, may repeat 2.5 mg dose 5
• Mean time to effect: Approximately 8.5 minutes for IV administration versus 35 minutes for intramuscular 5
• Alternative IV dosing: 5-10 mg IV every 3-4 hours 3

Clinical Context and Positioning

Role in Antiemetic Therapy

• First-line agent: Prochlorperazine is recommended as a first-line dopaminergic antagonist for nausea and vomiting in emergency settings 3
• Chemotherapy-induced nausea: Dosed at 10-20 mg orally 3-4 times daily 2
• Pretreatment prophylaxis: 10 mg orally before chemotherapy (optional for low emetogenic potential) 2
• Breakthrough nausea: 10 mg orally every 6 hours as needed 2

Special Populations

Elderly Patients

• Use lower dosages as elderly patients are more susceptible to hypotension and neuromuscular reactions 1
• Dosage should be increased more gradually and patients observed closely 1

Pediatric Patients (NOT recommended for Stemitil MD typically)

• Not recommended under 20 pounds or 2 years of age 1
• Dosing by weight for children 2-12 years ranges from 2.5 mg 1-2 times daily (20-29 lbs) up to 2.5 mg 3 times daily or 5 mg 2 times daily (40-85 lbs) 1

Critical Safety Considerations

Extrapyramidal Symptoms (EPS)

• Incidence: 14% in adult cancer patients receiving prochlorperazine 6
• Most common EPS: Akathisia, typically occurring within one week of initiation 6
• Pediatric risk: Children are more prone to develop extrapyramidal reactions even on moderate doses 1, 7
• Serious but rare: Tardive dyskinesia can occur with long-term use 8

Monitoring and Precautions

• Hypotension risk: Monitor blood pressure, particularly in elderly patients 1
• QT prolongation: Be aware of potential cardiac effects, especially in patients with cardiac risk factors 9
• Dehydration: Take particular precaution in children with acute illnesses or dehydration 1
• Duration limits: For non-psychotic anxiety, do not administer in doses more than 20 mg per day or for longer than 12 weeks 1

Alternative Routes When Oral Not Feasible

• Rectal suppositories: Available for patients unable to take oral medication 3
• Intravenous: Preferred for actively vomiting patients or when rapid control needed 5
• Sublingual alternatives: Consider ondansetron sublingual tablets for actively vomiting patients 3

When to Add or Switch Agents

Refractory Nausea

• Add ondansetron: 4 mg IV as a second agent when prochlorperazine alone cannot control symptoms 3
• Consider alternatives: Ondansetron or granisetron may be preferred to avoid movement disorder risks 8

Specific Clinical Scenarios

• Chemotherapy-induced nausea: Combine with dexamethasone 20 mg and 5-HT3 antagonists for moderate-high emetogenic chemotherapy 2
• Anticipatory nausea: Add lorazepam 0.5-2 mg IV/PO every 6 hours 3