What is a recommended antiemetic for nausea and vomiting associated with alcoholic gastritis?

Antiemetic for Alcoholic Gastritis

For nausea and vomiting associated with alcoholic gastritis, ondansetron (a 5-HT3 receptor antagonist) is the recommended first-line antiemetic based on its superior safety profile, lack of sedation, and absence of extrapyramidal side effects compared to other agents.

Primary Recommendation

Ondansetron should be used as the first-line antiemetic for alcoholic gastritis because it provides effective symptom control without the significant adverse effects associated with alternative agents 1. This recommendation is based on emergency department evidence showing ondansetron's efficacy and safety profile in treating nausea and vomiting from gastrointestinal causes 1.

Dosing and Administration

• Administer ondansetron 4-8 mg intravenously or orally for acute symptom control 1
• The medication can be repeated every 8 hours as needed 1
• Ondansetron works by selectively blocking 5-HT3 receptors with a selectivity ratio greater than 1,000 compared to other neurotransmitter receptors 2
• Unlike metoclopramide, ondansetron does not cause extrapyramidal side effects or significant behavioral depression 2

Alternative Agents (Second-Line)

If ondansetron is unavailable or ineffective, consider these alternatives with important caveats:

• Prochlorperazine 5-10 mg IV/IM - Monitor closely for akathisia that can develop at any time over 48 hours post-administration 1
• Metoclopramide 10 mg IV - Decrease infusion rate to reduce akathisia incidence; treat akathisia with IV diphenhydramine if it occurs 1
• Promethazine 12.5-25 mg IV - More sedating than other agents and has potential for vascular damage with IV administration; reserve for cases where sedation is desirable 1

Critical Safety Considerations

• Avoid droperidol except in refractory cases due to FDA black box warning regarding QT prolongation 1
• Monitor patients receiving prochlorperazine or metoclopramide for akathisia throughout the 48-hour period following administration 1
• Use promethazine cautiously with IV administration due to risk of vascular injury 1

Adjunctive Gastric Protection

• Initiate proton pump inhibitor (PPI) therapy concurrently at the lowest effective dose to protect the gastric mucosa, as alcoholic gastritis involves disruption of the gastric mucosal barrier 3
• Consider H2 blockers as an alternative if PPIs are contraindicated 3
• Antacid therapy helps patients who may have difficulty discriminating heartburn from nausea 3

Common Pitfalls to Avoid

• Do not use droperidol as first-line therapy - while historically more effective than prochlorperazine or metoclopramide, the FDA black box warning limits its use 1
• Do not assume akathisia will present immediately - this adverse effect can develop at any point within 48 hours of administration of dopamine antagonists 1
• Do not administer promethazine rapidly IV - slow administration reduces risk of vascular complications 1
• Do not overlook the need for gastric mucosal protection - antiemetic therapy alone does not address the underlying gastritis 3