How to manage nausea caused by Qelbree (viloxazine)?

Managing Qelbree (Viloxazine)-Induced Nausea

Start with metoclopramide 10-20 mg orally three to four times daily as first-line treatment for Qelbree-induced nausea, as it addresses both central and peripheral nausea mechanisms through dopamine receptor antagonism. 1

Initial Management Strategy

First-Line Antiemetic Therapy

• Metoclopramide 10-20 mg orally 3-4 times daily is the preferred initial agent because it works through dopamine receptor antagonism at the chemoreceptor trigger zone and has prokinetic effects that address gastric stasis 1, 2
• Prochlorperazine 5-10 mg four times daily or 10 mg every 6 hours as needed is an effective alternative dopamine antagonist 1, 2
• Haloperidol 0.5-1 mg every 6-8 hours can be used for dopaminergic pathway targeting 1, 2

Prophylactic Approach for High-Risk Patients

• For patients with prior history of medication-induced nausea, initiate prophylactic antiemetics when starting Qelbree 3
• Administer metoclopramide around the clock for the first few days when initiating viloxazine 1
• Most patients develop tolerance to medication-induced nausea within a few days to one week 1, 2

Escalation for Persistent Nausea

Second-Line Additions

• Add 5-HT3 receptor antagonists if nausea persists despite dopamine antagonist therapy: ondansetron 4-8 mg two to three times daily or granisetron 1 mg twice daily 1, 2
• Consider combining metoclopramide with ondansetron for synergistic relief 3, 2

Combination Therapy for Refractory Cases

• Combine metoclopramide with corticosteroids (dexamethasone 10 mg twice daily) for enhanced efficacy in persistent nausea 1, 2
• The triple combination of metoclopramide, ondansetron, and corticosteroids has proven particularly effective for refractory symptoms 1, 2

Alternative Antiemetic Options

Anticholinergic/Antihistamine Agents

• Meclizine 12.5-25 mg three times daily can be used as an alternative approach 1, 2
• Scopolamine transdermal patch 1.5 mg every 3 days is another option 1, 2

Atypical Antipsychotics

• Olanzapine can be effective for refractory nausea through multiple receptor antagonism 1, 2

Anxiety-Related Nausea

• Lorazepam is effective if anxiety contributes to nausea 1, 2
• Consider adding a benzodiazepine when anxiety is a contributing factor 4

Clinical Context for Qelbree

Nausea Incidence with Viloxazine

• Nausea occurred in 10.1% of adults receiving viloxazine ER in phase 3 trials 5
• Nausea was among the most common treatment-related adverse events in long-term studies (13.8% incidence) 6
• Nausea led to discontinuation in 2.5% of participants in long-term extension studies 6

Critical Monitoring and Pitfalls

Metoclopramide Safety Concerns

• Metoclopramide can cause extrapyramidal side effects and tardive dyskinesia with chronic use, particularly in elderly patients 1, 2
• Use metoclopramide for the shortest time necessary to control symptoms 7

Reassessment Before Escalating Therapy

• Rule out constipation, bowel obstruction, or fecal impaction before intensifying antiemetic therapy 1, 2
• Check for electrolyte abnormalities that may contribute to nausea 1, 2
• Consider gastroesophageal reflux and treat with proton pump inhibitors if necessary 1, 2
• Evaluate for other medication side effects that may be contributing 1, 2

Non-Pharmacologic Adjuncts

Dietary Modifications

• Recommend eating foods at room temperature 1, 2
• Consider dietary consultation for persistent symptoms 1, 2
• Advise small, frequent meals 7

Complementary Therapies

• Acupuncture, hypnosis, or cognitive behavioral therapy can be considered for refractory cases 1, 2

Dosing Considerations

Around-the-Clock vs. As-Needed Dosing

• If nausea develops despite prophylaxis, initiate antiemetics as needed initially 3
• If nausea persists, administer antiemetics on a regular schedule for one week 3
• Around-the-clock dosing provides greatest benefit for persistent symptoms 4