What is the best medication for intractable vomiting in hospice care?

Best Medication for Intractable Vomiting in Hospice Care

For intractable vomiting in hospice care, initiate treatment with dopamine receptor antagonists—specifically haloperidol or metoclopramide—as first-line therapy, then escalate systematically by adding 5-HT3 antagonists (ondansetron), corticosteroids (dexamethasone), and ultimately continuous IV/subcutaneous infusions if symptoms persist. 1

First-Line Treatment: Dopamine Receptor Antagonists

Start with either haloperidol (0.5-2 mg every 4-6 hours) or metoclopramide (5-10 mg every 6 hours), titrating to maximum benefit and tolerance. 1

• Haloperidol provides rapid clinical benefit with 79% of palliative care patients achieving complete resolution of nausea and vomiting within 48 hours 2
• Metoclopramide is the predominant first-line choice among palliative medicine clinicians (69% preference) and has the strongest evidence base for antiemesis unrelated to chemotherapy 1, 3
• Alternative dopamine antagonists include prochlorperazine (5-10 mg every 6-8 hours) or olanzapine 1
• Around-the-clock dosing provides more consistent benefit than PRN administration 1

Second-Line: Add 5-HT3 Antagonist

If vomiting persists after 48 hours of optimized dopamine antagonist therapy, add ondansetron (4-8 mg every 8 hours IV/PO). 1, 4

• Ondansetron can be combined with anticholinergic agents (scopolamine 1.5-3 mg topically every 72 hours) and/or antihistamines (meclizine) 1
• Monitor for QTc prolongation when using ondansetron, especially with other QT-prolonging medications 4
• Consider adding cannabinoids at this stage for refractory symptoms 1

Third-Line: Add Corticosteroids

If symptoms remain uncontrolled, add dexamethasone 4-8 mg twice to three times daily. 1

• Corticosteroids are particularly effective for CNS involvement (brain metastases, increased intracranial pressure), bowel obstruction, or gastric outlet obstruction 1
• Olanzapine can be added at this stage if not already tried 1

Fourth-Line: Continuous Infusion

For truly intractable vomiting, transition to continuous IV or subcutaneous infusion of antiemetics. 1

• A scheduled IV cocktail of metoclopramide 10 mg + diphenhydramine 25 mg + dexamethasone 4 mg every 6 hours achieved objective response in 90% of hospice patients, with symptom relief typically within 2 days 5
• Consider opioid rotation if the patient is receiving opioids, as this may be contributing to symptoms 1

Critical Context-Specific Considerations

For patients in the final weeks to days of life (dying patients), empiric treatment with haloperidol or metoclopramide without extensive investigation is appropriate. 1, 6

For bowel obstruction (common in hospice), use octreotide combined with dexamethasone, anticholinergics, and haloperidol—never use metoclopramide as it can worsen obstruction. 1, 6

For gastric outlet obstruction, combine corticosteroids + proton pump inhibitor + metoclopramide. 1

Common Pitfalls to Avoid

• Never use prokinetic agents (metoclopramide) in mechanical bowel obstruction—this masks progressive ileus and worsens gastric distension 4, 6
• Monitor for extrapyramidal symptoms with dopamine antagonists, particularly in younger patients 4
• Avoid repeated investigations in dying patients—focus on empiric symptom management 1, 6
• Haloperidol causes constipation (40% incidence), dry mouth (21%), and somnolence (19%) at day 7, though these are generally mild to moderate 2
• Maximal doses for individual antiemetics vary up to tenfold in clinical practice—titrate based on response rather than arbitrary dose limits 3

Non-Pharmacologic Adjuncts

Consider acupuncture, hypnosis, or cognitive behavioral therapy as complementary approaches, particularly in patients with weeks to days of life expectancy. 1

• Small, frequent meals are the most commonly recommended dietary modification 3, 6
• Ensure adequate hydration (at least 1.5 L/day) and consider thiamin supplementation to prevent Wernicke's encephalopathy in persistent vomiting 4