What are the treatment options for nausea?

Treatment of Nausea

For chronic nausea, start with metoclopramide 10-20 mg orally three to four times daily as first-line therapy, while for chemotherapy-induced nausea, use ondansetron 4-8 mg as first-line treatment. 1, 2

Treatment Algorithm Based on Etiology

Chemotherapy-Induced Nausea and Vomiting

• 5-HT3 receptor antagonists (ondansetron 4-8 mg or granisetron 1 mg orally twice daily) are first-line therapy 2
• Add dexamethasone 4 mg daily to enhance antiemetic effect 2
• For highly emetogenic chemotherapy (cisplatin ≥50 mg/m²), a single 24 mg oral dose of ondansetron is effective, with 66% of patients experiencing zero emetic episodes in 24 hours 3
• For refractory symptoms, add neurokinin-1 receptor antagonists such as aprepitant 80-125 mg daily 1

Chronic Nausea (≥4 weeks duration)

• Metoclopramide 10-20 mg orally three to four times daily is the first-line medication due to dual central and peripheral mechanisms through dopamine receptor antagonism and prokinetic effects 1
• Metoclopramide is the only FDA-approved medication specifically for gastroparesis-related symptoms 1
• Alternative first-line options include prochlorperazine 5-10 mg four times daily or haloperidol 0.5-1 mg every 6-8 hours 1

Opioid-Induced Nausea

• For patients with prior history of opioid-induced nausea, use prophylactic metoclopramide around the clock for the first few days when initiating opioids 1, 4
• Tolerance typically develops within a few days to one week 1, 4
• Alternative options include prochlorperazine 5-10 mg every 6 hours or haloperidol 0.5-1 mg 2

Radiation-Induced Nausea

• For upper abdominal radiation, use ondansetron 8 mg 2-3 times daily or granisetron 2 mg daily 2
• Consider adding dexamethasone for enhanced effect 2

Gastroparesis-Related Nausea

• Use 5-HT3 antagonists (ondansetron 4-8 mg or granisetron) combined with prokinetic agents like metoclopramide 5-20 mg three times daily 2
• For refractory cases, add aprepitant 80 mg daily 2

Vestibular/Motion Sickness-Related Nausea

• Scopolamine transdermal patch 1.5 mg every 3 days is recommended 2
• Meclizine 12.5-25 mg three times daily is an alternative 1

Anticipatory/Anxiety-Related Nausea

• Lorazepam 0.5-2 mg or alprazolam 0.25-0.5 mg three times daily 2, 4
• Behavioral therapy techniques such as hypnosis with systematic desensitization and guided imagery 2, 4

Second-Line and Combination Therapy

For Refractory Symptoms

• Add 5-HT3 receptor antagonists (ondansetron 4-8 mg twice or three times daily, or granisetron 1 mg twice daily or 34.3 mg transdermal patch weekly) 1
• Combine metoclopramide with corticosteroids (dexamethasone 10 mg twice daily) for enhanced efficacy 1
• The combination of metoclopramide with ondansetron and corticosteroids is particularly effective for refractory symptoms 1

Additional Therapeutic Options

• Atypical antipsychotics such as olanzapine for refractory nausea through multiple receptor antagonism 1
• Neuromodulators including tricyclic antidepressants (amitriptyline 25-100 mg/day, nortriptyline 25-100 mg/day) or mirtazapine 7.5-30 mg/day 1

Critical Safety Considerations and Pitfalls

Metoclopramide Warnings

• Can cause extrapyramidal side effects and tardive dyskinesia with chronic use, particularly in elderly patients 1, 2
• Risk increases with higher doses and prolonged use 2

QT Prolongation Risk

• Ondansetron and some dopamine antagonists can prolong the QT interval 5
• Domperidone doses above 10 mg three times daily are not recommended due to QT prolongation risk 1

Akathisia Risk

• Patients given prochlorperazine or metoclopramide must be monitored for akathisia that can develop at any time over 48 hours post-administration 6
• Decreasing the infusion rate can reduce incidence; treat with intravenous diphenhydramine 6

Promethazine Considerations

• More sedating than other comparative agents and has potential for vascular damage upon intravenous administration 6
• May be suitable when sedation is desirable 6

Reassessment Before Escalating Therapy

Before escalating antiemetic therapy, reassess for:

• Constipation, bowel obstruction or impaction 1
• Electrolyte abnormalities 1
• CNS pathology or brain metastases 1
• Medication side effects from other drugs 1
• Gastroesophageal reflux (treat with proton pump inhibitors or H2 blockers if present) 1

Non-Pharmacologic Adjuncts

• Eating food at room temperature 1, 4
• Small, frequent meals 7
• Dietary consultation for persistent symptoms 1, 4
• Acupuncture, hypnosis, or cognitive behavioral therapy for refractory cases 1
• Fluid and electrolyte replacement 7