What is the approach to managing intractable vomiting?

From the Guidelines

The approach to intractable vomiting begins with identifying and treating the underlying cause while providing supportive care, and the most effective initial treatment is with dopamine receptor antagonists such as metoclopramide 10mg IV/PO every 6 hours, as supported by the strongest evidence from 1. The management of intractable vomiting requires a comprehensive approach that includes:

• Identifying and treating the underlying cause, such as discontinuing unnecessary medications, checking blood levels of necessary medications, and managing chemotherapy/radiation therapy-induced nausea and vomiting as outlined in the NCCN Guidelines for Antiemesis 1
• Providing supportive care, including IV fluid resuscitation with normal saline or lactated Ringer's solution to correct dehydration and electrolyte abnormalities
• Using antiemetic therapy, such as metoclopramide 10mg IV/PO every 6 hours, or prochlorperazine 5-10mg IV/PO every 6 hours, and considering a combination approach with different antiemetic classes or second-line agents like promethazine 12.5-25mg IV/PO every 6 hours or haloperidol 0.5-2mg IV/PO every 8 hours for refractory cases
• Assessing for red flags like hematemesis, severe abdominal pain, or neurological symptoms that warrant urgent intervention
• Tailoring therapy to the specific cause and patient characteristics, adjusting doses for renal/hepatic impairment and monitoring for side effects, as recommended by 1 and 1 Some key points to consider in the management of intractable vomiting include:
• The use of continuous intravenous or subcutaneous infusions of different antiemetics may be necessary for managing intractable nausea and vomiting, as suggested by 1 and 1
• The importance of adequate hydration and fluid repletion, as well as correcting any possible electrolyte abnormalities, as emphasized by 1 and 1
• The potential need for multiple concurrent agents, perhaps in alternating schedules or by alternating routes, as recommended by 1
• The consideration of alternative therapies, such as acupuncture, hypnosis, and cognitive behavioral therapy, as suggested by 1 and 1

From the FDA Drug Label

Intractable vomiting is not directly addressed in the provided drug labels.

The FDA drug label does not answer the question.

From the Research

Intractable Vomiting Approach

• Intractable vomiting can be caused by a variety of organic and nonorganic disorders, including gastrointestinal (GI) and non-GI disorders 2.
• The initial evaluation of intractable vomiting is directed at assessing airway, breathing, and circulation, as well as hydration status and red flag signs such as bilious or bloody vomiting, altered sensorium, and severe dehydration 2.
• Management priorities for intractable vomiting include treatment of dehydration, stoppage of oral fluids/feeds, and decompression of the stomach with a nasogastric tube in patients with bilious vomiting 2.
• Antiemetic medications such as ondansetron (0.2 mg/kg oral; parenteral 0.15 mg/kg; maximum 4 mg) are indicated in children unable to take orally due to persistent vomiting, post-operative vomiting, chemotherapy-induced vomiting, cyclic vomiting syndrome, and acute mountain sickness 2.

Antiemetic Medications

• Ondansetron is a serotonin antagonist that has been shown to be effective in preventing nausea and vomiting associated with chemotherapy 3, 4.
• Ondansetron has been compared to metoclopramide in several studies, with results showing that ondansetron is more effective and has fewer adverse events 3, 4.
• A comprehensive review of treatments for nausea and vomiting found that ondansetron is a commonly used medication for the management of acute and chronic nausea and vomiting 5.
• A randomized controlled trial comparing ondansetron, metoclopramide, and placebo for adults with undifferentiated emergency department nausea and vomiting found that reductions in nausea severity were similar for all three groups, but there was a trend toward greater reductions in VAS ratings and a lesser requirement for rescue medication in the antiemetic drug groups 6.

Treatment Considerations

• The choice of antiemetic medication depends on the underlying cause of the vomiting, as well as the patient's medical history and current medications 2.
• Patients with intractable vomiting may require a combination of antiemetic medications and other treatments, such as fluid replacement and nutritional support 2.
• Newer treatments for nausea and vomiting, such as bioelectrical neuromodulation and immunotherapies, are being developed and may offer additional options for patients with intractable vomiting 5.