What are the indications for Compazine (prochlorperazine)?

Compazine (Prochlorperazine) Indications

Prochlorperazine is indicated for managing nausea and vomiting across multiple clinical contexts, including chemotherapy-induced, radiation-induced, postoperative, opioid-induced nausea, and palliative care settings. 1

Primary FDA-Recognized and Guideline-Supported Indications

Chemotherapy-Induced Nausea and Vomiting (CINV)

• Prochlorperazine 10 mg orally or IV is recommended by the American Society of Clinical Oncology for breakthrough or refractory CINV when first-line antiemetics (typically 5-HT3 antagonists like ondansetron) fail to control symptoms. 1
• For low to moderate emetogenic risk chemotherapy, it can be used as prophylaxis at 10 mg orally or IV, optionally combined with dexamethasone 20 mg. 1
• The mechanism involves dopaminergic pathway antagonism in the chemoreceptor trigger zone, making it particularly effective when serotonin antagonists alone are insufficient. 1
• Typical dosing is 10-20 mg orally or IV, administered 3-4 times daily as needed for breakthrough symptoms. 1

Radiation-Induced Nausea and Vomiting (RINV)

• For low emetic risk radiation therapy, prochlorperazine 10 mg oral or IV can be used either as rescue therapy or prophylactically. 1
• It is listed as an acceptable dopamine receptor antagonist option alongside metoclopramide for minimal to low-risk RINV. 1
• If rescue therapy is required during radiation treatment, prophylactic antiemetics should continue throughout the entire radiation course. 1

Opioid-Induced Nausea

• Prochlorperazine is an effective first-line agent for opioid-induced nausea, administered as 10 mg orally every 6 hours as needed. 1
• If nausea persists despite as-needed dosing, administer around-the-clock for one week, then adjust based on response. 1
• It can be combined with other antiemetics targeting different mechanisms (such as ondansetron) for synergistic effect when monotherapy fails. 1

Postoperative Nausea and Vomiting

• Prochlorperazine is recommended for postoperative nausea management in surgical patients, particularly those not amenable to further interventions. 1
• It should be part of a multimodal approach targeting multiple receptor pathways for optimal symptom control. 1

Palliative Care and End-of-Life Settings

• Prochlorperazine 5-10 mg administered 3-4 times daily (oral, IV, or subcutaneous routes) is recommended for managing nausea in palliative care patients. 1
• It is specifically indicated for nausea and vomiting due to bowel obstruction when used alongside other agents targeting dopaminergic pathways. 1
• In terminally ill patients with inoperable bowel obstruction, prochlorperazine can be combined with chlorpromazine and opioids for comprehensive symptom management. 1

Standard Dosing Across Indications

• Oral/IV: 5-10 mg administered 3-4 times daily for most indications. 1
• Pretreatment dosing: 10 mg orally given before chemotherapy, with additional doses every 6 hours as needed. 1
• For emergency department use, 2.5 mg IV push has been shown effective for rapid control of active vomiting, with mean cessation time of 8.5 minutes. 2

Critical Safety Considerations and Contraindications

Absolute Contraindications

• Avoid in patients with seizure disorders or pheochromocytoma. 1
• Do not use in patients with GI bleeding or mechanical bowel obstruction. 1

Extrapyramidal Symptoms (EPS) Risk

• The most significant adverse effect is extrapyramidal symptoms, particularly akathisia, which can occur within one week of initiation. 3
• In comparative studies, prochlorperazine showed a 14% incidence of extrapyramidal symptoms versus 0% with alternative agents like perospirone. 3
• In pediatric populations, EPS occurs in approximately 9% with single-dose and 4% with multiple-dose regimens. 4
• Tardive dyskinesia has been reported with long-term use, though rarely. 5

Special Population Considerations

• Caution is required in patients with severe renal or hepatic impairment, requiring dose adjustment. 1
• In pediatric use, sedation (10%) and EPS are the most common adverse effects, with rare serious events including seizure, neuroleptic malignant syndrome, and autonomic collapse. 4

Clinical Pitfall to Avoid

When using prochlorperazine for opioid-induced nausea, carefully monitor for akathisia within the first week, as this can be mistaken for anxiety or worsening of underlying symptoms and may lead to unnecessary dose escalation or additional medications. 3