Uses of Stemetil (Prochlorperazine)
Prochlorperazine is FDA-approved for three primary indications: control of severe nausea and vomiting, treatment of schizophrenia, and short-term treatment of generalized non-psychotic anxiety (maximum 20 mg/day for up to 12 weeks only). 1
Primary Clinical Applications
Nausea and Vomiting Control
Prochlorperazine serves as a first-line dopamine receptor antagonist for managing nausea and vomiting across multiple clinical settings. 2
- Chemotherapy-induced nausea and vomiting (CINV): Used as breakthrough or rescue therapy when first-line antiemetics (5-HT3 antagonists) fail to control symptoms 2
- Postoperative nausea and vomiting: Recommended as a first-line agent targeting dopaminergic pathways in emergency surgery settings 3, 2
- Radiation-induced nausea and vomiting (RINV): Utilized as rescue therapy for minimal emetic risk radiation, dosed at 10 mg oral or IV 3
- Cancer-related nausea: Recommended by the National Comprehensive Cancer Network for managing nonspecific nausea and vomiting in cancer patients 2
- Acute myocardial infarction: Effective for rapid control of nausea and vomiting in this setting 4
Dosing and Administration
- Standard antiemetic dosing: 5-10 mg orally or IV, administered 3-4 times daily as needed 3, 2
- Available formulations: Oral tablets, intravenous injection, and rectal suppositories provide flexibility for patients unable to take oral medications 2
- Frequency: Can be administered every 4-6 hours as needed for symptom control 2
Psychiatric Indications
- Schizophrenia treatment: FDA-approved for managing psychotic symptoms 1
- Non-psychotic anxiety: Approved only for short-term use (maximum 12 weeks) at doses not exceeding 20 mg/day, but is NOT recommended as first-line therapy due to risk of tardive dyskinesia 1
Migraine Management
- Headache pain relief: Suggested by the American Academy of Family Physicians for migraine patients, particularly when nausea is present 2
Combination Therapy Strategies
Prochlorperazine demonstrates enhanced efficacy when combined with other antiemetics for refractory symptoms. 2
- With dexamethasone: Provides enhanced delayed nausea control in chemotherapy patients 2
- With lorazepam: Useful for anxiety-related nausea 2
- With palonosetron and dexamethasone: Recommended by the Annals of Oncology for delayed nausea control 2
Critical Safety Considerations
The risk of extrapyramidal symptoms (EPS) and tardive dyskinesia limits long-term use and requires careful patient selection. 1, 5
- Extrapyramidal symptoms: Occur in approximately 4-14% of patients, with akathisia being the most common manifestation, typically appearing within one week of treatment 6, 7
- Tardive dyskinesia risk: Can develop with prolonged use, particularly when used beyond 12 weeks for anxiety or as chronic antiemetic therapy 1, 5
- Pediatric use: Associated with 9% incidence of EPS after single doses and 4% with multiple doses; sedation occurs in 10% of children 7
- Serious adverse events: Rare but documented cases include seizures, neuroleptic malignant syndrome, hemidystonia (which can mimic acute stroke), and autonomic collapse 7, 8
Clinical Context and Positioning
Prochlorperazine works by inhibiting dopamine receptors in the brain's chemoreceptor trigger zone, making it effective for centrally-mediated nausea. 2, 5
- Not first-line for anxiety: Despite FDA approval, benzodiazepines are preferred due to superior safety profile 1
- Alternative antiemetics available: Newer agents like ondansetron and granisetron do not carry the risk of movement disorders and may be preferred for long-term antiemetic needs 5
- Optimal use strategy: Reserve for acute severe nausea/vomiting in emergency and postoperative settings, or for breakthrough CINV when 5-HT3 antagonists alone are insufficient 2