From the Guidelines
The workup for chronic nausea and vomiting with any oral intake should begin with a thorough history and physical examination, focusing on duration, frequency, timing, and associated symptoms, as well as initial laboratory tests and imaging studies to evaluate for underlying causes such as gastroparesis or structural abnormalities 1. The initial evaluation should include:
- Complete blood count
- Comprehensive metabolic panel
- Thyroid function tests
- Amylase and lipase
- Pregnancy test in women of childbearing age Upper endoscopy is recommended to evaluate for structural abnormalities like gastritis, ulcers, or malignancy. Additional imaging studies should include an abdominal ultrasound to assess the gallbladder, liver, and pancreas, and potentially a CT scan of the abdomen if initial tests are inconclusive. Gastric emptying studies are essential to evaluate for gastroparesis, particularly in patients with diabetes or post-surgical changes, as they can help identify delayed gastric emptying, which is a common cause of chronic nausea and vomiting 1. For patients with neurological symptoms, brain imaging may be warranted to rule out central nervous system pathologies. While awaiting diagnosis, symptomatic treatment can include antiemetics such as:
- Ondansetron 4-8 mg every 8 hours 1
- Metoclopramide 10 mg before meals 1
- Prochlorperazine 5-10 mg every 6 hours 1 Small, frequent meals low in fat and fiber may help reduce symptoms. Patients should be monitored for signs of dehydration or malnutrition, and intravenous fluids or nutritional support may be necessary in severe cases. The comprehensive approach is necessary because chronic nausea and vomiting can result from various conditions including gastrointestinal disorders, metabolic abnormalities, medication side effects, or central nervous system pathologies. In addition to these measures, medications that target dopaminergic pathways, such as haloperidol, risperidone, metoclopramide, and prochlorperazine, can be used to manage nausea and vomiting, as well as octreotide for bowel obstruction caused by cancer, and ondansetron as a second agent to control symptoms 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Evaluation of Chronic Nausea and Vomiting
- Chronic nausea and vomiting are common symptoms that can significantly impact a patient's quality of life 2, 3.
- The evaluation of chronic nausea and vomiting involves distinguishing between gastrointestinal and non-gastrointestinal causes 3.
- A careful history of related factors, including associated symptoms, timing of onset and duration of symptoms, exacerbating or relieving factors, alarm symptoms, medication and substance use, relationship with recent food ingestion, and comorbidities, is essential to guide the initial evaluation and narrow the differential diagnosis 2.
Treatment Options
- Nonpharmacologic management options include fluid and electrolyte replacement, small, frequent meals, and avoidance of trigger foods 2.
- Antiemetic drugs, such as ondansetron and metoclopramide, can be effective in reducing symptoms of acute nausea and vomiting, but chronic symptoms are often more challenging to treat 2, 4.
- Pharmacologic therapy should be used for the shortest time necessary to control symptoms, and treatment should be based on a thoughtful discussion of benefits, side effects, and costs 3.
- Newer therapies, including immunotherapies, bioelectrical neuromodulation, behavioral and surgical therapies, and complementary medicine, are becoming available for the management of nausea and vomiting 5.
Specific Considerations for Gastroparesis
- Gastroparesis is a disorder characterized by delayed gastric emptying due to chronic abnormal gastric motility, and it is a common cause of chronic nausea and vomiting 6.
- Prokinetic agents, such as metoclopramide and domperidone, are the cornerstone of treatment for gastroparesis, and antiemetic agents, such as promethazine and ondansetron, are frequently administered to reduce nausea and vomiting 6.
- The co-administration of multiple pharmacological agents can lead to potential drug-drug interactions, and careful consideration of these interactions is necessary to minimize adverse effects 6.