Discontinue Carafate and Reassess the Underlying Cause
The patient's nausea and vomiting may be caused or worsened by sucralfate (Carafate) itself, which lists nausea and vomiting as known adverse effects—discontinue this medication immediately and initiate dopamine receptor antagonist therapy while investigating the underlying cause. 1
Immediate Medication Review and Discontinuation
Sucralfate (Carafate) causes nausea and vomiting in a subset of patients and should be stopped immediately, as the FDA label explicitly lists these as adverse reactions. 1
Pantoprazole (Protonix) can also cause nausea as an adverse effect in ≤6% of patients, though it is less commonly implicated than sucralfate. 2 Consider whether the PPI is truly necessary or if the dose can be reduced. 3
Both medications may be contributing to symptoms rather than treating them—the patient may be experiencing medication-induced nausea that will resolve with discontinuation. 1, 2
Rule Out Serious Underlying Causes First
Obtain complete blood count, serum electrolytes, glucose, liver function tests, lipase, and urinalysis to exclude metabolic causes and assess for dehydration. 4, 5
Prolonged vomiting causes hypokalemia, hypochloremia, and metabolic alkalosis that require immediate correction—check and replace potassium and magnesium specifically. 4, 5
Perform one-time esophagogastroduodenoscopy (EGD) or upper GI imaging to exclude obstructive lesions, gastric malignancy, or mechanical obstruction. 4, 5, 3
Never use antiemetics if mechanical bowel obstruction is suspected, as this can mask progressive ileus and gastric distension. 4, 5
Consider cannabis use history, as Cannabis Hyperemesis Syndrome should be suspected if heavy cannabis use preceded symptom onset—this is critical in younger patients. 4
Initiate First-Line Antiemetic Therapy
Start metoclopramide 10 mg IV/PO every 6 hours as the first-line dopamine receptor antagonist, as it is particularly effective for gastric stasis and can be titrated to maximum benefit. 6, 4, 5
Alternative first-line agents include prochlorperazine or haloperidol if metoclopramide is contraindicated or not tolerated. 6, 4, 5
Administer antiemetics around-the-clock rather than PRN, as prevention is far easier than treating established vomiting. 6, 4
Monitor for extrapyramidal symptoms (akathisia) with dopamine antagonists, particularly in young males, and treat with diphenhydramine 50 mg IV if they develop. 4, 5, 7
Escalation Strategy if Symptoms Persist After 4 Weeks
Add ondansetron 8-16 mg IV/PO to the dopamine antagonist regimen if symptoms persist after 4 weeks of first-line therapy, as it acts on different receptors (5-HT3) and provides complementary antiemetic coverage. 4, 5, 7
Monitor for QTc prolongation when using ondansetron, especially in combination with other QT-prolonging agents. 4, 5
Combine ondansetron with dexamethasone 10-20 mg IV, as this combination is superior to either agent alone and represents the highest level of evidence for refractory nausea. 4
Use agents from different drug classes simultaneously rather than sequential monotherapy, as no single agent has proven superior for breakthrough emesis. 4
Additional Therapeutic Considerations
If gastroparesis or gastritis is confirmed, continue metoclopramide as it promotes gastric emptying, and consider whether the PPI should be continued at a lower dose. 4
For truly refractory cases unresponsive to conventional therapy, dronabinol 2.5-7.5 mg PO every 4 hours is FDA-approved for refractory nausea. 6, 4
Consider adding an H2 blocker instead of continuing the PPI if dyspepsia is present, as patients may confuse heartburn with nausea. 4
Critical Pitfalls to Avoid
Do not continue both Protonix and Carafate without clear indication—these medications may be causing the problem rather than solving it. 3, 1
Avoid repeated endoscopy or imaging studies unless new symptoms develop. 4, 5
Do not use ondansetron as monotherapy initially—dopamine antagonists should be tried first and ondansetron added only if symptoms persist. 4, 5
Ensure adequate hydration with at least 1.5 L/day fluid intake and correct electrolyte abnormalities before assuming the problem is purely medication-related. 4, 5