What is the treatment for nausea and vomiting?

From the Guidelines

To treat nausea and vomiting, metoclopramide should be considered as the first-line treatment due to its strong evidence support, as concluded in a systematic review 1. When managing nausea and vomiting, it is essential to identify and treat the underlying cause, which can include chemotherapy-induced nausea and vomiting, gastric outlet obstruction, bowel obstruction, constipation, opioid use, or hypercalcemia.

• For chemotherapy-induced nausea and vomiting, the NCCN Guidelines for Antiemesis should be followed.
• For gastritis or gastroesophageal reflux, proton pump inhibitors and histamine-2 (H2) receptor antagonists can be used.
• Gastric outlet obstruction may benefit from treatment with corticosteroids, endoscopic stenting, or insertion of a decompressing G-tube.
• Nonspecific nausea and vomiting can be managed with dopamine receptor antagonists, such as prochlorperazine, haloperidol, metoclopramide, or olanzapine, or benzodiazepines for anxiety-related nausea.
• Persistent nausea and vomiting can be treated by titrating dopamine receptor antagonists to maximum benefit and tolerance, and adding 5-HT3 receptor antagonists, anticholinergic agents, antihistamines, corticosteroids, or continuous or subcutaneous infusion of antiemetics as needed.
• Opioid rotation or agents that target the cannabinoid system, such as dronabinol and nabilone, can also be considered for refractory chemotherapy-induced nausea and vomiting.
• Alternative therapies like acupuncture, hypnosis, or cognitive behavioral therapy can be considered, and palliative sedation can be used as a last resort if other efforts fail, as stated in the palliative care guidelines 1.

From the FDA Drug Label

For control of severe nausea and vomiting. For the treatment of schizophrenia. Prochlorperazine is effective for the short-term treatment of generalized non-psychotic anxiety. The answer to treating nausea and vomiting is to use prochlorperazine (PO), as it is effective for the control of severe nausea and vomiting 2.

• Key points:
  • Prochlorperazine is used for the control of severe nausea and vomiting.
  • It is also used for the treatment of schizophrenia and short-term treatment of generalized non-psychotic anxiety.
  • The use of prochlorperazine should be limited to 20 mg per day or for longer than 12 weeks to avoid persistent tardive dyskinesia.
• Dosage: The exact dosage for nausea and vomiting is not specified in the provided drug label, but it should not exceed 20 mg per day.
• Important consideration: Prochlorperazine should not be used for longer than 12 weeks to avoid persistent tardive dyskinesia.

From the Research

Treatment Options for Nausea and Vomiting

• Nonpharmacologic management options include fluid and electrolyte replacement, small, frequent meals, and avoidance of trigger foods 3
• Antiemetic drugs can effectively reduce symptoms of acute nausea and vomiting, but chronic symptoms are often more challenging to treat 3
• The choice of antiemetic drug depends on the cause of nausea and vomiting, with serotonin and neurokinin antagonists being highly effective in treating chemotherapy-induced nausea and vomiting 4
• Metoclopramide and antihistamines are first-line options for nausea and vomiting in pregnancy 4

Pharmacologic Therapy

• Serotonin antagonists and some dopamine antagonists, such as metoclopramide, can prolong the QT interval on the ECG 4
• Dopamine antagonists can cause extrapyramidal adverse effects, particularly in children 4
• Pharmacologic therapy should be used for the shortest time necessary to control symptoms 3
• In the emergency department setting, there is no definite evidence to support the superiority of any one drug over any other drug, or the superiority of any drug over placebo 5

Specific Treatments

• Ondansetron, prochlorperazine, and dexamethasone have been compared in the prevention of delayed chemotherapy-induced nausea and vomiting, with no clinically important difference in efficacy, adverse effects, or treatment satisfaction among the three treatments 6
• Droperidol has been shown to be statistically significantly superior to placebo in reducing nausea and vomiting in a single trial of 48 participants 5
• Metoclopramide, ondansetron, prochlorperazine, promethazine, and droperidol have been evaluated in the treatment of nausea and vomiting in the emergency department setting, with varying results 5

Emerging Therapies

• New and improved interventions are becoming available based on emerging understandings of the pathophysiology of nausea and vomiting, including bioelectrical neuromodulation, behavioral and surgical therapies, and complementary medicine 7