From the Guidelines
Chronic nausea is a complex condition that requires a comprehensive approach to diagnosis and treatment, and the most effective treatment is often directed at the underlying cause, with antiemetic medications such as ondansetron 4-8mg every 8 hours being a first-line option for many patients 1.
Causes of Chronic Nausea
Chronic nausea can be caused by various conditions, including:
- Gastrointestinal disorders (gastroparesis, GERD, peptic ulcer disease)
- Vestibular disorders
- Migraines
- Medication side effects
- Hormonal imbalances
- Anxiety disorders
- Central nervous system abnormalities
Investigations
Investigation typically begins with a thorough medical history and physical examination, followed by laboratory tests including:
- Complete blood count
- Metabolic panel
- Thyroid function tests
- Pregnancy test in women of childbearing age Additional diagnostic procedures may include:
- Upper endoscopy
- Gastric emptying studies
- Abdominal ultrasound
- CT scan
- MRI depending on suspected causes.
Treatment
Treatment is directed at the underlying cause and includes:
- Dietary modifications (small, frequent meals, avoiding trigger foods)
- Antiemetic medications (ondansetron 4-8mg every 8 hours, promethazine 12.5-25mg every 4-6 hours, or metoclopramide 5-10mg before meals)
- Specific treatments for identified conditions, such as:
- Gastroparesis: prokinetic agents like metoclopramide or erythromycin may help
- GERD: treated with proton pump inhibitors like omeprazole 20mg daily
- Vestibular disorders: may respond to vestibular rehabilitation therapy and medications like meclizine 12.5-25mg every 6 hours
- Anxiety-related nausea: might benefit from cognitive behavioral therapy and sometimes SSRIs like sertraline starting at 25mg daily Hydration is essential during treatment, and patients should monitor for warning signs like weight loss, dehydration, or blood in vomit that require immediate medical attention. According to a recent study, ondansetron is a recommended first-line option for the management of chronic nausea, including opioid-related nausea 1. Treatment duration varies based on the underlying cause, with some conditions requiring long-term management. In patients with refractory gastroparesis, domperidone, a dopamine D2-receptor antagonist, may be an effective option, with a recommended starting dose of 10 mg 3 times a day 1. Additionally, 5-HT3 receptor antagonists, such as granisetron, may also be effective in decreasing symptom scores by 50% in patients with refractory gastroparesis symptoms 1. It is essential to note that treatment should always prioritize the patient's quality of life, morbidity, and mortality, and the most recent and highest quality study should be considered when making a definitive recommendation 1.
From the Research
Chronic Nausea Causes
- Chronic nausea and vomiting (CNV) can be caused by a variety of gastrointestinal and non-gastrointestinal disorders 2, 3, 4
- Gastrointestinal causes include gastroparesis, cyclic vomiting syndrome, and other conditions 3, 4
- Non-gastrointestinal causes include medications, vestibular disorders, neurologic disorders, and psychogenic disorders 3, 5, 4
- Medications and toxins can also cause chronic nausea and vomiting 3, 5, 6
Investigations
- A comprehensive clinical history and physical examination are essential for diagnosing CNV 2, 3, 5
- Specific investigations, guided by clinical assessment, can help diagnose CNV 2, 3, 5
- Investigations may include tests to rule out anatomic, mechanical, and biochemical causes of CNV 4
- Gastric emptying studies can help distinguish between delayed and normal gastric emptying 4
Treatment
- Treatment of CNV should be based on the underlying cause 3, 5, 4
- Nonpharmacologic management options include fluid and electrolyte replacement, small frequent meals, and avoidance of trigger foods 3
- Antiemetic drugs, such as serotonin antagonists and dopamine antagonists, can be effective in reducing symptoms of CNV 3, 6
- The choice of antiemetic drug depends on the cause of CNV and the patient's individual needs 6
- Treatment should be tailored to the individual patient, taking into account the benefits, side effects, and costs of different treatment options 4