Can an 82-year-old female with a history of previous myocardial infarction (PMX) stroke, brain aneurysm, diabetes mellitus (DM), menorrhagia, cholecystectomy, colon polyps, and tubal ligation, who has not responded to Zofran (ondansetron) for nausea, be given an alternative antiemetic medication?

From the Guidelines

This 82-year-old female patient can receive another antiemetic medication since her nausea has not subsided after Zofran administration, with options including prochlorperazine or metoclopramide, as suggested by the most recent guidelines 1. When considering alternative antiemetic medications, it's essential to choose agents with different mechanisms of action to provide complementary effects.

• Prochlorperazine (Compazine) 5-10 mg IV/PO every 6 hours is a dopamine antagonist that can be effective for nausea and vomiting.
• Metoclopramide (Reglan) 10 mg IV/PO every 6 hours is both a dopamine antagonist and prokinetic agent, which can help manage nausea and also improve gastrointestinal motility. Given her age and complex medical history, including a stroke, it's crucial to start with lower doses and monitor closely for potential side effects, such as sedation, hypotension, or extrapyramidal reactions, especially with metoclopramide 1. The patient's history of brain aneurysm and stroke should also be considered when selecting an antiemetic, as some medications may have a higher risk of adverse effects in these patients. It's also important to assess for other potential causes of nausea, such as constipation, CNS pathology, or other underlying conditions, as recommended by the guidelines 1.

From the FDA Drug Label

Metoclopramide is a prescription medicine used to: • relieve symptoms of slow stomach emptying in people with diabetes • prevent nausea and vomiting that can happen with cancer chemotherapy • prevent nausea and vomiting that may happen after surgery, if your doctor decides that you should not be treated with a stomach tube and suction

The patient was given Zofran at 18:34, and nausea has not subsided. Metoclopramide can be used to prevent nausea and vomiting. However, the patient's medical history, including diabetes, brain aneurysm, and stroke, should be considered before administering metoclopramide.

• The patient's diabetes may require a dose adjustment of insulin when taking metoclopramide.
• The patient should be monitored for abnormal muscle movements and uncontrolled spasms. The decision to administer metoclopramide should be made by a doctor, considering the patient's medical conditions and the potential side effects of the medication 2.

From the Research

Patient Assessment

The patient is an 82-year-old female with a history of PMX stroke, brain aneurysm, DM, menorrhagia, cholecystectomy, colon polyps, and tubal ligation, presenting with bilateral leg pain and nausea. She was given Zofran at 18:34, but her nausea has not subsided.

Antiemetic Options

Considering the patient's ongoing nausea despite initial treatment with Zofran (ondansetron), alternative antiemetic options can be explored. According to the studies:

• Metoclopramide is an effective antiemetic agent, although it may cause extrapyramidal adverse effects and prolong the QT interval on the ECG 3, 4.
• Promethazine is a suitable option when sedation is desirable, but it may cause vascular damage upon intravenous administration and has the potential for sedation 5.
• Prochlorperazine is another option, but patients must be monitored for akathisia that can develop at any time over 48 hours post-administration 5.
• Droperidol is effective, but its use is limited due to the potential for QT prolongation 5.

Treatment Considerations

Given the patient's complex medical history, it is essential to consider the potential interactions and side effects of any new medication. The choice of antiemetic agent should be based on the patient's specific needs and medical history. As stated in the study, ondansetron is as effective as promethazine and is not associated with sedation or akathisia, making it a suitable first-line agent for most patient populations 5. However, since the patient has already received ondansetron without relief, an alternative agent such as metoclopramide or prochlorperazine may be considered 4.

Key Points to Consider

• The patient's nausea has not subsided despite initial treatment with ondansetron.
• Alternative antiemetic options, such as metoclopramide or prochlorperazine, may be considered.
• The choice of antiemetic agent should be based on the patient's specific needs and medical history, taking into account potential interactions and side effects 5, 3, 4.