Nausea and vomiting medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: {{VVS}

Overview

  • Mainstay of treatment of nausea and vomiting is correcting any electrolyte imbalance, dehydration, malnutrition, and suppression of symptoms while evaluating and treating the underlying cause. [1]
  • Dietary recommendations include a low-fat, low-fiber diet with frequent small meals if able to tolerate oral intake. Liquid diet is recommended in case solid diet is not well tolerated. [2]
  • Medical therapy involves two groups of drugs i.e., antiemetics and prokinetics. Antiemetics suppress nausea and vomiting and typically act centrally. Prokinetics modulate gastrointestinal motility.

Medical Therapy

  • Mainstay of treatment of nausea and vomiting is correcting any electrolyte imbalance, dehydration, malnutrition, and suppression of symptoms while evaluating and treating the underlying cause. [1]
  • Dietary recommendations include a low-fat, low-fiber diet with frequent small meals if able to tolerate oral intake. Liquid diet is recommended in case solid diet is not well tolerated. [2]
  • Medical therapy involves two groups of drugs i.e., antiemetics and prokinetics. Antiemetics suppress nausea and vomiting and typically act centrally. Prokinetics modulate gastrointestinal motility.

Antiemetics

  • Benzodiazepines are used for anticipatory nausea and postoperative nausea and vomiting. Eg., Lorazepam 0.5-2mg oral, SL (sublingual) or IM (intramuscular), Alprazolam 0.25-1mg oral or IV (intravenous). [3]
  • Serotonin antagonists are used in postoperative, post-radiation and chemotherapy induced nausea and vomiting. Eg., Ondansetron 4-8mg oral or IV, Granisetron 1-2 mg every 4-8 hours or 0.075mg-0.25mg every 24 hours oral or IV. [1]
  • Antihistamines are used in motion sickness and labrythitis. Eg., Meclizine 25-50mg every 24 hours oral, Diphenhydramine, Cyclizine, Hydroxazine 25-50mg every 6-8 hours, 25–75 mg every 8 hours, 25–50 mg every 4–6 hours, 25–100 mg every 6–8 hours oral, IM or IV. [2] [4]
  • Anticholenergic agents are used in motion sickness. Eg., Scopolamine 0.3–0.6 mg every 24 hours SL, IV, IM or transdermal. [5] [6]
  • Phenothiazines are antidopaminergics which are effective for migraine, motion sickness, vertigo, postoperative and chemotherapy induced nausea nd vomiting. Eg., Prochlorperazine, Promethazine, Chlorpromazine, Perphenazine 5–10 mg every 6–8 hours, 12.5 –25 mg every 4–6 hours, 10–25 mg every 4–6 hours, 4–8 mg every 8–12 hours Oral, IV or IM. [7] [8]
  • Droperidol is a Butyrophenone and a restricted drug used for postoperative and chemotherapy induced nausea and vomiting, 0.625–1.25 mg every 24hours IM or IV [5]
  • Cannabinoids are used for chemotherapy induced nausea and vomiting. Eg., Dronabinol, Nabilone 2.5–10 mg every 6–8 hours, 1–2 mg every 8–12 hours oral. [8] [9]
  • Corticosteroids are used for acute or delayed chemotherapy induced or postoperative nausea and vomiting. Eg., Dexamethasone 4–8 mg every 4–6 hours Oral, IM or IV. [8] [10]
  • NK-1 Receptor Antagonist is used in acute as well as delayed chemotherapy-induced nausea and vomiting. It has also been used in gastroparesis-associated nausea and vomiting. Eg., Aprepitant 80–125 mg every 24 hours oral. [11] [12] [13]

Prokinetics

  • Prokinetic agents are used for only prokinetic activity (eg, Erythromycin) or both prokinetic and antiemetic activity (eg, Benzamides like Metoclopramide and Domperidone are shown to be efficacious in chemotherapy induced vomiting and gastroparesis). Metoclopramide 10–20 mg every 6–8 hours Oral, IM or IV, Domperidone 10mg every 8–24 hours oral, Erythromycin 250–500mg every 8 hours oral or IV. [14] [15]

Miscellaneous therapy

  • Novel and non-traditional therapies for nausea and vomiting include Tricyclic antidepressants (TCAs), Gabapentin and Olanzapine. Gabapentin is shown effective in life-threatening refractory emesis following posterior fossa surgery. TCAs (Amitriptyline, Nortriptyline, Doxepin, Desipramine, Imipramine) 10–100 mg/day oral, Gabapentin 300–900 mg three times daily oral, Olanzapine 5–10 mg/day oral. [16] [17] [18] [19] [20]
  • Ginger has some efficacy to reduce postoperative nausea and vomiting, morning sickness and motion sickness. [21] [22]
  • Gastric electric stimulation(GES) is a surgical procedure used in refractory gastroparesis. [23]
  • Alternative approaches include hypnosis, acupressure and acupuncture. [24] [25]

References

  1. ↑ 1.0 1.1 1.2 Hasler WL, Chey WD (December 2003). "Nausea and vomiting". Gastroenterology. 125 (6): 1860–7. doi:10.1053/j.gastro.2003.09.040. PMID 14724837.
  2. ↑ 2.0 2.1 2.2 Singh P, Yoon SS, Kuo B (January 2016). "Nausea: a review of pathophysiology and therapeutics". Therap Adv Gastroenterol. 9 (1): 98–112. doi:10.1177/1756283X15618131. PMC 4699282. PMID 26770271.
  3. ↑ Di Florio T, Goucke R (August 1993). "Reduction of dopamine release and postoperative emesis by benzodiazepines". Br J Anaesth. 71 (2): 325. doi:10.1093/bja/71.2.325. PMID 8123420.
  4. ↑ Flake ZA, Scalley RD, Bailey AG (March 2004). "Practical selection of antiemetics". Am Fam Physician. 69 (5): 1169–74. PMID 15023018.
  5. ↑ 5.0 5.1 Quigley EM, Hasler WL, Parkman HP (January 2001). "AGA technical review on nausea and vomiting". Gastroenterology. 120 (1): 263–86. doi:10.1053/gast.2001.20516. PMID 11208736.
  6. ↑ Golding JF, Stott JR (June 1997). "Comparison of the effects of a selective muscarinic receptor antagonist and hyoscine (scopolamine) on motion sickness, skin conductance and heart rate". Br J Clin Pharmacol. 43 (6): 633–7. doi:10.1046/j.1365-2125.1997.00606.x. PMC 2042789. PMID 9205824.
  7. ↑ Sanger GJ, Andrews PL (October 2006). "Treatment of nausea and vomiting: gaps in our knowledge". Auton Neurosci. 129 (1–2): 3–16. doi:10.1016/j.autneu.2006.07.009. PMID 16934536.
  8. ↑ 8.0 8.1 8.2 Chepyala P, Olden KW (April 2008). "Nausea and vomiting". Curr Treat Options Gastroenterol. 11 (2): 135–44. doi:10.1007/s11938-008-0026-6. PMID 18321441.
  9. ↑ Herman TS, Einhorn LH, Jones SE, Nagy C, Chester AB, Dean JC, Furnas B, Williams SD, Leigh SA, Dorr RT, Moon TE (June 1979). "Superiority of nabilone over prochlorperazine as an antiemetic in patients receiving cancer chemotherapy". N Engl J Med. 300 (23): 1295–7. doi:10.1056/NEJM197906073002302. PMID 375088.
  10. ↑ Apfel CC, Korttila K, Abdalla M, Kerger H, Turan A, Vedder I, Zernak C, Danner K, Jokela R, Pocock SJ, Trenkler S, Kredel M, Biedler A, Sessler DI, Roewer N (June 2004). "A factorial trial of six interventions for the prevention of postoperative nausea and vomiting". N Engl J Med. 350 (24): 2441–51. doi:10.1056/NEJMoa032196. PMC 1307533. PMID 15190136.
  11. ↑ Madsen JL, Fuglsang S (April 2008). "A randomized, placebo-controlled, crossover, double-blind trial of the NK1 receptor antagonist aprepitant on gastrointestinal motor function in healthy humans". Aliment Pharmacol Ther. 27 (7): 609–15. doi:10.1111/j.1365-2036.2008.03618.x. PMID 18208572.
  12. ↑ Curran MP, Robinson DM (2009). "Aprepitant: a review of its use in the prevention of nausea and vomiting". Drugs. 69 (13): 1853–78. doi:10.2165/11203680-000000000-00000. PMID 19719336.
  13. ↑ Chong K, Dhatariya K (May 2009). "A case of severe, refractory diabetic gastroparesis managed by prolonged use of aprepitant". Nat Rev Endocrinol. 5 (5): 285–8. doi:10.1038/nrendo.2009.50. PMID 19444262.
  14. ↑ Javid FA, Bulmer DC, Broad J, Aziz Q, Dukes GE, Sanger GJ (January 2013). "Anti-emetic and emetic effects of erythromycin in Suncus murinus: role of vagal nerve activation, gastric motility stimulation and motilin receptors". Eur J Pharmacol. 699 (1–3): 48–54. doi:10.1016/j.ejphar.2012.11.035. PMID 23201066.
  15. ↑ Tack J, Janssens J, Vantrappen G, Peeters T, Annese V, Depoortere I, Muls E, Bouillon R (July 1992). "Effect of erythromycin on gastric motility in controls and in diabetic gastroparesis". Gastroenterology. 103 (1): 72–9. doi:10.1016/0016-5085(92)91097-n. PMID 1612359.
  16. ↑ Prakash C, Lustman PJ, Freedland KE, Clouse RE (September 1998). "Tricyclic antidepressants for functional nausea and vomiting: clinical outcome in 37 patients". Dig Dis Sci. 43 (9): 1951–6. doi:10.1023/a:1018878324327. PMID 9753257.
  17. ↑ Guttuso T (August 2014). "Gabapentin's anti-nausea and anti-emetic effects: a review". Exp Brain Res. 232 (8): 2535–9. doi:10.1007/s00221-014-3905-1. PMID 24668130.
  18. ↑ Guttuso T, Vitticore P, Holloway RG (March 2005). "Responsiveness of life-threatening refractory emesis to gabapentin-scopolamine therapy following posterior fossa surgery. Case report". J Neurosurg. 102 (3): 547–9. doi:10.3171/jns.2005.102.3.0547. PMID 15796394.
  19. ↑ Navari RM, Einhorn LH, Passik SD, Loehrer PJ, Johnson C, Mayer ML, McClean J, Vinson J, Pletcher W (July 2005). "A phase II trial of olanzapine for the prevention of chemotherapy-induced nausea and vomiting: a Hoosier Oncology Group study". Support Care Cancer. 13 (7): 529–34. doi:10.1007/s00520-004-0755-6. PMID 15700131.
  20. ↑ Passik SD, Navari RM, Jung SH, Nagy C, Vinson J, Kirsh KL, Loehrer P (2004). "A phase I trial of olanzapine (Zyprexa) for the prevention of delayed emesis in cancer patients: a Hoosier Oncology Group study". Cancer Invest. 22 (3): 383–8. doi:10.1081/cnv-200029066. PMID 15493359.
  21. ↑ Ernst E, Pittler MH (March 2000). "Efficacy of ginger for nausea and vomiting: a systematic review of randomized clinical trials". Br J Anaesth. 84 (3): 367–71. doi:10.1093/oxfordjournals.bja.a013442. PMID 10793599.
  22. ↑ Keating A, Chez RA (2002). "Ginger syrup as an antiemetic in early pregnancy". Altern Ther Health Med. 8 (5): 89–91. PMID 12233808.
  23. ↑ McCallum RW, Dusing RW, Sarosiek I, Cocjin J, Forster J, Lin Z (February 2010). "Mechanisms of symptomatic improvement after gastric electrical stimulation in gastroparetic patients". Neurogastroenterol Motil. 22 (2): 161–7, e50–1. doi:10.1111/j.1365-2982.2009.01389.x. PMID 19719511.
  24. ↑ Marchioro G, Azzarello G, Viviani F, Barbato F, Pavanetto M, Rosetti F, Pappagallo GL, Vinante O (August 2000). "Hypnosis in the treatment of anticipatory nausea and vomiting in patients receiving cancer chemotherapy". Oncology. 59 (2): 100–4. doi:10.1159/000012144. PMID 10971166.
  25. ↑ Lee A, Fan LT (April 2009). "Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting". Cochrane Database Syst Rev (2): CD003281. doi:10.1002/14651858.CD003281.pub3. PMC 3113464. PMID 19370583.

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