Drug Therapy for Nausea and Vomiting

Antiemetics

• Blocks the hyperactive response of the chemoreceptor trigger zone (CTZ) to various stimuli

  • the response that produces non beneficial nausea and vomiting

Emetics

• Agent used to induce vomiting to rid the stomach of toxins or drugs

• No longer recommended in most cases

  • we dont really give meds that induce vomiting at home anymore 

    • now we just give activated charcoal instead of emetics when we have toxicity

Antiemetics Common Adverse Effects:

• drowsiness

• dizziness

• confusion

• dry mouth

• urinary retention

• tachycardia

Antiemetics Drug Interactions

• Taking antiemetics with alcohol may cause severe CNS depression

• we need to check if pt is on anticoagulant or antiarrhythmics

Antiemetic Patient Teaching

• Warn patients about driving or performing any hazardous tasks

• Each drug also has specific miscellaneous adverse effects - check before administering

• Teach patients to change positions slowly to avoid hypotensive effects

Antiemetics Administration For Chemotherapy

• For chemotherapy

  • Antiemetics are often given 30 to 60 minutes before chemotherapy begins

Antiemetics with Older Adults

• More likely to develop adverse effects including sedation, confusion, dizziness, fluid imbalance, and CV effects.

• Safety concern

  • Fall Risk

• Renal/Hepatic

Antiemetics and Anti-nausea Drugs

• Phenothiazines

• Antihistamines

• 5-HT₃ Receptor Antagonists

• Substance P/neurokinin₁ Receptor Antagonists

• Miscellaneous

Prochlorperazine (Compro)

• Phenothiazine

• we dont use as much anymore

  • we use this when patients don’t respond to other meds 

• a lot of pts will be given this IV prior to chemotherapy 

  • or before anesthetic procedures to reduce nausea

• Depresses the CTZ to tx N/V

  • Tx: Prevention of chemo induced emesis

• Depresses the CNS to tx psych disorders

Prochlorperazine (Compro) Psych Disorders Indications

• Schizophrenia or psychosis

• Migraines

• Intractable Hiccups

Prochlorperazine (Compro) Contraindications

• Beers Criteria:

  • Inappropriate for older adults and under 18 yrs

• Contraindicated with pregnancy

Prochlorperazine (Compro) Adverse Effects

• Orthostatic hypotension

• Asthma exacerbation

• Anticholinergic effects

Prochlorperazine (Compro) Black Box Warning

• Older adults w/ dementia related psychosis r/t risk of death

Antihistamines (H₁ receptor blockers) 

• Vistaril (hydroxyzine)

• dimenhydrinate (Dramamine)

• meclizine (Antivert)

• Blocks action of acetylcholine

• Prevents stimulation of the CTZ

Antihistamines (H₁ receptor blockers) Treatment

• Motion Sickness

• Sedation

• Anxiety

Antihistamines (H₁ receptor blockers) Routes

• Vistaril (hydroxyzine)

  • given also for substance use disorders (relieves anxiety)

  • only PO & IM

• Dramamine & Meclizine (Bonine) can be OTC

Antihistamines (H₁ receptor blockers) Adverse Effects

• Anticholinergic effects

• Concern: Prolonged QT interval

• Concern: Torsade de Pointes

Antihistamines (H₁ receptor blockers) Contraindications

• Pregnancy

Ondansetron (Zofran)

• 5-HT₃ Receptor Blocker
  (serotonin blocker)

• Blocks receptors in CTZ & Gl tract

Ondansetron (Zofran) Indications

• N/V

• Chemo/Rad therapy induced nausea

• Post OP N/V drug of choice

Ondansetron (Zofran) Adverse Effects

• Diarrhea

• Constipation

• HA

• Dizziness

• Concern: Prolonged QT interval

• Concern: Torsade de Pointes

• Pain at injection site

Ondansetron (Zofran) Contraindications

• Pts on antidysrhythmic agents

Ondansetron (Zofran) Routes

• can be given as dissolving tablet

  • do not swallow; wait for tablet to disintegrate (No water needed) 

  • Can be given IV; works immediately

  • Can be given PO, but it may not be best for nauseous or vomiting pt

Aprepitant (Emend)

• Substance P/neurokinin₁ receptor antagonist

• Blocks receptors in the brain that cause nausea

Aprepitant (Emend) Indications

• Chemo/Rad therapy induced nausea

  • IV given 30-60 minutes before treatment

• Used as a preventive

Aprepitant (Emend) Synergistic

• Often used with 5-HT₃ receptor antagonists (serotonin blockers) & corticosteroids to tx acute n/v with chemo

Aprepitant (Emend) Adverse Effects

• CNS Effects

Aprepitant (Emend) QSEN Safety Alerts

• Decreases INR which increases the risk of blood clots

  • INR checks for 2 weeks post use

Miscellaneous Anti Nausea Drugs

• Olanzapine (Zyprexa)

• Dronabinol (Marinol)

• Emetrol

• Scopolamine

• Marijuana (Cannabis)

Olanzapine (Zyprexa)

• can also be used for bipolar patients & schizophrenia

Dronabinol (Marinol)

• Used for cancer pts or underweight pts 

  • can be addictive like marijuana 

  • Dronabinol part of marijuana that relieves nausea, can make pt eat

Emetrol

• available OTC, can be given to kids 

  • decreases contractions in GI tract = relief of spasming & nausea

  • has fructose in it; caution for diabetics

  • can also be used for morning sickness in pregnancy

Scopolamine

• prevents CTZ zone from being triggered

  • can come in a patch

  • used for chemo induced nausea or motion sickness

  • can also be used for end of life care; can help dry up secretions pt may have

  • remember anytime we use any patches to use gloves; patches usually last about 72 hours

    • document where and when you put it on 

    • can make pts drowsy so it may not be best choice

    • pts with glaucoma; scopolamine can increase IOP

Marijuana (Cannabis)

• more recent studies say that it may not be too helpful for nausea

  • chemo patients use this for many ways

    • appetite stimulant, nausea, pain

Ginger

• can be used to decrease nausea

• S/E: Increased Bleeding risk with anticoagulant

Peppermint

• Don't use concurrently with:

  • iron

  • antibiotics

  • seizure meds

  • cardiac or BP meds

  • or meds to decrease stomach acid

Acupuncture & Acupressure

• Acupressure wristbands may be helpful

Nausea & Vomiting Assessment

• Assess allergy

• Assess emesis (quantity, frequency, content)

• Assess liver & renal labs

• Assess BP

• Assess for pregnancy or lactation

Nausea & Vomiting Non Pharmacological Interventions 

• Darkening the room

• Put a cool cloth behind the neck or forehead

• Deep breathing