Nausea and vomiting

What type of N&V are antihistamines used for? Give examples.

Cinnarizine, cyclizine, promethazine hydrochloride / teoclate.

Effective against nausea and vomiting resulting from many underlying conditions.

What type of N&V are phenothiazines used for and how do they work? Give examples.

Chlorpromazine hydrochloride, prochlorperazine, trifluoperazine.

They are dopamine antagonists and act centrally by blocking the chemoreceptor trigger zone.

What type of N&V are 5HT₃-receptor antagonists used for and how do they work? Give examples.

Granisetron, ondansetron and palonosetron.

Management of nausea and vomiting in patients receiving cytotoxics

When can dexamethasone be used as an antiemetic?

Dexamethasone has antiemetic effects and is used in the management of chemotherapy-induced nausea and vomiting.

What are the first and second line treatments for nausea and vomiting during pregnancy? Include self care advice.

Typically resolves within 16 to 20 weeks of pregnancy.

Self-care advice: rest, oral hydration and dietary changes.

• plain biscuits or crackers in the morning

• bland, small, frequent protein-rich meals

• Cold meals if nausea is smell-related

• Drinking little and often

Non-pharmacological option: ginger

Antiemetics should be considered for persistent symptoms.

First line options:

• Chlorpromazine

• Cyclizine

• Prochlorperazine

• Promethazine

• Doxylamine with pyridoxine (Xonvea) - the only one licensed for use in pregnant women.

Second line: domperidone, ondansetron, metoclopramide

What must we consider for antiemetic choice in palliative care? Give some suitable options.

Swallowing ability, interactions, identify cause.

• Metoclopramide

• Domperidone

• Antipsychotics - haloperidol, levomepromazine [broad-spectrum antiemetic]

• Cyclizine

• Dexamethasone

What antiemetic is offered in the pre-op period?

Lorazepam - due to nerves

What antiemetic is offered in the post-op period?

• 5HT₃-receptor antagonists - granisetron, ondansetron

• dexamethasone

• droperidol

• haloperidol

• Cyclizine for N&V caused by opioids and general anaesthetics

• Prochlorperazine

What antiemetic can be given for motion sickness?

Hyoscine hydrobromide

What is the recent MHRA update with hyoscine hydrobromide?

Risk of anticholinergic side effects, including hyperthermia with hyoscine hydrobromide patches.

Counsel patients / carers to seek immediate medical attention and remove the patch if signs and symptoms of serious anticholinergic side-effects occur;

• hyperthermia

• urinary retention

• delirium and hallucinations

• seizures

Immediate action should also be taken to reduce body heat if a high temperature develops - risk of respiratory paralysis and coma.

Which antiemetics can be given in patients with Parkinson’s? Which ones do we avoid?

Avoid antiemetics that are also antipsychotics e.g. prochlorperazine, haloperidol, chlorpromazine. Also avoid metoclopramide.

Low-dose domperidone can be used

Which patient groups cannot use domperidone? MHRA alert.

No longer indicated in children aged under 12 years or those weighing less than 35 kg - not as effective in this population.

What cardiac abnormalities can be caused by domperidone?

Arrythmias - increased risk of ventricular arrhythmia in patients over 60 years.

CONTRAINDICATED in cardiac disease, impaired cardiac conduction, GI haemorrhage / obstruction / perforation.

What is the maximum time domperidone should be used?

7 DAYS

What is the one common side effect with domperidone?

Dry mouth - domperidone dry mouth

What is the MHRA warning for domperidone?

Risk of neurological adverse effects—restricted dose and duration of use:

• Short-term use only (up to 5 days)

• Usual recommended dose is 10 mg, repeated up to 3 times daily

Particularly extrapyramidal disorders - therefore must be avoided in Parkinson’s disease.

What are the two indications metoclopramide can be used in children aged 1-18?

• Post-operative nausea and vomiting

• Prevention of delayed chemotherapy-induced nausea and vomiting

All other indications, patient must be 18 years and over.

What are some common side effects with domperidone?

Drowsiness and diarrhoea