Management of Nausea & Vomiting Dr Iain Lawrie Specialist Registrar in Palliative Medicine.
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Transcript of Management of Nausea & Vomiting Dr Iain Lawrie Specialist Registrar in Palliative Medicine.
![Page 1: Management of Nausea & Vomiting Dr Iain Lawrie Specialist Registrar in Palliative Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022070412/56649d6f5503460f94a515a0/html5/thumbnails/1.jpg)
Management ofNausea & Vomiting
Dr Iain LawrieSpecialist Registrar
in Palliative Medicine
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Vomit
Vomiting Centre
Cortical Structures
Gut Mucosa
Vestibular Apparatus
D2 5-HT3 ACh
H1 5-HT2 ACh
Chemoreceptor Trigger Zone
D2 5-HT3 Ach
H1, ACh
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Vomit
Vomiting Centre
Cortical Structures
Gut Mucosa
Vestibular Apparatus
D2 5-HT3 ACh
H1 5-HT2 ACh
H1 AChMotion
Emotions, sights, smells,
raised ICP
GI obstruction, bowel colic, tumour mass,
constipation
Chemoreceptor Trigger Zone
D2 5-HT3 AChDrugs, toxins,
uraemia, hypercalcaemia
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Vomit
Vomiting Centre
Cortical Structures
Gut Mucosa
Vestibular Apparatus
D2 5-HT3 ACh
H1 5-HT2 ACh
H1 AChMotion
Emotions, sights, smells,
raised ICP
GI obstruction, bowel colic, tumour mass,
constipation
Chemoreceptor Trigger Zone
D2 5-HT3 AChDrugs, toxins,
uraemia, hypercalcaemia
Metoclopramide, Levomepromazine
Granisetron
Haloperidol Metoclopramide
Levomepromazine Granisetron
Dexamethasone
Cyclizine, Hyoscine HBr
Cyclizine, Levomepromazine, Hyoscine HBr
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Factors to consider
Mechanism of action of anti-emetic drugs
Response to anti-emetics already given Combinations of drugs should have
different actions Levomepromazine has multiple
receptor affinities
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Factors to consider
Effects of anti-emetics on GI motility (prokinetic / antikinetic)
Adjuvant use of anti-secretory drugs Adjuvant use of corticosteroids Adverse effects of drugs Cost of drugs
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Management
Correct reversible causes stop gastric irritant drugs treat gastritis
• PPIs / antacids treat cough
• antitussive treat constipation
• laxatives
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Management
Raised ICP- steroids / radiotherapy
Anxiety Hypercalcaemia
- rehydration +/- bisphosphonates
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Causes of drug-induced N&V Gastric irritation
Gastric stasis
CTZ stimulation
5HT3-receptor stimulation
Antibiotics, iron, NSAIDs
Antimuscarinics, opioids, TCA
Antibiotics, cytotoxics, digoxin
Antibiotics, cytotoxics, SSRIs
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What if it’s not working?
Is it being absorbed? Is the dose optimum? Do you have the correct cause? Most anti-emetics can be given SC Doses usually the same PO, SC and IV
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Prescribing an anti-emetic
Choice depends on cause of N&V Give regularly Alternative to oral route if unable to
absorb- subcutaneous stat doses- continuous subcutaneous infusion (driver)- rectal route
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Anti-emetics – dopamine antagonists Haloperidol (D2)
Metoclopramide (D2, 5-HT3, 5-HT4 agonist) Prochlorperazine (D2) Domperidone (D2) Levomepromazine (D2, ACh, H1, 5-HT3)
Side effects- EPSE- sedation in higher doses- reduce seizure threshold
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Anti-emetics – histamine antagonists Cyclizine (H1, ACh) Levomepromazine (D2, ACh, H1, 5-HT3)
Side effects- drowsiness- anticholinergic effects- postural hypotension
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Anti-emetics - anticholinergics Hyoscine butylbromide (ACh) Hyoscine hydrobromide (ACh) Cyclizine (ACh) Levomepromazine (D2, ACh, H1, 5-HT3)
Side effects- sedation- anticholinergic effects
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Anti-emetics - prokinetics
Metoclopramide (D2, 5-HT3, 5-HT4 agonist)
Domperidone (D2)
Side effects:- colic- EPSE (not domperidone – doesn’t cross BBB)
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Anti-emetics – serotonin antagonists Ondansetron, granisetron, tropisetron
Side effects- constipation
Place in palliative care- obstruction / stretch- resistant N&V
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Anti-emetics - steroids
Dexamethasone Reduce permeability of BBB & area postrema
to emetogenic substances Reduce neuronal content of GABA in the
brain stem Reduce leuenkephalin release Reduce oedema around lesion or tumour
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Gastric stasis & irritation
Nausea made worse by eating Large volume vomits Early fullness & bloating Belching & reflux Hiccups Epigastric fullness & tenderness
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Gastric stasis & irritation
1st line metoclopramide
Adjuncts- antiflatulent- PPI- stop irritant drugs
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Bowel obstruction without colic Variable nausea Vomiting dependent on site of
obstruction Abdominal distension Background aching pain Constipation Absent or ‘hyperactive’ bowel sounds
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Bowel obstruction without colic 1st line metoclopramide 2nd line cyclizine or haloperidol
(substitute)
Adjuvants- diamorphine- octreotide- docusate- steroids
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Bowel obstruction with colic
Symptoms as before, but with colicky pains
1st line cyclizine OR haloperidol PLUS buscopan
2nd line cyclizine AND haloperidol OR levomepromazine
Adjuvants- diamorphine, octreotide, docusate
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Chemical induced N&V
Significant nausea Variable vomiting Few other GI symptoms Evidence of presence
i.e. new drug started, biochemistry results
1st line haloperidol / metoclopramide 2nd line ADD cyclizine OR substitute
levomepromazine
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Raised intracranial pressure
Known intracerebral tumour Early morning headaches Predominant nausea Intermittent vomiting Papilloedema Neurological deficit Seizures
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Raised intracranial pressure
1st line dexamethasone & cyclizine
2nd line ADD haloperidol
3rd line 5-HT3 antagonist (substitute)
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Motion / movement related N&V Nausea & vomiting worse on movement Can be associated with cranial nerve
lesions and base of skull metastases
1st line cyclizine
2nd line hyoscine hydrobromide
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Indeterminate N&V
1st line haloperidol OR cyclizine
2nd line haloperidol AND cyclizine
3rd line levomepromazine (substitute)
4th line consider metoclopramide, dexamethasone, 5HT3 antagonist
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Summary
Try to determine the cause wherever possible
1/3 of patients will need more than one anti-emetic
Eliminate reversible causes
Continue anti-emetic indefinitely if cause is not self-limiting