Download Document

Management of
Nausea and Vomiting
John A. Mulder, MD
Vice President, Medical Services
Faith Hospice
Assessment
• Onset
• Frequency
• Relationship to
eating
• Relationship to
medications
• Current nausea
medications
• Chronic or
progressing
• Alleviating factors
• Severity
• Scale: 1-10
• Goal
Assess cause:
• Chemoreceptor trigger zone (CTZ)
• Gastrointestinal/bowel
• Vestibular
• Cortical/anxiety
• Vomiting center
Opioids (and metabolites)
Metabolic problems
Intracranial
pressure
Other drugs
NAUSEA
Bowel obstruction
Constipation
Peptic ulcer disease
Autonomic failure
Driver, L, and Bruera, E., The MD Anderson Palliative Care Handbook
Common Causes in Cancer Patients
• Treatment-related factors
– Chemotherapy
– Radiation Therapy
– Opioid Therapy
– Other drugs (antibiotics, NSAIDs, SSRIs,
etc.)
Common Causes in Cancer Patients
• Pathophysiologic/metabolic/biochemical
– Constipation
– Autonomic dysfunction (gatroparesis, stasis)
– Gastric/duodenal ulcer
– GERD/gastritis
– Liver failure/hepatomegaly/ascites
– Infection/sepsis/fever
– Coughing
– Increased intracranial pressure
Common Causes in Cancer Patients
• Pathophysiologic/metabolic/biochemical
– Oral/esophageal infection/lesions
– Pain
– Dehydration
– Electrolyte imbalance
– Hypercalcemia
– Uremia
– Endocrine dysfunction
Common Causes in Cancer Patients
• CNS/psychophysiologic problems
– Vestibular disturbance
– Cerebrocortical mechanisms (anticipatory
N/V)
– Limbic mechanisms (hypersensitivity to
taste and smell)
– Anxiety
Most patients have multifactoral causes
Treatment Considerations
• Constipation regimen
• Decompress obstruction; disimpact
• If no nausea and tolerated, support only
• Oral hygiene
• Small stomach: small portions, frequent
meals, cold foods tolerated better
• Odors
• Avoid odors of cooking (ventilation)
• Perfumes, scents, etc.
• Opioid rotation
• Steroids or RT for increased ICP
• Reassurance/relaxation for anticipatory
nausea/high anxiety
• Correct electrolyte imbalance
• Volume repletion for dehydration
• Hypercalcemia treatment with
hydration, steroids, bisphosphonates
• Adjustment of nutritional supplements
Review medication list
• a. Digitalis
• b. Theophylline
• c. Chemotherapy
• d. Antibiotics
–1. Erythromycin
–2. Tetracycline
–3. Metronidazole (Flagyl)
–4. Ciprofloxacin (Cipro)
Pharmacologic treatment
Conventional antiemetics :
• metoclopramide (Reglan) – po, pr, iv, sc
• prochlorperazine (Compazine) - po, pr, iv, sc
• droperidol (Inapsine) - im, iv, sc
• promethazine (Phenergan) - po, pr, iv, sc
• scopolomine (Transderm Scop, Scopace) –
td, po
• meclizine (Antivert) - po
Pharmacologic treatment
Selective serotonin 5-HT3 antagonists:
• ondansetron (Zofran, Zuplenz) - po, iv, sc, sl
• granisetron (Kytril, Granisol, Sancuso) - po,
iv, sc, td
• polonosetron (Aloxi) – iv
• dolasetron (Anzemet) – iv
Pharmacologic treatment
Cannabinoid receptor agonists:
• nabilone (Cesamet) – PO
• dronabinol (Marinol) – PO
Pharmacologic treatment
Others:
• aprepitant (Emend) – PO, IV
– Selective human substance P/neurokinin 1
receptor antagonist
Anticholinergic agents
• Hyoscyamine (Levsin)
Motility Problem
• a. Metoclopramide (Reglan) 5-20mg a.c.
• b. Cisapride (Propulsid) 10-20mg QID
Movement induced; initiation of opioids
• a. Scopolamine (Transderm Scop Patch) Q
72hrs
• b. Meclizine (Antivert) 12.5-25mg Q 6hrs
Alternative antiemetics (cont.)
• d. Combination suppositories: BRD
– 1. Benadryl
25 mg
– 2 .Reglan
10 mg
1-2 PR Q 4hr
– 3. Dexamethasone 2 mg
• e. ABHR
– 1. Ativan
0.5 mg
– 2. Benedryl
12.5 mg
1 Q 6hr
– 3. Haldol
0.5 mg
– 4. Reglan
10 mg
Unconventional antiemetics :
• Haloperidol (Haldol)
• Lorazepam (Ativan)
• Diphenhydramine (Benadryl)
• Corticosteroids (Decadron)
• Sea Bands
• Cannabinoids (Marinol)
BAD Drip
• 50 cc D5W
• 200 mg Benedryl
• 8 mg Ativan
• 20 mg Decadron
• 0.2 – 2.0 ml/h
RBD Drip
• 50 cc 0.9% sodium chloride
• 80 mg Reglan
• 100 mg Benadryl
• 8 mg Decadron
• 0.5 – 1.5 ml/h
Random thoughts . . .
• Metoclopramide 1st drug of choice because of
peripheral (GI) effects and central effects (CTZ)
• Antihistamines have no antidopaminergic effect
(not 1st line in treating opioid-related nausea)
• Phenothiazines very sedating, can cause other
side effects
• NG tube may be necessary for mgmt of copious
vomiting, abd distention, obstruction, etc.
• Combining drugs of different mechanisms may
yield positive results in addressing multifactoral
etiology
Random thoughts . . .
• Anticipatory, PO, RTC dosing most likely to
provide greatest benefit
• Corticosteroids often exert excellent antiemetic
effects
• Always R/O constipation/impaction in terminally
ill patient presenting with chronic N/V
• 5-HT3 antagonists among most effective for
chemotherapy induced N/V, but have minial
effects on opioid-induced emesis and have no
promotility effects
Costs
Drug
Phenergan
PO
.02/mg
Inj
.09/mg
PR
.16/mg
Compazine
.08/mg
----
.12/mg
Haldol
.14/mg
$1.80/mg
----
-------
-------
$6.00/mg
----
Emend
$275.50/kit
Hyoscyamine $2.48/mg
Zofran
$4.73/mg
Costs
Drug
PO
Inj
PR
Reglan
.02/mg
.36/mg
----
Antivert
.004/mg
----
----
Marinol
$1.68/mg
----
----
Costs
Drug
ABHR
Sea bands
$1.25/dose
Cream
$6.20/pair
Scope patch
$5.48/each
$3.95/supp
John Mulder, MD
VP of Medical Services
Faith Hospice
616-293-3615
[email protected]