Nausea and vomiting

Nausea and vomiting

The choice of antiemetic will be influenced by the cause(s) of nausea and vomiting. The oral or subcutaneous routes are the preferred routes in Palliative Care. Thorough patient assessment includes full history, examination and investigations where appropriate.

Causes to consider:

•Abnormal biochemistry (e.g. hypercalcaemia, uraemia or hyponatremia) – Treat where appropriate

•Drugs (e.g. opioids, bisphosphonates, metronidazole, anticonvulsants) – Anti-emetics may be necessary for a few days when opioid treatment is initiated. Not all patients require this

•Avoid drugs with anticholinergic effects in patients with gastric stasis (e.g. hyoscine, antidepressants, cyclizine)

•Constipation – Prevent and treat aggressively

•Gastritis – Use a proton pump inhibitor e.g. lansoprazole

•Chemotherapy induced nausea & vomiting – A short course of 5HT3-receptor antagonists may be appropriate

•Raised intracranial pressure (See Corticosteroids)

•Anxiety: Psychological care with or without benzodiazepines

•Oropharyngeal thrush: A course of antifungal treatment

CHANGING ANTI-EMETICS
1. Ensure the anti-emetic is used regularly, to a maximum dose and for a sustained period of time before changing (e.g. 24hrs)
•If first line drug is ineffective, change to an alternative first line drug (see table below)
2. If first line drug was partially effective, another complementary anti-emetic drug may be added (see table below)
3. Haloperidol with cyclizine is often effective, especially by continuous subcutaneous infusion
4. Cyclizine and other anticholinergic drugs may antagonise some of the effects of metoclopramide and other prokinetic agents. The combination should therefore be avoided if possible
5. Re-assess patient
A continuous subcutaneous infusion via a syringe driver may be considered for patients
•who are vomiting for longer than 24 hours or
•who have nausea unresponsive to appropriate oral anti-emetics
Non-pharmacological measures may complement medical management and may be particularly helpful in drug-resistant nausea and vomiting, e.g. advice on posture and diet, acupuncture, complementary therapies, psychological treatments such as anxiety management
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Raised intracranial (as above):  Steroids see Corticosteroids

4. For bowel obstruction see bowel obstruction