Antiemetics in palliative care

• review medication and if possible stop or reduce drugs likely to cause nausea
  
  
• treat any identifiable cause
  • 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 5HT 3 -receptor antagonists may be appropriate
    • raised intracranial pressure
    • anxiety: psychological care with or without benzodiazepines
    • oropharyngeal thrush: a course of antifungal treatment
      
      
• give regular anti-emetic if the patient is nauseated
  
  
• tailor treatment to the severity and frequency of symptoms:
  • for mild nausea and vomiting (less than once a day), give oral medication
  • for moderate nausea and vomiting (more than once a day) give s.c. or rectal medication
  • for severe or continuous nausea and vomiting, give s.c. medication via a syringe driver
    
    
• different regimens may be used where nausea & vomiting is due to:
  • gastric stasis or gastritis
  • bowel obstruction
  • morphine, toxic or metabolic effects
  • raised intracranial pressure
  • anxiety or sensory stimuli
  • chemotherapy

A step by step approach to management of nausea and vomiting is linked in the menu below.

Reference:

1. Dr Michael Cushen, St Elizabeth Hospice, Ipswich 5/96
2. West Midlands Palliative Care Physicians (2007). Palliative care - guidelines for the use of drugs in symptom control.
3. West Midlands Palliative Care Physicians (2012). Palliative care - guidelines for the use of drugs in symptom control.