step by step approach to management of nausea and vomiting in palliative care

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1) First line - single agent based on underlying cause. Use regularly and to maximum dose before changing. If one drug is ineffective then use an alternative first line agent.

Cause of NauseaSuggested DrugDose and Route
Drug induced and biochemicalhaloperidol

oral: 1.5-3mg od - bd

s.c. 2.5-5mg/24hr

Evidence of gastric stasis

metoclopramide

 

oral: 10-20mg tds before meals

s.c. 30-100mg/24hr

 

OR

domperidone (does not cross the blood brain barrier so fewer side effects)

oral: 10mg tds

p.r. 30mg bd or tds

If GI tract involvement or cerebral turmour, or if the above have not worked cyclizine

oral: 50mg tds

s.c. 150mg/24hr

2) Second line - add another first line age (e.g. cyclizine and haloperidol) or change to 'broad spectrum' agent

Cause of NauseaSuggested DrugDose and Route
Broad spectrum anti-emetic useful if multiple possible causeslevomepromazine (acts at multiple receptor sites)

oral: 6mg-25mg nocte

s.c. 6.25-25mg/24h

 

3) Third line - if other drugs are not controlling symptoms try

Suggested drug Dose and Route
3 day course of 5HT3-receptor antagonist e.g. ondansetron, granisetron or tropisetron

ondansetron - oral: 8mg bd; s.c. up to 24mg per 24 hrs

granisetron - oral/s.c. 1-2mg per 24hrs

 

 

Nausea and vomiting caused by moderately- to highly- emetogenic chemotherapy

  • neurokinin receptor antagonists for example Aprepitan
Aprepitant 80mg- 125mg OD PO Capsules: 80mg, 125mg

Raised intracranial pressure or intractable nausea and vomiting

  • steroids
 

Notes:

  • when changing antiemetics
    • ensure the anti-emetic is used regularly, and to a maximum dose before changing
    • if first drug is ineffective, change to an alternative first line drug
    • if first line drug was partially effective, another anti-emetic drug may be added (see Second line treatment)
    • haloperidol with cyclizine is often effective, especially by continuous subcutaneous infusion
    • 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
    • re-assess patient

The respective summary of product characteristics must be consulted before prescribing any of the drugs detailed.

Reference:

  1. West Midlands Palliative Care Physicians (2003). Palliative care - guidelines for the use of drugs in symptom control.
  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.

Last reviewed 01/2018