Drugs for the Relief of Nausea
For more up to date information, specifically the one you are taking go to http://www.patient.co.uk/doctor/The-Treatment-of-Nausea-and-Vertigo.htm?
Treatment of Nausea and Vertigo
Nausea and vomiting represent a progressive response to increasing stimulation of a complex reflex co-ordinated by the vomiting centre in the brainstem. It receives input from the chemoreceptor trigger zone (CTZ), vestibular system, cerebral cortex and mechanoreceptors in the gut and visceral surfaces.2
Vertigo is an illusion of movement caused by disorders of the vestibular system, associated with balance disturbance and nausea.3
Blockade of the neurotransmitters and receptors involved in these pathways allows pharmacological management of nausea, vomiting and vestibular disorders.2
|Accurate diagnoses of the cause of nausea or vertigo is vital before treatment is initiated:|
More than 70% of women are affected by nausea or vomiting during pregnancy and causes include:4
First trimester nausea is usually mild and self-limiting but, should vomiting continue, initial steps include:
- Reassurance and encouragement to rest
- Drinking small amounts more frequently
- Small, cold, frequent, carbohydrate-rich meals
- Use of glucose tablets and biscuits to boost blood sugar levels
- Avoidance of cold or sweet drinks, caffeine and alcohol
- Avoidance of other foods or smells that trigger nausea5
|No drugs are licensed for treatment of nausea or vomiting during pregnancy in the UK.|
- First-line drug therapy includes the antihistamines, promethazine and cyclizine. These drugs have been widely studied and there is no apparent increased risk of congenital malformations.
- Prochlorperazine and metoclopramide are less well studied and so used as second-line therapy.
- Domperidone is not recommended as there are no published trials of safety during pregnancy.
- Other supplements such as pyridoxine (vitamin B6), multivitamins and ginger root may be effective treatments - more research is needed before these products can be recommended in practice.5,6
Women should be referred to secondary care for fluid and electrolyte replacement and vitamin supplementation if there is evidence of:
are many causes of nausea in palliative patients, particularly those
with advanced cancers.
Common causes include:2
- Meningeal irritation or stretch by tumour or metastases
- Abdominal or pelvic tumour causing malignant bowel obstruction or mesenteric/liver metastases
- Gastric stasis due to opioids or mechanical resistance
- Toxins (such as drugs) or metabolic disorders, e.g. hypercalcaemia or hyponatraemia
Anti-emetic treatment in palliative care is particularly challenging as:
- There are often multiple causes of nausea or vomiting which need to be treated separately
- Investigation and identification of the specific cause may not be appropriate2
Simple interventions include:
- Regular treatment with first-line anti-emetics such as cyclizine, metoclopramide or haloperidol should be prescribed for 24-48 hours and then reviewed.2
- If nausea persists, consider substitution of the first-line anti-emetic with levomepromazine ± dexamethasone as adjunct therapy.
- Ranitidine can be used to reduce gastric secretions in gastric outflow obstruction and hyoscine or octreotide may be useful in distal obstruction.2
Nausea remains one of the most feared and debilitating side-effects of cytotoxic therapy.7Symptoms vary with:
- Cytotoxic agent: cisplatin, dacarbazine and high-dose cyclophosphamide are highly emetogenic
- Women > men
- Age < 50 years
- Susceptibility to motion sickness
Nausea is divided into 3 phases according to onset, which are managed differently:
Acute (first 24 hours of treatment)
- Best prevented by 5HT3 antagonist with dexamethasone. Mirtazipine and olanzapine are cheaper and have similar 5HT binding efficacy8
- Addition of aprepitant improves nausea due to cisplatin
- Nabilone may be used if symptoms remain poorly controlled
Delayed (> 24 hours after treatment)
- Symptoms reduced with good control of acute phase7
- Prevented with dexamethasone ± metoclopramide/prochlorperazine
Anticipatory (prior to subsequent doses)
- Ideally prevented by earlier symptom control
- Lorazepam has beneficial anxiolytic and amnesic properties
- Type of anaesthetic agent, particularly volatile agents and opiates
- Nature and duration of surgery
- Women > men
- Past history of post-operative nausea or motion sickness
Post-operative nausea and vomiting has traditionally been treated with metoclopramide, antihistamines or phenothiazines but only a modest reduction in symptomatology has been possible.1 However combinations of drugs including 5HT3 antagonists and dexamethasone are gradually improving results.11
is a paroxysmal disorder with attacks of headache,
nausea, vomiting and other features.
Nausea may respond to treatment with 5HT1 agonists but conventional anti-emetics are also useful.12 Metoclopramide, domperidone, phenothiazine or an antihistamine should be taken with the onset of symptoms.13
of motion sickness is achieved using hyoscine or an antihistamine.
Hyoscine is most efficacious but may be poorly tolerated. Antihistamine
may then be useful and the choice of compound depends largely on the
desire to avoid or encourage sedation.
Other anti-emetics such as 5HT3 antagonists, metoclopramide and domperidone are ineffective and should not be prescribed.
- Treatment of vestibular disorders depends on specific treatment of the underlying cause, combined with symptomatic control.
- Patient should be reassured that the disequilibrium should eventually be overcome by central adaptation. Anxiety exacerbates vertigo and may limit activities until these adjustments are made.
- Drugs that sedate the vestibular brainstem axis, such as prochlorperazine, reduce symptoms but prolonged use should be avoided, as they will prevent central compensation.3
- A disorder involving progressive distension of the membranous labyrinth, resulting in vertigo, tinnitus and hearing loss.
- Prochlorperazine and cinnarizine are effective treatments for acute attacks of vertigo.
- If recurrent, troublesome episodes occur, maintenance treatment is recommended.
- Betahistine is said to reduce the frequency, duration and intensity of attacks.
- Diuretic therapy and salt restriction may be useful.
- Pharmacological treatment is often inadequate so ablative procedures may be necessary.14
- Quigley EM, Hasler WL, Parkman HP; AGA technical review on nausea and vomiting. Gastroenterology. 2001 Jan;120(1):263-86.
- Palliative care - nausea and vomiting, Clinical Knowledge Summaries (2007)
- Kanagalingam J, Hajioff D, Bennett S; Vertigo. BMJ. 2005 Mar 5;330(7490):523.
- Jewell D, Young G; Interventions for nausea and vomiting in early pregnancy. Cochrane Database Syst Rev. 2003;(4):CD000145. [abstract]
- Nausea and vomiting in pregnancy, Clinical Knowledge Summaries (May 2008)
- White B; Ginger: an overview. Am Fam Physician. 2007 Jun 1;75(11):1689-91. [abstract]
- Aapro M; Optimising antiemetic therapy: what are the problems and how can they be overcome? Curr Med Res Opin. 2005 Jun;21(6):885-97. [abstract]
- Kast RE, Foley KF; Cancer chemotherapy and cachexia: mirtazapine and olanzapine are 5-HT3 antagonists with good antinausea effects. Eur J Cancer Care (Engl). 2007 Jul;16(4):351-4. [abstract]
- Apfel CC, Kranke P, Katz MH, et al; Volatile anaesthetics may be the main cause of early but not delayed postoperative vomiting: a randomized controlled trial of factorial design. Br J Anaesth. 2002 May;88(5):659-68. [abstract]
- Dodds C and Hutton P. Fundamental Principles and practice of anaesthesia, First edition (2002). London: Martin Dunitz Ltd.
- POEM; Combinations of antiemetics are better for post-operative nausea and vomiting. BMJ 2004;329 (28 August), doi:10.1136/bmj.329.7464.0-e
- Diener HCh; Pharmacological approaches to migraine. J Neural Transm Suppl. 2003;(64):35-63. [abstract]
- Migraine, Clinical Knowledge Summaries (2008)
- Meniere's disease, Clinical Knowledge Summaries (2007)
Internet and further reading
- Kuo CH, Pang L, Chang R; Vertigo - part 2 - management in general practice. Aust Fam Physician. 2008 Jun;37(6):409-13. [abstract]
- Talley NJ; Functional nausea and vomiting. Aust Fam Physician. 2007 Sep;36(9):694-7. [abstract]
- Harker N. Montgomery A. Fahey T; Interactive case report outlining issues surrounding treatment of nausea and vomiting in pregnancy. Treatment of nausea and vomiting during pregnancy: presentation. BMJ 2004 328: 276
As with all information on these pages 100% accuracy or relevance is not guaranteed and all information must be consulted with your GP.
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