Nausea and vomiting

Nausea, the feeling that a patient needs to or is about to vomit, is an extremely common and distressing symptom in patients with life limiting illness. It is often multifactorial with significant psychological influence. Treatment is therefore centred around the cause and type of nausea and is likely to require holistic assessment and intervention.

Assessment should first rule out reversible causes such as constipation or hypercalcaemia. Gastric irritation, reflux, cough, and anxiety equally may respond better to non-antiemetic treatments and need exploring.

Non-drug treatments

• Relaxation techniques
• Psychotherapy
• Acupuncture
• Ginger
• Acupressure bands

Drug Treatment

Potential Causes	Symptomatic features	Suggested Treatment
Chemical
Medication induced (opioids, chemotherapy)	Persistent and often severe nausea without relief from vomiting. May coincide with introduction of new medication or chemotherapy times	Haloperidol* Levomepromazine* Ondansetron with chemotherapy for short course
Uraemia/ hypercalcaemia
Carcinomatosis
Mechanical
Bowel obstruction	Intermittent nausea generally relieved by vomiting. Can be large volume vomit with food debris and potentially faeculent. Reduced/absent bowel movements. +/- colicky abdominal pain	NG tube insertion for decompression Prokinetic agents: Metoclopramide* Domperidone (Avoid if colic present) Antisecretory Hyoscine hydrobromide Octreotide Haloperidol* Levomepromazine* Cyclizine Hyoscine butylbromide may be a greater benefit if colic. Trial of steroids if malignant disease Erythromycin can be of help in gastric stasis
Constipation
Drugs (opioids, anticholinergics)
Autonomic failure and gastric stasis
Hepatomegaly
Physiological
Raised intracranial pressure	May be associated with headache Worse in the morning Worse on bending, coughing, and sneezing Possible associated with other neurological features	Cyclizine Dexamethasone Levomepromazine*
Radiotherapy
Cerebellar disease		Prochlorperazine*
Gastritis/ oesophagitis	Often associated with reflux, regurgitation and relieved by food	Proton pump inhibitor Antacids Metoclopramide*
Movement/ positional	Related to movement	Cyclizine Levomepromazine* Prochlorperazine*
Anticipatory
Previous experiences/ psychological	In advance of scheduled chemotherapy, or at the sight/thought of food Worsened by ruminating on potential nausea	Levomepromazine* Metoclopramide Benzodiazepines
Anxiety		Benzodiazepines Sertraline
Unclear
No single cause identified	Multiple features and risks	Haloperidol* Levomepromazine* Dexamethasone trial

* NB Parkinson’s Disease

Due to the risk of extrapyramidal side effects with many antiemetic medications the medication of choice is domperidone while still able to swallow, for all causes of nausea and vomiting. Ondansetron is also safe but has significant propensity for constipation when taken regularly for >48 hours, which may in turn worsen nausea. In the table above * denotes drugs which should be avoided in Parkinson’s disease.

Where nausea and vomiting are not controlled by domperidone in a patient with Parkinson’s disease, and ondansetron is not appropriate, low dose olanzapine may be beneficial. This of course needs to be under supervision and the risk of extrapyramidal side effects discussed.

DRUG	PRN DOSE	CSCI DOSE
Cyclizine	50mg PO/SC TDS	150mg
Ondansetron	4mg PO/SC TDS	16mg-24mg
Domperidone	10mg PO TDS	UNAVAILABLE
Haloperidol*	1.5mg-3mg PO ON 0.5mg SC 4 hourly	2.5mg-5mg
Levomepromazine*	6mg-12.5mg PO TDS 6.25mg SC 4 hourly	6.25mg-25mg
Metoclopramide*	10mg PO/SCTDS	30mg-60mg
Hyoscine butylbromide	20mg PO/SC QDS	60mg-120mg
Hyoscine hydrobromide	150-300mcg TDS 300mcg/hr patch 400mcg SC TDS	400mcg-1200mcg
Prochlorperazine*	5mg-10mg PO TDS 12.5mg IM BD	Not available SC in UK
Olanzapine	2.5mg-5mg PO ON	Not available SC in UK