6. Nausea and Vomiting Treatment Overview

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Questions and Answers

Which of the following is a common side effect associated with Dronabinol?

  • Diarrhea
  • Increased pain
  • Reduced cognitive processes
  • Appetite enhancement (correct)

What is the primary mechanism of action of Dronabinol at the receptor level?

  • Inverse agonist at CB1R
  • Antagonist at CB2R
  • Strong full agonist at CB1R
  • Weak partial agonist at CB1R and CB2R (correct)

Which of the following best describes the classification of an Anthracycline and cyclophosphamide (AC) regimen in terms of emetogenicity?

  • Low emetic risk
  • Non-emetogenic
  • Moderate emetic risk
  • Highly emetic risk (correct)

What is a paradoxical and rare condition associated with long-term and daily cannabis use, characterized by severe vomiting?

<p>Cannabinoid hyperemesis syndrome (B)</p> Signup and view all the answers

Besides its action at the CB1R and CB2R receptors, what is another proposed mechanism of action of dronabinol in the context of nausea and vomiting?

<p>Inhibition of endorphins in the emetic center (C)</p> Signup and view all the answers

Which of the following best describes the mechanism of action of ondansetron in the treatment of nausea and vomiting?

<p>Selective antagonist of the serotonin 5-HT3 receptor subtype. (A)</p> Signup and view all the answers

A patient experiencing nausea and vomiting also presents with extrapyramidal symptoms. Which antiemetic drug class is most likely the cause of these symptoms?

<p>D2 receptor antagonists. (A)</p> Signup and view all the answers

A patient with persistent nausea and vomiting due to gastroparesis would most likely benefit from which medication?

<p>Metoclopramide. (D)</p> Signup and view all the answers

Which of the following is a common side effect associated with the use of scopolamine?

<p>Mydriasis. (B)</p> Signup and view all the answers

A patient is vomiting due to activation of which receptors in the vomiting center?

<p>H1 receptor, M1 receptor, NK1 receptor, 5-HT3 receptor (B)</p> Signup and view all the answers

Which of the following medications is most likely to be prescribed for a patient experiencing nausea and vomiting secondary to chemotherapy?

<p>Aprepitant (D)</p> Signup and view all the answers

A patient who has overdosed on an antihistamine presents with delirium, hallucinations, and agitation. What is the most appropriate interpretation?

<p>This presentation is consistent with an overdose of an antihistamine. (B)</p> Signup and view all the answers

Which of the following best describes the role of enterochromaffin cells in the nausea and vomiting response?

<p>They release serotonin, which activates 5-HT3 receptors on vagal afferent nerves. (A)</p> Signup and view all the answers

A patient with motion sickness is looking for a medication to help alleviate symptoms. Which of the following would be the most appropriate choice?

<p>Cinnarizine (A)</p> Signup and view all the answers

What occurs during the ‘retch’ phase of the vomiting process?

<p>Rhythmic action of respiratory muscles against a closed glottis. (B)</p> Signup and view all the answers

A patient has severe vomiting and develops metabolic alkalosis. How did the vomiting likely cause this?

<p>Loss of hydrogen ions. (C)</p> Signup and view all the answers

Which of the following antiemetic agents is associated with a risk of QT interval prolongation?

<p>Ondansetron. (B)</p> Signup and view all the answers

A patient is taking ondansetron and is experiencing severe constipation. What could be a possible reason for this?

<p>It is a common and expected side effect of ondansetron. (A)</p> Signup and view all the answers

Which of the following is a major target for Scopolamine?

<p>Muscarinic Acetylcholine Receptors (D)</p> Signup and view all the answers

What is the primary mechanism of action of aprepitant in preventing nausea and vomiting?

<p>Blocking substance P/neurokinin 1 (NK1) receptors. (A)</p> Signup and view all the answers

Which factor is most associated with an increased risk of postoperative nausea and vomiting (PONV), according to the information provided?

<p>Female sex and laparoscopic surgery with anesthesia over 180 minutes (A)</p> Signup and view all the answers

In the context of nausea and vomiting, which of the following is considered a common cause arising from the intraperitoneal region?

<p>Motility dysfunctions (B)</p> Signup and view all the answers

According to the table, which of the following would be classified as an extra-peritoneal cause of nausea and vomiting?

<p>Depression (D)</p> Signup and view all the answers

Besides cancer treatment, what other cause of nausea and vomiting is explicitly listed as a metabolic disorder in the provided content?

<p>Malnutrition and anorexia (D)</p> Signup and view all the answers

Which of the following is most likely to cause nausea and vomiting by mechanisms that are classified as pharmacotherapy or other metabolic disorders, according to the table?

<p>Oral hypoglycemic agents (B)</p> Signup and view all the answers

What is the initial physiological change that allows gastric contents to be propelled into the esophagus during emesis?

<p>Relaxation of the lower esophageal sphincter. (A)</p> Signup and view all the answers

Which of the following best describes the recommended approach for antiemetic administration when treating recurrent vomiting?

<p>Administer antiemetics regularly, rather than on an as-needed basis. (C)</p> Signup and view all the answers

Besides the vomiting center, where else are 5-HT3, NK1, and dopamine receptors found that play a key role in emesis?

<p>The afferent fibers of the vagus nerve in the Chemoreceptor Trigger Zone. (A)</p> Signup and view all the answers

Why is it recommended to use one antiemetic agent first, prior to adding a second agent?

<p>To observe the side effects of a single drug and avoid interactions. (A)</p> Signup and view all the answers

What is the primary information gathered during initial assessment of a patient presenting with nausea and vomiting?

<p>A focused history and physical examination to identify the etiology. (C)</p> Signup and view all the answers

Which of the following neurotransmitter receptors is NOT a target of Cinnarizine?

<p>Serotonin 5-HT3 receptor (A)</p> Signup and view all the answers

Dimenhydrinate is indicated for the treatment of which condition?

<p>Nausea, vomiting and vertigo of motion sickness (A)</p> Signup and view all the answers

Which of the following receptor types is NOT directly associated with the integration phase of emetic stimulus processing?

<p>Muscarinic (C)</p> Signup and view all the answers

Which type of antagonist is shared between Cinnarizine and Dimenhydrinate?

<p>Histamine H1 receptor antagonist (D)</p> Signup and view all the answers

A patient experiencing nausea and vomiting related to motion sickness would likely benefit from a drug that targets which of the following pathways?

<p>Labyrinth, vestibular nuclei, H1, and mACh receptors (B)</p> Signup and view all the answers

Which of the following best describes the primary effect of Aminoglycosides as presented in the diagram?

<p>Affects the inner ear in relation to motion (D)</p> Signup and view all the answers

Which of the following mechanisms represents the effect of emetics such as Opioids, Cholinomimetics, and L-DOPA?

<p>Stimulating the blood-borne emetic system (C)</p> Signup and view all the answers

Which of these antiemetic drugs functions primarily as a neurokinin antagonist?

<p>Aprepitant (A)</p> Signup and view all the answers

A medication targeting the 5-HT3 receptor would be MOST effective for which of the following causes of nausea and vomiting?

<p>Endogenous toxins or drugs (D)</p> Signup and view all the answers

What is the main difference between first and second generation H1 receptor antagonists, as explained in the context of Cinnarizine and Dimenhydrinate?

<p>First generation agents are sedating (A)</p> Signup and view all the answers

According to the provided diagrams, what is the common effect of both Cinnarizine and Dimenhydrinate on the cerebellum?

<p>Act on both Muscarinic and Histamine receptors (B)</p> Signup and view all the answers

In the context of antiemetic treatment, where do granisetron and ondansetron exert their effect beyond the solitary tract nucleus?

<p>Esophagus and stomach (C)</p> Signup and view all the answers

A patient is experiencing vertigo and vestibular symptoms. Which of the following drugs would be MOST appropriate to treat the symptoms?

<p>Cinnarizine (D)</p> Signup and view all the answers

Which of the following areas or signals does NOT directly contribute to the vomiting reflex according to the information provided?

<p>Sensory Input of pain (D)</p> Signup and view all the answers

Which of the following drug classes is LEAST associated with the direct input stage of the emetic pathway as it is defined in the text?

<p>Dopamine receptor antagonists (C)</p> Signup and view all the answers

A patient undergoing cancer chemotherapy is experiencing severe nausea and vomiting. Based on the text, activation of which of the following receptors is LEAST likely to be involved?

<p>H1 receptors (B)</p> Signup and view all the answers

What is the primary mechanism of action of cinnarizine in reducing blood viscosity?

<p>Blocking calcium entry into red blood cells, increasing their flexibility. (A)</p> Signup and view all the answers

Which of the following describes the dual mechanism of action of Dimenhydrinate?

<p>Anticholinergic and antihistaminic properties. (C)</p> Signup and view all the answers

How does cinnarizine exert its anti-vasoconstrictor effect?

<p>By blocking the entry of calcium into smooth muscle cells, preventing contraction. (C)</p> Signup and view all the answers

A patient presents with symptoms of delirium, hallucinations, and violence after an overdose. Which medication is most likely the cause?

<p>Dimenhydrinate (B)</p> Signup and view all the answers

Which primary receptor type is targeted by ondansetron to prevent nausea and vomiting?

<p>Serotonin 5-HT3 receptors (C)</p> Signup and view all the answers

Which of these is NOT primarily a mechanism of action of cinnarizine?

<p>Anticholinergic properties affecting nausea and vomiting. (A)</p> Signup and view all the answers

Which structure is NOT directly part of the labyrinth?

<p>Superior vestibular nucleus (C)</p> Signup and view all the answers

A person taking an anti-vertigo medication reports experiencing drowsiness, headache, and nausea. Which of the following medications is most likely the culprit?

<p>Cinnarizine (C)</p> Signup and view all the answers

Aprepitant is thought to modulate the effects of chemotherapeutic agents primarily within which area?

<p>Central nervous system (B)</p> Signup and view all the answers

Which of the following best describes the mechanism of action of dronabinol at Cannabinoid receptors?

<p>Partial agonist activity (C)</p> Signup and view all the answers

Which of the following is NOT an identified target receptor within the Chemoreceptor Trigger Zone (Area Postrema)?

<p>NK1 receptors (B)</p> Signup and view all the answers

Which of the following is NOT a blood-borne emetic listed?

<p>Aminoglycosides (B)</p> Signup and view all the answers

Beyond its action on cannabinoid receptors, dronabinol's action against nausea and vomiting is proposed to involve which of the following?

<p>Inhibition of endorphins in the emetic center, suppression of prostaglandin synthesis, and/or inhibition of medullary activity through a cortical action (C)</p> Signup and view all the answers

Which of the following is NOT considered a local irritant that can induce vomiting?

<p>Cardiac Glycosides (D)</p> Signup and view all the answers

Which of the following pathways or receptors listed is directly associated with the mechanism of action of Aprepitant, according to the diagram?

<p>NK-1 receptor (B)</p> Signup and view all the answers

Which of the following accurately describes the metabolic pathway of Dronabinol?

<p>Extensive hepatic metabolism via cytochrome P450 (C)</p> Signup and view all the answers

Flashcards

Dronabinol (Marinol)

A synthetic form of delta-9-tetrahydrocannabinol, the primary psychoactive component of cannabis. It acts as a weak partial agonist at both CB1R and CB2R receptors, producing effects similar to smoking cannabis.

Cannabinoid Hyperemesis Syndrome

A rare condition in long-term cannabis users characterized by severe and repeated episodes of vomiting. It can lead to dehydration, electrolyte imbalances, and even death.

Cannabinoids

A family of chemical compounds found in cannabis plants, including THC and CBD, with diverse effects on the body.

Metabolism

Refers to the body's ability to process and eliminate drugs and toxins.

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CB1R and CB2R Agonist

Drugs that specifically target and activate cannabinoid receptors in the body, like CB1R and CB2R.

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Nausea

The unpleasant feeling of impending vomiting, often accompanied by pallor and increased salivation.

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Vomiting

The forceful expulsion of stomach contents, often accompanied by sweating and a feeling of relief.

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Enterochromaffin cells

A group of cells in the lining of the digestive tract that release serotonin, a chemical messenger involved in triggering the vomiting reflex.

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5-HT3 receptor

A type of receptor on vagal afferent nerves that is activated by serotonin, leading to the initiation of the vomiting reflex.

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Vomiting center

The area in the brainstem that controls the vomiting reflex, receiving signals from various parts of the body.

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Pre-expulsion

A phase of the vomiting process where the stomach relaxes and food moves backward, preparing for expulsion.

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Retch

A phase of the vomiting process where the respiratory muscles contract rhythmically, building pressure in the stomach.

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Expulsion

A phase of the vomiting process where the abdominal muscles contract and the esophageal sphincter relaxes, expelling the stomach contents.

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5-HT3 antagonists

Drugs that block the action of serotonin at 5-HT3 receptors, effectively reducing nausea and vomiting.

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D2 receptor antagonists

Drugs that block the action of dopamine at D2 receptors, reducing nausea and vomiting.

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NK1 receptor antagonists

Drugs that block the action of substance P at NK1 receptors, reducing chemotherapy-induced nausea and vomiting.

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Antihistamines

Antihistamines, a class of drugs that block the action of histamine, a chemical that can cause various reactions including nausea and vomiting.

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Anticholinergics

Belladonna alkaloids with anticholinergic effects, primarily used to treat motion sickness and prevent postoperative nausea and vomiting.

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Hypokalemia

A condition characterized by low blood potassium levels, commonly occurring due to severe vomiting.

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Metabolic alkalosis

A condition characterized by an imbalance in the body's acid-base balance, often resulting from loss of hydrogen ions due to vomiting.

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Chemotherapy-induced nausea and vomiting

Nausea and vomiting are a common and distressing side effect of cancer treatment, affecting up to 80% of patients.

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Intraperitoneal causes of nausea and vomiting

This category includes disorders that affect areas within the abdominal cavity, such as the stomach, intestines, and pancreas.

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Extra-peritoneal causes of nausea and vomiting

This category includes disorders that affect areas outside the abdominal cavity, such as the heart, brain, and vestibular system.

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Pharmacotherapy and other metabolic disorders causing nausea and vomiting

This category includes conditions and substances that directly interfere with the body's functions, like drugs or hormonal imbalances.

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Abandonment of antineoplastic treatment due to nausea and vomiting

A serious complication of chemotherapy that can lead to patients discontinuing their treatment, potentially hindering their recovery.

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Chemoreceptor Trigger Zone (CTZ)

A collection of specialized cells located in the medulla oblongata that detect changes in blood chemistry and trigger vomiting.

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What is the Vomiting Center?

The area in the brainstem that controls the vomiting reflex, receiving signals from various parts of the body.

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What are Enterochromaffin cells?

A group of cells in the lining of the digestive tract that release serotonin, a chemical messenger involved in triggering the vomiting reflex.

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What are 5-HT3 antagonists?

Drugs that block the action of serotonin at 5-HT3 receptors, effectively reducing nausea and vomiting.

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What are D2 receptor antagonists?

Drugs that block the action of dopamine at D2 receptors, reducing nausea and vomiting.

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What are NK1 receptor antagonists?

Drugs that block the action of substance P at NK1 receptors, reducing chemotherapy-induced nausea and vomiting.

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What is Cannabinoid Hyperemesis Syndrome?

A rare condition in long-term cannabis users characterized by severe and repeated episodes of vomiting.

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What is Dronabinol (Marinol)?

A synthetic form of delta-9-tetrahydrocannabinol, the primary psychoactive component of cannabis. It acts as a weak partial agonist at both CB1R and CB2R receptors, producing effects similar to smoking cannabis.

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What are Cannabinoids?

A class of chemical compounds found in cannabis plants, including THC and CBD, with diverse effects on the body.

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What is Cinnarizine?

Cinnarizine is a medication used to treat motion sickness and dizziness. It blocks histamine receptors and calcium channels, decreasing the signals that cause nausea and dizziness.

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What is Dimenhydrinate?

Dimenhydrinate is a combination medicine that contains diphenhydramine and theophylline. It's used to prevent and treat motion sickness, nausea, and vomiting. It works by blocking histamine receptors.

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How are Cinnarizine and Dimenhydrinate similar?

Cinnarizine and Dimenhydrinate both work by blocking histamine receptors. They both help to reduce nausea and dizziness, but have slight differences.

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What class of antihistamines are Cinnarizine and Dimenhydrinate?

Cinnarizine and Dimenhydrinate are both known as 'first generation' antihistamines because they also have a sedative effect.

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What other mechanism of action does Cinnarizine have?

Cinnarizine blocks the action of calcium channels, which play a role in muscle contraction and nerve signaling. Blocking these channels reduces the signals that cause nausea and dizziness.

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How does Dimenhydrinate work?

Dimenhydrinate blocks histamine receptors which are involved in allergic reactions and also play a role in regulating the brain's response to nausea and dizziness.

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What's a side effect of Cinnarizine and Dimenhydrinate?

Some antihistamines like Cinnarizine and Dimenhydrinate have sedative effects. This means that they can make you feel drowsy or sleepy.

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Is there a class of antihistamines that don't cause drowsiness?

While some antihistamines have a sedative effect, others are known as 'second generation' antihistamines because they have a lesser sedative effect.

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Dronabinol's mechanism of action

The ability of dronabinol to activate cannabinoid receptors, specifically CB1 and CB2.

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Cannabinoid receptors (CB1 and CB2)

A group of receptors in the brain and peripheral nervous system involved in various processes, including appetite, pain perception, and mood.

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Dronabinol Metabolism

The process by which the body breaks down and eliminates drugs, like dronabinol.

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Cytochrome P450

A specific enzyme primarily responsible for breaking down dronabinol in the liver.

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Adverse effects of dronabinol

A potential issue with using dronabinol.

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Dronabinol Indications (uses)

Using dronabinol to treat conditions like anorexia in AIDS patients or nausea and vomiting from chemotherapy.

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Cinnarizine and Dimenhydrinate: Antihistamine and Calcium Channel Blocker

Cinnarizine and Dimenhydrinate are antihistamine and calcium channel blocker drugs that primarily work against motion sickness and vertigo. They are used to manage nausea, vomiting, and dizziness associated with various conditions.

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Cinnarizine's Anti-vasoconstrictor and Blood Viscosity Effects

Cinnarizine inhibits the influx of calcium ions into smooth muscle cells, preventing vasoconstriction. It also impacts red blood cells, improving their flexibility and reducing blood viscosity, leading to better microcirculation.

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Cinnarizine's Calming Effect on the Vestibular Labyrinth

Cinnarizine affects the vestibular hair cells by blocking calcium channels, preventing the release of neurotransmitters and reducing firing frequency, effectively calming the vestibular labyrinth.

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Ondansetron: A Serotonin 5-HT3 Antagonist

Ondansetron, a serotonin 5-HT3 antagonist, effectively blocks the action of serotonin at 5-HT3 receptors, preventing nausea and vomiting associated with various conditions such as chemotherapy and surgery.

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Dimenhydrinate: Anticholinergic and Antihistamine Properties

Dimenhydrinate is a drug with anticholinergic and antihistamine properties. It acts centrally, affecting the vestibular nuclei to control vertigo and the brainstem to manage nausea and vomiting.

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Cinnarizine: Calcium Antagonist Affecting the Labyrinth and Circulation

Cinnarizine possesses calcium antagonist properties, affecting the labyrinth (inner ear) and improving cerebral circulation. It helps manage vertigo and dizziness by reducing the signals from the inner ear to the brain.

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Cinnarizine and Dimenhydrinate: Dual Mechanism of Action

Cinnarizine and Dimenhydrinate work through a dual mechanism of action. Cinnarizine targets the labyrinth, while Dimenhydrinate focuses on the vestibular nuclei and brainstem.

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Ondansetron: A Selective 5-HT3 Receptor Antagonist

Ondansetron is a selective antagonist for 5-HT3 receptors, blocking the action of serotonin and effectively preventing nausea and vomiting caused by various reasons, including chemotherapy and surgery.

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Study Notes

Nausea and Vomiting Treatment

  • Nausea is an unpleasant sensation associated with an imminent urge to vomit, characterized by cutaneous pallor and sialorrhea (increased saliva). It is triggered by serotonin (5-HT) release from enterochromaffin cells in the digestive tract lining. Serotonin activates 5-HT3 receptors on vagal afferent nerves, signaling the vomiting reflex in the solitary tract nucleus and chemoreceptor trigger zone (CTZ).

  • Vomiting (emesis) is the violent expulsion of stomach contents, often accompanied by diaphoresis (sweating). It involves a coordinated series of contractions in the stomach, esophagus, and abdominal/respiratory muscles.

Causes of Nausea and Vomiting

  • Intraperitoneal Causes: Infections (pylorus, duodenum, colon, enteric infections), inflammatory bowel disease, motility disorders.

  • Extraperitoneal Causes: Cardiovascular conditions (myocarditis, infarction), motion sickness (kinetosis), cancer, hemorrhages, abscesses, hydrocephalus, eating disorders (anorexia nervosa, bulimia), psychological factors, depression, metabolic disorders (uremia, ketoacidosis), pregnancy, hepatic insufficiency, alcohol, radiation therapy, and chemotherapy.

  • Pharmacotherapy/Other: Chemotherapy agents, oral hypoglycemic agents, oral contraceptives, pregnancy, hepatic insufficiency, alcohol, and radiation therapy.

Vomiting Center

  • The vomiting center is located in the nucleus of the tractus solitarius.
  • It coordinates the intricate process of vomiting, involving contractions of the pharynx, gastrointestinal tract, and abdominal muscles, to expel stomach contents.
  • The center can be stimulated by signals from the gut, chemoreceptor trigger zone (CTZ), cerebral cortex, and vestibular system.

Phases of Vomiting

  • Pre-expulsion: Gastric relaxation and retrograde peristalsis (reverse movement).
  • Retching: Rhythmic action of respiratory muscles (contraction of abdominal and intercostal muscles, diaphragm) against a closed glottis to increase intra-gastric pressure.
  • Expulsion: Intense abdominal muscle contraction and relaxation of the upper esophageal sphincter, thereby expelling the stomach contents.

Treatment

  • A thorough medical history and physical examination are essential to pinpoint the underlying cause.
  • Treat the underlying disease or condition inducing nausea and vomiting.
  • Correct metabolic imbalances (e.g., hypokalemia, hypochloremia, metabolic alkalosis).
  • Administer targeted antiemetic therapy based on the cause.

Antiemetic Therapy

  • 5-HT3 Receptor Antagonists (Ondansetron, Granisetron): Block serotonin receptors, primarily used for chemotherapy-induced nausea and vomiting (CINV), postoperative nausea and vomiting (PONV), and radiation therapy-induced emesis. Potential side effects include headache, constipation, QT interval prolongation, and serotonin syndrome.

  • D2-receptor antagonists (Prochlorperazine, Metoclopramide): Block dopamine receptors and in the case of Metoclopramide, increase gastric emptying and lower esophageal sphincter (LES) tone. Used for nausea and vomiting, and gastroparesis (e.g., diabetic gastroparesis), and persistent GERD. Side effects can include extrapyramidal symptoms, hyperprolactinemia, anxiety, drowsiness, restlessness, depression, and GI distress.

  • NK1 Receptor Antagonists (Aprepitant, Fosaprepitant): Block substance P/neurokinin 1 receptors, primarily used for CINV. Side effects include fatigue and gastrointestinal distress.

  • H1 Receptor Antagonists (Cinnarizine, Dimenhydrinate): Block histamine receptors, utilized for motion sickness, nausea, and vomiting prevention and treatment. Side effects include drowsiness, fatigue, parkinsonian symptoms, and headache. Overdose can cause delirium, hallucinations, and violence.

  • Serotonin 5-HT3 antagonists (Ondansetron—Palonosetron): These are selective serotonin receptor antagonists, used for CINV, PONV. They can cause QT interval prolongation. Overdose cases in Ondansetron are associated with "sudden blindness" (amaurosis).

  • Anticholinergic drugs (Scopolamine): Block acetylcholine receptors, often used as a skin patch for motion sickness and PONV prevention. Side effects include dry mouth, dizziness, drowsiness, agitation, dilated pupils, and low blood pressure.

  • Neurokinin Antagonists (Aprepitant): Block substance P receptors (NK1), particularly used for CINV. Side effects include fatigue, anorexia, and various gastrointestinal symptoms.

  • Cannabinoids (Dronabinol): Synthetic THC, used for anorexia in AIDS patients and CINV. Side effects include headache, nausea, appetite changes, pain reduction, and cognitive changes. Cannabinoid hyperemesis syndrome is a rare, adverse reaction to chronic cannabis use, leading to severe vomiting and dehydration.

Chemotherapy-Induced Nausea and Vomiting (CINV) Treatment Strategies

  • Various risk categories (low, moderate, high) of emetogenicity exist in chemotherapy. Treatment strategies are adjusted based on the risk profile.
  • Strategies incorporate multiple antiemetic classes for effective prevention.

Treatment During Pregnancy

  • H1 antagonists are considered a safe option for nausea and vomiting.
  • Doxylamine, with pyridoxine, and Meclizine are used for vertigo and morning sickness during pregnancy.

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