10 Nausea and Vomiting.docx
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Nausea and Vomiting Pharmacotherapy Learning Objectives Describe treatment and prevention strategies for simple (including motion sickness) and pregnancy-induced nausea and vomiting (pharmacologic and nonpharmacologic recommendations) Recommend appropriate prophylactic and treatment regimen for pos...
Nausea and Vomiting Pharmacotherapy Learning Objectives Describe treatment and prevention strategies for simple (including motion sickness) and pregnancy-induced nausea and vomiting (pharmacologic and nonpharmacologic recommendations) Recommend appropriate prophylactic and treatment regimen for postoperative and chemotherapy-induced nausea and vomiting Construct a monitoring plan to assess for benefit, adverse effects, and toxicity from antiemetic drug therapy Pathophysiology Overview Goals of Treatment Prevent or eliminate nausea/vomiting Avoid adverse effects Limit cost Approaches to Treatment Non-Pharmacologic Treatment Dietary Avoidance of trigger food Moderation of dietary intake Food diary Physical Assume a stable physical position Resolution of systemic illness Psychological Relaxation Hypnosis Yoga Acupuncture Choosing a Pharmacologic Agent Suspected etiology Frequency, duration, and severity of episodes Ability to use enteral (oral) route Success of previous antiemetic medication use Pharmacologic Treatment Targets Histamine Histamine-1 Receptor Antagonist Useful for nausea and vomiting associated with vertigo and motion sickness Serotonin 5HT3 Receptor Antagonist Useful for acute simple, CINV, and PONV Dopamine Butyrophenones Useful as breakthrough therapy for CINV Phenothiazine Useful in simple and low emetogenic CINV Neurokinin-1 NK1 Receptor Antagonist Useful in CINV and PONV GI Tract Histamine-2 Receptor Antagonist Useful in simple nausea and vomiting related to reflux Other GI Tract Agents Useful in simple nausea and vomiting related to reflux or gastroparesis Miscellaneous Cannabinoids Useful in refractory CINV Benzodiazepine Useful in anticipatory nausea and vomiting Other Miscellaneous Useful in breakthrough CINV and prophylaxis Pharmacologic Treatment Common Types of Nausea and Vomiting Simple Pregnancy CINV RINV PONV Simple Nausea/Vomiting OTC Antacids Anti-histamines Rx Usually unnecessary Can use any of the agents PRN Pregnancy-Induced Nausea/Vomiting Dietary/lifestyle modifications and non-pharmacologic options preferred treatment Chemotherapy-Induced Nausea/Vomiting (CINV) CINV Phases Chemotherapy Regimen Emetic Risk High Emetic Risk (>90%) Moderate Emetic Risk (30-90%) Low Emetic Risk (10-30%) Prior to chemotherapy (choose 1) Dexamethasone 8-12 mg PO/IV Metoclopramide 10-20 mg PO/IV, then q4-6 hours PRN Prochlorperazine 10 mg PO/IV, then q4-6 hours PRN 5-HT3 Antagonist Breakthrough CINV Agents for Breakthrough CINV Anticipatory CINV Radiation Induced Nausea/Vomiting (RINV) Post-Operative Nausea/Vomiting (PONV) PONV PONV Prophylaxis Pearls: 5-HT3 and dexamethasone have the most evidence Ondansetron are considered the “gold standard” Droperidol also has evidence, but need to watch for adverse effects Other agents may be effective PONV Treatment Rescue therapy with another MoA Do not repeat drug given for prophylaxis within 6 hours Do not repeat scopolamine or dexamethasone Key Takeaways Simple nausea/vomiting if often self-limiting and will often be treated with OTC options ACOG guidelines have a great pregnancy-induced nausea/vomiting algorithm (see slide 33) CINV agents and timing depends on the emetic risk of the chemotherapy The number of agents for PONV depends on the number of patient- and anesthesia-related risk factors The choice of antiemetic agent depends largely on the etiology of the nausea/vomiting
