Nausea & Vomiting_student version-1.pdf

Nausea & Vomiting Integrated Disease Management I (PHRC 4931) Melissa Santibañez, Pharm.D., FCCM, BCCCP Assistant Professor, Critical Care Department of Pharmacy Practice Nova Southeastern University College of Pharmacy March 2024 Objectives Define nausea and vomiting and the etiologies associated P...

Nausea & Vomiting Integrated Disease Management I (PHRC 4931) Melissa Santibañez, Pharm.D., FCCM, BCCCP Assistant Professor, Critical Care Department of Pharmacy Practice Nova Southeastern University College of Pharmacy March 2024 Objectives Define nausea and vomiting and the etiologies associated Pregnancy considerations Post-operative considerations Recognize the clinical presentation of nausea and vomiting Gather subjective and objective information about the patient with nausea and vomiting in order to understand the relevant medical and medication history and clinical status of the patient 2 Physiology Review General digestion (1 minute): https://pharmacy-lwwhealthlibrarycom.ezproxylocal.library.nova.edu/multimediaPlayer.aspx?multim ediaid=6634110 Physiology of vomiting (8 minutes): https://www.youtube.com/watch?v=GSHTLWbwKgo 3 Overview of Emesis & Anti-Emetics 4 Definitions Nausea Inclination to vomit or a feeling in the throat or epigastric region alerting an individual that vomiting is imminent Vomiting Ejection or expulsion of gastric contents through the mouth 5 Etiologies Gastrointestinal Gastroparesis Gastroesophageal reflux (GERD) Irritable bowel syndrome (IBS) Infections Cardiovascular Metabolic Neurologic Drug-induced Module-specific Pregnancy Post-operative nausea/vomiting (PONV) 6 Clinical Presentation Simple: Queasiness, discomfort Requires only symptomatic therapy Self-limiting; spontaneous resolution Complex: Weight loss; fever; abdominal pain Not relieved after anti-emetics Patient progressively deteriorates Develops fluid-electrolyte imbalances Requires further GI evaluation 7 Overview of Anti-Emetics Antihistamines Diphenhydramine (Benadryl) Dimenhydrinate (Dramamine) Doxylamine (Unisom) Meclizine (Antivert, Bonine) Hydroxyzine (Vistaril) Promethazine (Phenergan) [both antihistamine + phenothiazine] Anticholinergics Scopolamine (Transderm Scop) Dopamine Receptor Antagonists Phenothiazines: Prochlorperazine (Compazine) Chlorpromazine (Thorazine) Metoclopramide (Reglan) Trimethobenzamide (Tigan) Haloperidol (Haldol) Droperidol (Inapsine) NK-1 Receptor Antagonists Aprepitant (Emend) 5-HT3 Antagonists Ondansetron (Zofran) Dolasetron (Anzemet) Granisetron (Sancuso) Palonosetron (Aloxi) Miscellaneous Antacids Steroids (e.g., dexamethasone, methylprednisolone) Cannabinoids Pyridoxine (vitamin B6) 8 Side Effects of Anti-Emetics Side Effects Anti-Emetics Sedation Antihistamines; Phenothiazines; Metoclopramide; Haloperidol, Droperidol Dry mouth Antihistamines; Scopolamine Constipation 5-HT3 antagonists; Phenothiazines; Haloperidol, Droperidol Hypotension Phenothiazines; Metoclopramide; Haloperidol, Droperidol Headache Lightheadedness 5-HT3 antagonists Aprepitant QT interval prolongation 5HT3 antagonists EXCEPT palonosetron Haloperidol; Droperidol 9 Goals of Therapy To prevent, lessen, or eliminate N/V regardless of the cause Minimize adverse effects of drug therapy for N/V 10 Pregnancy Considerations 11 N/V in Pregnancy Onset typically at 6 – 9 weeks gestation Resolves by 16 – 20 weeks “Morning sickness” Not accurately named May occur at any time of day Symptom severity: mild to incapacitating 0.3% – 3% develop hyperemesis gravidarum Persistent vomiting Requires hospitalization 12 Management of N/V in Pregnancy Prevention Start prenatal vitamin 1 month prior to pregnancy Nonpharmacologic Options Change prenatal vitamins to folic acid only supplement Ginger Dietary changes Frequent small meals every 1-2 hours Avoid spicy or fatty foods and other potential triggers 13 Management of N/V in Pregnancy Pharmacologic Options Add one of the following: 1st line therapy: Pyridoxine (Vitamin B6) ± Doxylamine Persistent Symptoms Dimenhydrinate PO* Diphenhydramine PO* Prochlorperazine PR Promethazine PO/PR * Discontinue pyridoxine/doxylamine before starting a different antihistamine 14 Management of N/V in Pregnancy Metoclopramide PO/IM Ondansetron PO Promethazine PO/PR/IM Persistent symptoms? Assess fluid status No dehydration Trimethobenzamide IM IV fluid replacement Dehydration Dimenhydrinate IV Metoclopramide IV Ondansetron IV Promethazine IV Persistent Symptoms Chlorpromazine IV/IM Methylprednisolone PO/IV 15 Steroids in Pregnancy Methylprednisolone Dose: 16 mg PO/IV TID x 3 days 2-week taper to lowest effective dose Max duration: 6 weeks May be beneficial in hyperemesis gravidarum Risk of oral clefts Avoid use before 10 weeks gestation 16 Question #1 MJ is a 32-year-old African-American female who is pregnant with her first child and nonpharmacologic therapies are no longer helping her nausea and vomiting. Which of the following is the recommended first-line therapy for the treatment of nausea and vomiting in a pregnant woman? a. Meclizine b. Ondansetron c. Doxylamine d. Metoclopramide 17 Post-Operative Considerations 18 Definitions PONV “Post-operative nausea/vomiting” Occurs in the post-anesthesia care unit (PACU) or in the immediate 24 hours after a procedure PDNV “Post-discharge nausea/vomiting” Occurs after ambulatory surgery 19 Risk Factors Patient-related risks Female gender Age < 50 years History of PONV and/or motion sickness Nonsmoking status Use of postoperative opioids Surgery-related risks Type of surgery (bariatric, cholecystectomy, laparoscopic, gynecological) General vs. regional anesthesia Use of volatile anesthetics and nitrous oxide Duration of anesthesia 20 APFEL Simplified Risk Score Gan TJ, Belani KG, Bergese S, et al. Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesth Analg 2020 Aug;131(2):411-448. 21 Risk Category Number of Risk Factors Percentage Risk Risk Category 0–1 10 – 20% Low risk 2–3 40 – 60% Moderate risk ≥4 80% High risk 22 Risk Stratification for Prophylaxis 1-2 risk factors Give 2 agents ≥3 risk factors Give 3-4 agents 23 Selected Agents for Prophylaxis Drug Timing of dose Scopolamine (transdermal patch) Evening prior or 2-4 hours prior to surgery Aprepitant (PO) Within 3 hours prior to induction of anesthesia Dexamethasone (IV) Methylprednisolone (IV) Promethazine (IV) Palonosetron (IV) Ondansetron (ODT, IV) Granisetron (IV) Haloperidol (IM, IV) Droperidol (IV) At induction of anesthesia At induction of anesthesia At induction of anesthesia End of surgery End of surgery 24 Recommended Combination therapy 5-HT3 antagonist + Dexamethasone 5-HT3 antagonist + Aprepitant 5-HT3 antagonist + Droperidol Aprepitant + Dexamethasone Haloperidol + Dexamethasone + Ondansetron *5-HT3 antagonists = Ondansetron, Granisetron, Palonosetron* 25 Failure of PONV Prophylaxis < 6 hours since initial prophylactic dose Administer antiemetic from a different class used in initial prophylaxis regimen Do not repeat dose of prophylactic antiemetic ≥ 6 hours since initial prophylactic dose May re-dose any antiemetic used for prophylaxis EXCEPT dexamethasone and scopolamine Repeat second dose of a shortacting antiemetic if no other options Ondansetron Droperidol / Haloperidol 26 No PONV Prophylaxis Administered If PONV develops at any point: Low dose 5-HT3 antagonist via any route Ondansetron Dexamethasone IV Droperidol IV Promethazine IV 27 Question #2 Which of the following is considered a risk factor for developing postoperative nausea and vomiting? a. Use of local anesthetics b. Positive smoking history c. History of motion sickness d. Age > 70 years old 28 References Gravatt L, Donohoe KL, DiPiro CV. Nausea and Vomiting. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach, 12e. New York, NY: McGraw-Hill Education, 2023. Kale-Pradhan P, Wilhelm S, McConachie S. Nausea and vomiting. PharmacotherapyFirst: A Multimedia Learning Resource. https://doiorg.ezproxylocal.library.nova.edu/10.21019/pharmacotherapyfirst.nv_overview. ACOG Practice Bulletin No. 189: Nausea and Vomiting of Pregnancy. Obstet Gynecol. 2018;131:e15-e30. Gan TJ, Belani KG, Bergese S, et al. Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesth Analg. 2020;131(2):411-448. doi: 10.1213/ANE.0000000000004833. 29 Nausea & Vomiting Integrated Disease Management I (PHRC 4931) Melissa Santibañez, Pharm.D., BCCCP Assistant Professor, Critical Care Department of Pharmacy Practice Nova Southeastern University College of Pharmacy Email: [email protected]