P&T Nausea & Vomiting
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- Nausea is the unpleasant feeling or sensation that may be immediately followed by vomiting
- Vomiting is the expulsion of gastric content. This is NOT voluntarily controlled
- Retching is the movement of abdominal and thoracic muscles before vomiting.
Which 4 areas provide input to vomiting center?
Involves Brain and GI.
- Chemoreceptor trigger zone, with neurotransmitters dopamine and serotonin.
- Vestibular apparatus
- Cerebral cortex
- Visceral GI tract afferent nerves
Of the 4 areas that provide input to the vomiting center, which is the most important with regards to where drugs will act/affect?
Chemoreceptor trigger zone (CTZ)
Hypercalcemia can cause nausea and vomiting.
What are the 2 main etiologies for nausea and vomiting?
Drug Induced : Opioid family, narcotics (Primary reason), cardiac glycosides, Broncodilators (digoxin, theophylline), antibiotics
Medical conditions: Fluid & electrolyte disorders, pregnancy, GI obstruction, Increase Intracranial pressure, Surgery, peritonitis, dysfunctional bowel syndrome, metastasis, etc.
What are some possible acute complications from N&V?
- 1) Dehydration
- 2) Aspiration
- 3) Malnutrition
- 4) Electrolyte or acid/base abnormalities
- 5) Esophageal tears
What is the ultimate goal of therapy for N&V?
To determine the cause and use of the most appropriate agent(drug)
- Example: Gastroenteritis is due to food eaten. Usually short lived, can use compazine.
- CINV: can be severe. Always pre-treat, continue for 24-72 hrs after therapy
True/False: Post operative nausea and vomitting (PONV) is more common in adults than children.
- 2x higher in children than adults.
List risk factors for PONV in adults (5):
- 1.) Female
- 2.) Non-smoker
- 3.) Family Hx of motion sickness/PONV
- 4.) Long surgeries (2-3 hrs) OR use of nitrous oxide
- 5.) Post-operative use of opioids
True/False: Prophylaxis vs. treatment therapies are different for N&V.
What are the three broad categories to examine as causes of N&V?
- 1.) Dietary
- 2.) Physical
- 3.) Pscyhological
List the seven non-pharmacological therapies for N&V.
- 1.) Relaxation
- 2.) Biofeedback (?)
- 3.) Self hypnosis
- 4.) Cognitive distraction
- 5.) Guided imagery
- 6.) Systematic desensitization
- 7.) Accupressure therapy
What are the 4 categories of drugs that treat N&V?
- 1.) 5 HT3 receptor antagonists (serotonin antagonists)
- 2.) Anticholinergics (including antihistamines)
- 3.) Antidopaminergics (including phenothiazines)
- 4.) Misc.
What drugs are included in the class of phenothiazines?
- 1.) prochlorperazine (Compazine)*
- 2.) chlorpromazine (Thorazine)
- 3.) thiethylperazine (Torecan)
- 4.) promethazine (Phenergan)
What is the PO dosing for prochlorperazine (Compazine)?
5-10 mg PO q 4-6 hrs
What is the IM dose for prochlorperazine (Compazine)?
5-10 mg IM q 3-4 hrs
What is the IV dose of prochlorperazine (Compazine)?
2.5 - 10 mg IV q 3-4 hrs
What is the rectal dose of prochlorperazine (Compazine)?
25 mg rectally q 6 hrs
List adverse effects of the phenothiazines (dopamine blockers):
- - Sedation (most common)
- - anticholingeric effects
- - alpha adrenergic blocking effects
- - EPS
What is the black box warning for promethazine (Phenergan)?
Do not use in children under 2 years of age.
True/False: Phenergan can be administered IV.
Use caution --> very caustic to tissues, must be diluted, and administered only into a large vein or central venous site.
Start with a low dose = 6.25 - 12 mg over 10 -15 mins.
Which phenothiazine may be used for PONV?
What classes of drugs are categorized as anti-dopaminergics (dopamine blockers)?
- 1.) phenothiazines
- 2.) butyrophenones
- 3.) benzamides
What are symptoms of EPS?
Who is at highest risk?
- - muscle spasms
- - restlessness
- - gait disturbances
*Children and elderly patients*
What 2 drugs are classified as butyrophenones?
- 1.) haloperidol (Haldol)
- 2.) droperidol (Inapsine)
True/False: haloperidol is a common drug used to treat N&V.
- Used only when other treatments fail.
List the adverse effects for the butyrophenones:
- - sedation
- - somnolence (drowsiness/sedation)
- - dystonic reactions (movement disorder)
What is the black box warning associated with the butyrophenones?
QT prolongation or Torsades de pointes may occur.
What is the only use for droperidol?
Only used in cases pre-operative anaesthesia.
What is the only drug classified as a Benzamide?
True/False: metoclopramide is both a dopamine and serotonin blocker
- Its a serotonin blocker at higher doses
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What are the main side effects of metoclopramide (Reglan)?
With what population is metoclopramide never used and why not?
Children. Due to the risk of EPS
What corticosteroid can be used for N&V?
dexamethasone (Decadron) - used on a short-term basis
When is dexamethasone (Decadron) used for N&V?
Its used as a last resort, but routinely used in CINV.
Serotonin antagonists block what kind of receptors?
What are the 4 Serotonin antagonists used for N&V?
- 1.) ondansetron (Zofran) **Need to know dosing
- 2.) granisetron (Kytril)
- 3.) dolasetron (Anzemet)
- 4.) palonosetron (Aloxi)
True/False. Ondansetron has no clinical advantage over other SSRI's.
What are the dosage forms and strengths for ondansetron (Zofran)?
- Tablet - 4, 8 and 24 mg
- Oral disintegrating - 4 and 8 mg
- Solution - 4mg/5ml
- Injection - 2 mg/ml and 32 mg/50 ml
When is ondansetron used for N&V?
- 1.) IV 4 mg usually given for pre-op (1 dose)
- 2.) PONV: 4 mg IV/IM before induction of anesthesia or at onset of N/V
- 3.) Chemo-induced
- a) by mouth 8-32 mg BID-TID
- b) IV: three 0.15 mg/kg doses (1/2 pre, then 4 & 8 hrs post) or single 32 mg dose
True/False. Headache is the most common side effect for ondansetron.
What are the rare side effects of ondansetron?
Elevation in liver transaminases, constipation, diarrhea or QT interval prolongation
Name the drug that is a neurokinin receptor antagonist (selective antagonist of substance P).
What are the indications for metoclopramide (Reglan)?
- - CINV
- - PONV
- - Post-operative gastric motility
What is/are the indications for aprepitant (Emend)?
aprepitant is ONLY used for CINV.
Why must women taking aprepitant (Emend) use a another form of birth control pills use another form of contraception?
aprepitant (Emend) inhibits CYP3A4, reducing the efficacy of oral birth control pills.
What drugs fall under the class of antihistamines used for N&V?
- - diphenhydramine (Benadryl)
- - dymenhydrinate (Dramamine)
- - meclizine (Antivert)
- - trimethobenzamide (Tigan)
- - scopolamine (Transderm Scop)
True/False: the antihistamine class of drugs are generally ineffective at treating N&V, unless it is associated with motion sickness.
What are common side effects of the antihistamines used for N&V?
- - Drowsiness/sedation
- - Dry mouth
- - Blurred vision
- - Children have a paradoxical experience (insomnia)
Which antihistamine is the exception to the rest, as it causes less sedation than compazine and may be used as an alternative to compazine should the drowsiness become a problem?
What drug is classified as a benzodiazepine?
What is/are the indications for lorazepam (Ativan)?
- Treatment for anticipated N&V.
- For example, as pre-chemotherapy treatment.
What is a common side effect of the benzodiazepines?
True/False: The cannabinoids are scheduled drugs.
What drugs are classified as cannabinoids?
- - dronabinol (Marinol)
- - nabilone (Cesamet)
What is the only indication for the cannabinoids?
What are the common side effects for the cannabinoids?
- - CNS effects
- - dizziness
- - dysphoria
- - mood & sensory changes
- - paranoid ideation
- - blurred vision
- - hypotension
- - tachycardia
What medications may be given as treatment for EPS / acute dystonic reactions?
*First ensure the patient has stable airway and respiratory activity
- - diphenhydramine
- 0.7-1 mg/kg/dose IV/PO q 4-6 hrs PRN
- - benztropine (Cogentin)
- 1-2 mg IV/PO q 4-6 hrs PRN (works faster)
True/False: Whenever possible, administer anti-emetics before N&V occur.
True/False: first-line treatment of N&V in pregnant women is compazine.
- Most cases are due to a deficiency in pyridoxine (Vit B6). Give this first. If N&V does not subside, consider anti-emetics.
What are some recommended medications for the treatment of CINV?
- - aprepitant (Emend)
- - dexamethasone (Decadron)
- - Serotonin 5 HT3 receptor antagonists
What are some recommended medications for the treatment of Gastroenteritis?
Gastroenteritis is short lived and self limiting, but can be treated with prochlorperazine (Compazine)
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