Objectives
review mechanisms/physiology of nausea and
vomiting
review possible causes of nausea/vomiting in
palliative patients
understand rationale behind selecting specific
antiemetics
develop a systematic approach to managing
nausea and vomiting
Definitions
Nausea - an unpleasant feeling of the need
to vomit
Vomiting - the expulsion of gastric contents
through the mouth, caused by forceful and
sustained contraction of the abdominal
muscles and diaphragm
50 - 60 %
30 %
Cortex
Sensory input
Anxiety, memory
Meningeal irritation
Increased ICP
GI
Vomiting
Center
VOMITING
serotonin release from mucosal
enterochromaffin cells
obstruction
stasis
inflammation
CENTRE
(Central Pattern
Generator)
Vestibular
motion
CNS lesions
opioids
aggravates most
nausea
Cortex
Sensory input
Anxiety, memory
Meningeal irritation
Increased ICP
Muscarinic
Serotonin
Neurokinin-1
Cannabinoid
Histamine
Dopamine
GI
Vomiting
Center
VOMITING
serotonin release from mucosal
enterochromaffin cells
obstruction
stasis
inflammation
CENTRE
(Central Pattern
Generator)
Vestibular
motion
CNS lesions
opioids
aggravates most
nausea
RECEPTOR ANTAGONISM
D2
H1
Ach
5HT
5HT
5H
T4
++
Metoclopramid
e
++
+
Domperidone
++
++
Haloperidol
++
++
Methotrimepr
azine
++
++
++
+
++
CPZ
++
++
++
Olanzapine
++
Prochlorperazi
ne
++
Dimenhydrinat
e
++
++
++
+
++
+
++
++
Ondansetron
+++
+
Granisetron
+++
CB1 +
2
NK1
Notes
NK1 Antagonists
(Aprepitant)
not approved outside of chemotherapy-induced emesis
Substance P - induces vomiting; binds to NK-1 receptors in
the abdominal vagus, the nucleus tractus solitarius, and the
area postrema
NK1 antagonists inhibit action of substance P in emetic
pathways in both the central and peripheral nervous systems
decrease emesis after cisplatin, ipecac, apomorphine, and
radiation therapy
combinations if necessary
Clinical Scenario
Mechanism
Chemotherapy
Sepsis; metabolic; renal
or hepatic failure
5HT3 antagonists;
metoclopramide; haloperidol;
methotrimeprazine
Opioid-Induced
Bowel obstruction
mechanical impasse
stimulation of CTZ
stimulation of gut stretch
receptors, peripheral
pathways
dexamethasone; octreotide;
metoclopramide if incomplete
obst; haloperidol
Radiation
stimulation of peripheral
pathways via 5HT3 released
from enterochromaffin cells
in gut
5HT3 antagonists
Brain tumor
raised ICP
aggravated by movement
dexamethasone;
dimenhydrinate
Motion-related
vestibular pathway
dimenhydrinate; scopolamine
Examples
metoclopramide 10 - 20 mg po/iv/sq/pr q4-8h
haloperidol 0.5 - 1 mg po/sq/iv q6-12h
prochlorperazine 5 - 20 mg po/pr/iv q4-8h
CPZ 25 - 50 mg po/pr/iv q6-8h
olanzapine start with 2.5 5 mg once/day
methotrimeprazine 2.5 - 10 mg po/sl/sq/iv q4-8h
domperidone 10 mg po q4-8h
Dopamine
Antagonists
Prokinetic
Examples
Serotonin
Antagonists
Cannabinoids
nabilone 1 2 mg po bid
dronabinol 2.5 mg po bid, titrated up
Miscellaneous
Non-Pharmacological Approaches
Accupuncture
Herbs
o Ginger
o Peppermint