Management of Nausea and Vomiting John A. Mulder, MD Vice President, Medical Services Faith Hospice.
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Transcript of Management of Nausea and Vomiting John A. Mulder, MD Vice President, Medical Services Faith Hospice.
![Page 1: Management of Nausea and Vomiting John A. Mulder, MD Vice President, Medical Services Faith Hospice.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b71b5550346d6338b4ebe/html5/thumbnails/1.jpg)
Management of
Nausea and Vomiting
John A. Mulder, MDVice President, Medical Services
Faith Hospice
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Assessment• Onset• Frequency• Relationship to eating• Relationship to medications• Current nausea medications
• Chronic or progressing• Alleviating factors• Severity• Scale: 1-10• Goal
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Assess cause:• Chemoreceptor trigger zone (CTZ)• Gastrointestinal/bowel• Vestibular• Cortical/anxiety• Vomiting center
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NAUSEA
Opioids (and metabolites)
Bowel obstruction
Metabolic problemsIntracranial pressure
Other drugs
Autonomic failure
Peptic ulcer disease
Constipation
Driver, L, and Bruera, E., The MD Anderson Palliative Care Handbook
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Common Causes in Cancer Patients• Treatment-related factors
– Chemotherapy– Radiation Therapy– Opioid Therapy– Other drugs (antibiotics, NSAIDs,
SSRIs, etc.)
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Common Causes in Cancer Patients• Pathophysiologic/metabolic/
biochemical– Constipation– Autonomic dysfunction (gatroparesis,
stasis)– Gastric/duodenal ulcer– GERD/gastritis– Liver failure/hepatomegaly/ascites– Infection/sepsis/fever– Coughing– Increased intracranial pressure
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Common Causes in Cancer Patients• Pathophysiologic/metabolic/
biochemical– Oral/esophageal infection/lesions– Pain– Dehydration– Electrolyte imbalance– Hypercalcemia– Uremia– Endocrine dysfunction
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Common Causes in Cancer Patients• CNS/psychophysiologic problems
– Vestibular disturbance– Cerebrocortical mechanisms
(anticipatory N/V)– Limbic mechanisms (hypersensitivity
to taste and smell)– Anxiety
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Most patients have multifactoral causes
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Treatment Considerations• Constipation regimen• Decompress obstruction; disimpact• If no nausea and tolerated, support
only• Oral hygiene• Small stomach: small portions,
frequent meals, cold foods tolerated better
• Odors• Avoid odors of cooking (ventilation)• Perfumes, scents, etc.
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• Opioid rotation• Steroids or RT for increased ICP• Reassurance/relaxation for
anticipatory nausea/high anxiety• Correct electrolyte imbalance• Volume repletion for dehydration• Hypercalcemia treatment with
hydration, steroids, bisphosphonates
• Adjustment of nutritional supplements
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Review medication list• a. Digitalis • b. Theophylline • c. Chemotherapy• d. Antibiotics
–1. Erythromycin–2. Tetracycline–3. Metronidazole (Flagyl)–4. Ciprofloxacin (Cipro)
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Pharmacologic treatmentConventional antiemetics :• metoclopramide (Reglan) – po, pr, iv, sc• prochlorperazine (Compazine) - po, pr,
iv, sc• droperidol (Inapsine) - im, iv, sc• promethazine (Phenergan) - po, pr, iv,
sc• scopolomine (Transderm Scop, Scopace)
– td, po• meclizine (Antivert) - po
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Pharmacologic treatmentSelective serotonin 5-HT3 antagonists:• ondansetron (Zofran, Zuplenz) - po, iv,
sc, sl• granisetron (Kytril, Granisol, Sancuso) -
po, iv, sc, td • polonosetron (Aloxi) – iv• dolasetron (Anzemet) – iv
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Pharmacologic treatmentCannabinoid receptor agonists:• nabilone (Cesamet) – PO• dronabinol (Marinol) – PO
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Pharmacologic treatmentOthers:• aprepitant (Emend) – PO, IV
– Selective human substance P/neurokinin 1 receptor antagonist
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Anticholinergic agents• Hyoscyamine (Levsin)
Motility Problem• a. Metoclopramide (Reglan) 5-20mg a.c.• b. Cisapride (Propulsid) 10-20mg QID
Movement induced; initiation of opioids• a. Scopolamine (Transderm Scop Patch) Q
72hrs• b. Meclizine (Antivert) 12.5-25mg Q 6hrs
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Alternative antiemetics (cont.)• d. Combination suppositories: BRD
– 1. Benadryl 25 mg– 2 .Reglan 10 mg 1-2 PR Q
4hr– 3. Dexamethasone 2 mg
• e. ABHR– 1. Ativan 0.5 mg– 2. Benedryl 12.5 mg 1 Q 6hr– 3. Haldol 0.5 mg– 4. Reglan 10 mg
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Unconventional antiemetics :• Haloperidol (Haldol)• Lorazepam (Ativan)• Diphenhydramine (Benadryl)• Corticosteroids (Decadron)• Sea Bands• Cannabinoids (Marinol)
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BAD Drip• 50 cc D5W• 200 mg Benedryl• 8 mg Ativan• 20 mg Decadron• 0.2 – 2.0 ml/h
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RBD Drip• 50 cc 0.9% sodium chloride• 80 mg Reglan• 100 mg Benadryl• 8 mg Decadron• 0.5 – 1.5 ml/h
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Random thoughts . . .• Metoclopramide 1st drug of choice
because of peripheral (GI) effects and central effects (CTZ)
• Antihistamines have no antidopaminergic effect (not 1st line in treating opioid-related nausea)
• Phenothiazines very sedating, can cause other side effects
• NG tube may be necessary for mgmt of copious vomiting, abd distention, obstruction, etc.
• Combining drugs of different mechanisms may yield positive results in addressing multifactoral etiology
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Random thoughts . . .• Anticipatory, PO, RTC dosing most likely
to provide greatest benefit• Corticosteroids often exert excellent
antiemetic effects• Always R/O constipation/impaction in
terminally ill patient presenting with chronic N/V
• 5-HT3 antagonists among most effective for chemotherapy induced N/V, but have minial effects on opioid-induced emesis and have no promotility effects
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Costs
Drug PO Inj PRPhenergan .02/mg .09/mg .16/mg
Compazine .08/mg ---- .12/mg
Haldol .14/mg $1.80/mg
----
Emend $275.50/kit
---- ----
Hyoscyamine
$2.48/mg ---- ----
Zofran $4.73/mg $6.00/mg
----
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Costs
Drug PO Inj PR
Reglan .02/mg .36/mg ----
Antivert .004/mg ---- ----
Marinol $1.68/mg ---- ----
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Costs
Drug
ABHR $1.25/doseCream
$3.95/supp
Sea bands $6.20/pair
Scope patch $5.48/each
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John Mulder, MDVP of Medical Services
Faith Hospice616-293-3615