Manikandan antiemetics (1)
Transcript of Manikandan antiemetics (1)
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AntiemeticsAntiemetics
Dr.S.Manikandan
Department of Pharmacology
Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER),
Pondicherry. INDIA.
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Manikandan 2
Vomiting Centre (medulla)
Cerebral cortex
Anticipatory emesisSmellSight
Thought
Vestibular nucleiMotion
sickness
Pharynx & GIT
Chemo & radio therapy Gastroenteritis
Chemoreceptor Trigger Zone
(CTZ)(Outside BBB)
Cancer chemotherapyOpioids
Muscarinic, 5 HT3 & Histaminic H1
5 HT3 receptors
Dopamine D2
5 HT3,,Opioid Receptors
Muscarinic Histaminic H1
P athophysiology of Emesis
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Manikandan 3
Now answer this question
Which group of drugs can be used as antiemetics ?
Serotonin 5 HT3 Antagonists
Dopamine D2 Antagonist
Anticholinergics
H1 Antihistaminics
Cannabinoids
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Manikandan 4
Serotonin 5 HT 3 Antagonist
Potent antiemetics
Even though 5 HT3 receptors are present in vomiting centre & CTZ, the antiemetic action is restricted to emesis caused by vagal stimulation.
High first pass metabolism
Excreted by liver & kidney
No dose reduction in renal insufficiency but needed in hepatic insufficiency
Given once or twice daily – orally or intravenously.
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Drugs AvailableOndansetron 32 mg / day
Granisetron 10 µg / kg / day
Dolasetron 1.8 mg / kg / day
I ndicationsChemotherapy induced nausea & vomiting – given
30 min. before chemotherapy.
Postoperative & postradiation nausea & vomiting
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Manikandan 6
Adverse EffectsExcellent safety profile
Headache & constipation
All three drugs cause prolongation of QT interval, but more pronounced with dolasetron.
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Manikandan 7
Dopamine D 2 Antagonist
Antagonise D2 receptors in CTZ.
Drugs available
Metoclopramide 2.5 mg b.d
Domperidone 10 mg b.d
Both drugs are also prokinetic agents due to their 5 HT4 agonist activity.
Domperidone – oral ; Metoclopramide – oral & i.v
Metoclopramide crosses BBB but domperidone cannot.
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Manikandan 8
Now answer this question
Which is a better antiemetic – Metoclopramide or Domperidone ?
As CTZ is outside BBB both have antiemetic effects.
But as metoclopramide crosses BBB it has adverse effects like extrapyramidal side effects..
Domperidone is well tolerated.
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Manikandan 9
P henothiazines & Butyrophenones
Phenothiazines
Prochlorperazine
Promethazine
Phenothiazines are antipsychotics with potent antiemetic property due to D2 antagonism.
Butyrophenone
Droperidol
Droperidol used for postop. nausea & vomiting, but cause QT prolongation.
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Manikandan 10
H1 Antihistaminics
Most effective drugs for motion sickness
Drugs available
Meclizine
Cyclizine
Dimenhydrinate
Diphenydramine
Promethazine – Used in pregnancy, used by
NASA for space motion sickness
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Manikandan 11
Anticholinergics
Scopolamine (hyoscine) – used as transdermal patch for motion sickness
Cannabinoids
Dronabinol – used as adjuvant in chemotherapy induced vomiting.It is a psychoactive substance
Nabilone
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Manikandan 12
Now answer this question
A physician prescribed Tab.Ondansetron for prophylaxis of motion sickness. Even though ondansetron is a potent antiemetic it didn’t produce any effect in this patient. Can you explain why ?
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Manikandan 13
Explanation :
Vestibular nuclei has only muscarinic and H1 histaminic receptors.
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Points to Ponder
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Manikandan 15
Even though both atropine and scopolamine are antimuscarinic, only scopolamine is used in the treatment of motion sickness. Why ?
Generally transdermal patches are applied over the arm or chest. But scopolamine transdermal patch is applied behind the ear. Why?
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Manikandan 16