Transcript Document
Management of Nausea and Vomiting John A. Mulder, MD Vice President, Medical Services Faith Hospice Assessment • Onset • Frequency • Relationship to eating • Relationship to medications • Current nausea medications • Chronic or progressing • Alleviating factors • Severity • Scale: 1-10 • Goal Assess cause: • Chemoreceptor trigger zone (CTZ) • Gastrointestinal/bowel • Vestibular • Cortical/anxiety • Vomiting center Opioids (and metabolites) Metabolic problems Intracranial pressure Other drugs NAUSEA Bowel obstruction Constipation Peptic ulcer disease Autonomic failure Driver, L, and Bruera, E., The MD Anderson Palliative Care Handbook Common Causes in Cancer Patients • Treatment-related factors – Chemotherapy – Radiation Therapy – Opioid Therapy – Other drugs (antibiotics, NSAIDs, SSRIs, etc.) 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 Common Causes in Cancer Patients • Pathophysiologic/metabolic/biochemical – Oral/esophageal infection/lesions – Pain – Dehydration – Electrolyte imbalance – Hypercalcemia – Uremia – Endocrine dysfunction Common Causes in Cancer Patients • CNS/psychophysiologic problems – Vestibular disturbance – Cerebrocortical mechanisms (anticipatory N/V) – Limbic mechanisms (hypersensitivity to taste and smell) – Anxiety Most patients have multifactoral causes 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. • 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 Review medication list • a. Digitalis • b. Theophylline • c. Chemotherapy • d. Antibiotics –1. Erythromycin –2. Tetracycline –3. Metronidazole (Flagyl) –4. Ciprofloxacin (Cipro) Pharmacologic treatment Conventional 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 Pharmacologic treatment Selective 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 Pharmacologic treatment Cannabinoid receptor agonists: • nabilone (Cesamet) – PO • dronabinol (Marinol) – PO Pharmacologic treatment Others: • aprepitant (Emend) – PO, IV – Selective human substance P/neurokinin 1 receptor antagonist 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 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 Unconventional antiemetics : • Haloperidol (Haldol) • Lorazepam (Ativan) • Diphenhydramine (Benadryl) • Corticosteroids (Decadron) • Sea Bands • Cannabinoids (Marinol) BAD Drip • 50 cc D5W • 200 mg Benedryl • 8 mg Ativan • 20 mg Decadron • 0.2 – 2.0 ml/h RBD Drip • 50 cc 0.9% sodium chloride • 80 mg Reglan • 100 mg Benadryl • 8 mg Decadron • 0.5 – 1.5 ml/h 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 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 Costs Drug Phenergan PO .02/mg Inj .09/mg PR .16/mg Compazine .08/mg ---- .12/mg Haldol .14/mg $1.80/mg ---- ------- ------- $6.00/mg ---- Emend $275.50/kit Hyoscyamine $2.48/mg Zofran $4.73/mg Costs Drug PO Inj PR Reglan .02/mg .36/mg ---- Antivert .004/mg ---- ---- Marinol $1.68/mg ---- ---- Costs Drug ABHR Sea bands $1.25/dose Cream $6.20/pair Scope patch $5.48/each $3.95/supp John Mulder, MD VP of Medical Services Faith Hospice 616-293-3615 [email protected]