This site is intended for healthcare professionals

Sign in
Go to /sign-in page

You can view 5 more pages before signing in

Step by step approach to management of nausea and vomiting in palliative care

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

1) First line - single agent based on underlying cause. Use regularly and to maximum dose before changing. If one drug is ineffective then use an alternative first line agent.

Cause of Nausea

Suggested Drug

Dose and Route

Drug induced and biochemical

haloperidol

oral: 1.5-3mg od - bd

s.c. 2.5-5mg/24hr

Evidence of gastric stasis

metoclopramide

 

oral: 10-20mg tds before meals

s.c. 30-100mg/24hr

OR

domperidone (does not cross the blood brain barrier so fewer side effects)

oral: 10mg tds

p.r. 30mg bd or tds

If GI tract involvement or cerebral turmour, or if the above have not worked

cyclizine

oral: 50mg tds

s.c. 150mg/24hr

2) Second line - add another first line age (e.g. cyclizine and haloperidol) or change to 'broad spectrum' agent

Cause of Nausea

Suggested Drug

Dose and Route

Broad spectrum anti-emetic useful if multiple possible causes

levomepromazine (acts at multiple receptor sites)

oral: 6mg-25mg nocte

s.c. 6.25-25mg/24h

 

3) Third line - if other drugs are not controlling symptoms try

Suggested drug

Dose and Route

3 day course of 5HT3-receptor antagonist e.g. ondansetron, granisetron or tropisetron

ondansetron - oral: 8mg bd; s.c. up to 24mg per 24 hrs

granisetron - oral/s.c. 1-2mg per 24hrs

 

 

Nausea and vomiting caused by moderately- to highly- emetogenic chemotherapy

  • neurokinin receptor antagonists for example Aprepitan

Aprepitant 80mg- 125mg OD PO Capsules: 80mg, 125mg

Raised intracranial pressure or intractable nausea and vomiting

  • steroids

Notes:

  • when changing antiemetics
    • ensure the anti-emetic is used regularly, and to a maximum dose before changing
    • if first drug is ineffective, change to an alternative first line drug
    • if first line drug was partially effective, another anti-emetic drug may be added (see Second line treatment)
    • haloperidol with cyclizine is often effective, especially by continuous subcutaneous infusion
    • cyclizine and other anticholinergic drugs may antagonise some of the effects of metoclopramide and other prokinetic agents. The combination should therefore be avoided if possible
    • re-assess patient

The respective summary of product characteristics must be consulted before prescribing any of the drugs detailed.

Reference:

  1. West Midlands Palliative Care Physicians (2003). Palliative care - guidelines for the use of drugs in symptom control.
  2. West Midlands Palliative Care Physicians (2007). Palliative care - guidelines for the use of drugs in symptom control
  3. West Midlands Palliative Care Physicians (2012). Palliative care - guidelines for the use of drugs in symptom control.

Create an account to add page annotations

Create a free account

Add information to this page that would be handy to have on hand during a consultation, such as a web address or phone number. This information will always be displayed when you visit this page

The content herein is provided for informational purposes and does not replace the need to apply professional clinical judgement when diagnosing or treating any medical condition. A licensed medical practitioner should be consulted for diagnosis and treatment of any and all medical conditions.

Connect

Copyright 2024 Oxbridge Solutions Limited, a subsidiary of OmniaMed Communications Limited. All rights reserved. Any distribution or duplication of the information contained herein is strictly prohibited. Oxbridge Solutions receives funding from advertising but maintains editorial independence.