Nausea Vomiting

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Information about Nausea Vomiting

Published on October 13, 2008

Author: pattersonby


Nausea & Vomiting: Nausea and Vomiting Brooke Y. Patterson, PharmD, BCPS NU 7080 Advanced Pharmacology Research College of Nursing Background: Background Acute gastroenteritis is a common cause of acute care seeking and is 2nd only to the common cold as a cause of lost work time 50-90% of pregnant women experience nausea, 25-55% experience vomiting More than 50% of patients receiving chemotherapy experience nausea Up to 90% of medication package inserts list nausea as a potential side effect Pathophysiology: Pathophysiology The GI tract interacts with the CNS in 3 main levels Parasympathomimetic and sympathetic nervous systems Enteric brain neurons Smooth muscle cells 5 neurotransmitter receptor sites of primary importance in the vomiting reflex Muscarinic Dopamine Histamine Serotonin Substance P Diagnosis: Diagnosis A variety of disorders can produce nausea with or without vomiting Abdominal pain with vomiting  organic etiology Abdominal distension and tenderness  bowel obstruction Vomiting of food eaten several hours earlier  gastric obstruction or gastroparesis Early morning vomiting  pregnancy Vertigo and nystagmus  vestibular neuritis Treatment: Treatment Few published studies compare common antiemetic drugs in specific disorders Drug selection in may clinical situations is based on empiric data and provider experience Medications should be given based on the suspected cause of nausea and emesis A Stepwise Approach To Selecting Antiemetics: A Stepwise Approach To Selecting Antiemetics Determine what the source or trigger for N/V is and what receptors are mediating the response Initial drug therapy should be based on receptors’ medicating the N/V If unknown etiology, follow algorithm Cholinergic Receptor: Cholinergic Receptor Medications to use: anti-cholinergics Scopolamine patch Apply patch to hairless area behind ear; may be left on for up to 24 hours Adverse effects: sedation, urinary obstruction, blurred vision, exacerbation of glaucoma Histamine Receptor: Histamine Receptor Medications to use: antihistamines, histamine-2 receptor antagonists See allergic rhinitis lecture for antihistamines and GERD lecture for H2-antagonists Dopamine Receptor: Dopamine Receptor Medications to use: dopamine antagonists Phenothiazines Butyrophenones Metoclopramide 10-20mg PO Q 4-6 h prn Phenothiazines: Phenothiazines Butyrophenones: Butyrophenones Dopamine Receptor Agents: Dopamine Receptor Agents Phenothiazine Adverse Effects EPS reactions Hypersensitivity reaction Hepatotoxic QRS-complex widening Acute cardiac death Butyrophenone Adverse Effects Torsades de pointes (Black box warning) QT prolongation (Black box warning) Limits use Metoclopramide Adverse Effects EPS reactions (pretreat with diphenhydramine) Somnolence Serotonin Receptor: Serotonin Receptor Medications to use: Serotonin (5HT3) antagonists Adverse Effects QT prolongation QRS widening Hypersensitivity reactions (rare) Should be reserved for CINV 5HT3 Antagonists: 5HT3 Antagonists Miscellaneous Agents Used in Nausea/Vomiting: Miscellaneous Agents Used in Nausea/Vomiting Acid reducers Antacids, PPIs, H2-antagonists N/V due to acid reflux Benzodiazepines Excellent for refractory N/V Lorazepam DOC Dexamethasone CINV Mechanism unknown Algorithm for Nausea/Vomiting of Unknown Etiology: Algorithm for Nausea/Vomiting of Unknown Etiology Promethazine 12.5-25mg PO/PR/IV Q 6 hours PRN Prochlorperazine 25mg PR/PO BID or 5-10mg IV over 2 min 3-4X day (Max 40mg QD) Metoclopramide IV/PO QAC and HS Lorazepam 0.5-1mg IV PRN Discontinue, then try Continue and add Discontinue prochlorperazine and add Case: Case UA is a 61 yo WM with a PMH significant for GERD and BPH. He calls his primary care provider reporting a 2-day history of nausea, vomiting, and general fatigue. He has not been able to keep water down X 2 days, and is afraid he is becoming very dehydrated.

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