Nausea in Cancer

1. See Also
   1. Cancer Related Bowel Obstruction
   2. Opioid Adverse Effect Management
   3. Constipation in Cancer
   4. Diarrhea in Cancer
   5. Cachexia in Cancer
2. Causes
   1. Common Causes
      1. Small Bowel Obstruction
      2. Autonomic failure
      3. Hypercalcemia
      4. Narcotic bowel Syndrome
         1. Disappears 2-3 weeks after starting Narcotic
         2. Associated with Intracranial Pressure
   2. Mnemonic: 11 M's
      1. Metastases (Cerebral, Liver)
      2. Meninges irritated (Increased Intracranial Pressure)
      3. Movement (Vestibular stimulation)
      4. Mentation (Anxiety)
      5. Medications (Opioids, Chemotherapy, NSAIDs)
      6. Mucosal irritation (NSAIDs, GERD, Hyperacidity)
      7. Mechanical obstruction (Constipation, Tumor, Cancer Related Bowel Obstruction)
      8. Motility (Ileus, Opioids)
      9. Metabolic (HypercalcemiaHyponatremia, Uremia)
      10. Microbes (Local infection, Sepsis)
      11. Myocardial dysfunction (ischemia, CHF)
3. General Rules
   1. Attempt to identify a cause
   2. Consider combining Antiemetics if one not effective
      1. Use from different classes
   3. Avoid Nasogastric Tubes
4. Algorithm
   1. Always consider non-pharmacologic management first
      1. Small Frequent Meals
      2. Avoid bland foods (patient eats what they want)
   2. Starting Antiemetic agents
      1. Prochlorperazine (Compazine)
      2. Dimenhydrinate (Dramamine)
      3. Metoclopramide (Reglan)
   3. Consider specific agents
      1. Chemotherapy-induced Nausea
         1. Acute Chemotherapy-induced Nausea
            1. Give agents 30 minutes before Chemotherapy
            2. Ondansetron 32 mg IV or 24 mg PO and
            3. Dexamethasone 4 mg
         2. Delayed Chemotherapy-induced Nausea
            1. Metoclopramide (Reglan) 1-2 mg IV or PO q2-4h and
            2. Dexamethasone 4 mg
      2. Other specific uses
         1. Anxiety related Nausea: Benzodiazepines, Cannabinoids
         2. Bowel Obstruction: Octreotide
         3. Gastroparesis: Metoclopramide
         4. Increased Intracranial Pressure: Dexamethasone
         5. Opioid-related bowel dysfunction: Methylnaltrexone
   4. Refractory Nausea
      1. Combine 2-3 drugs from above
      2. Consider Haloperidol (Haldol)
         1. Start at 0.5 to 2 mg PO IV or SC q6 hours
         2. Titrate to 10 to 15 mg total daily dose
      3. Consider adding prednisone or Dexamethasone
   5. Emesis continues
      1. Consider Rectal route (e.g. Compazine)
      2. Consider Subcutaneous route (e.g. Haldol)
      3. Consider Transdermal route (e.g. Scopolamine)
   6. Other cause specific management
      1. See Cancer Related Bowel Obstruction
      2. Anxiety: Benzodiazepines or cannabinoids
      3. Gastroparesis: Metoclopramide (Reglan)
      4. Increased Intracranial Pressure: Dexamethasone
      5. Medication related
         1. See Chemotherapy related Nausea treatment as above
         2. See Opioid Adverse Effect Management for Opioid-Induced Nausea
5. Preparations: Antiemetics
   1. Anticholinergics
      1. Scopolamine (Transdermal 1.5 mg patch) 1-2 patches replaced every 48 to 72 hours
   2. Phenothiazines
      1. Prochlorperazine (Compazine) 5-10 mg PO or IV every 6-8 hours or 25 mg rectally every 12 hours
      2. Promethazine (Phenergan) 25-50 mg orally, rectally or IV every 6 hours
         1. Overused, sedating and relatively ineffective in Palliative Care
      3. Chlorpromazine (Thorazine) 12.5 to 25 mg IV every 6-8 hours or 25-50 mg orally every 8 hours
   3. Butyrophenones
      1. Haloperidol (Haldol) 0.5 to 2 mg orally or IV every 4-8 hours
      2. Droperidol (Inapsine) 1.25 to 2.5 mg IV
   4. Antihistamines
      1. Meclizine (Antivert)
         1. Indicated for vestibular associated Emesis
      2. Diphenhydramine (Benadryl) 12.5 to 50 mg orally, rectally, or IV every 4-12 hours
      3. Hydroxyzine (Atarax, Vistaril)
   5. Gastrokinetic agents
      1. Metoclopramide (Reglan) 5-20 mg orally or IV every 6 hours
         1. Indicated for partial Small Bowel Obstruction
   6. 5-HT3 Receptor Antagonists
      1. Ondansetron (Zofran) 4-8 mg orally or IV every 4-8 hours
      2. Granisetron (Kytril) 1 mg orally or IV twice daily
      3. Dolasetron (Anzemet)
   7. Cannabinoids
      1. Nabilone (Cesamet) 1-2 mg orally every 12 hours
      2. Dronabinol (Marinol) 5-10 mg orally, rectally or sublingual every 6-8 hours
   8. Miscellaneous
      1. Dexamethasone (Decadron) 2-8 mg orally or IV every 4-8 hours
      2. Lorazepam (Ativan) 0.5 to 2 mg orally or IV every 6 hours
6. References
   1. Ross (2001) Am Fam Physician 64(5):807-14