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