Hematology and Oncology Book

Cancer

  • Nausea in Cancer

http://www.fpnotebook.com/

Nausea in CancerAka: Vomiting in Cancer, Nausea in Terminally Ill Patients, Cancer Related Nausea

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  1. 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)
      8. Motility (Ileus, Opioids)
      9. Metabolic (Hypercalcemia Hyponatremia, Uremia)
      10. Microbes (Local infection, Sepsis)
      11. Myocardial dysfunction (ischemia, CHF)
  2. 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
  3. 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. 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
    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)
  4. Antiemetics available
    1. Anticholinergics
      1. Scopolamine (Transdermal) every 72 hours
    2. Phenothiazines
      1. Prochlorperazine (Compazine)
    3. Butyrophenones
      1. Haloperidol (Haldol)
      2. Droperidol (Inapsine)
    4. Antihistamines
      1. Meclizine (Antivert)
        1. Indicated for vestibular associated Emesis
      2. Promethazine (Phenergan)
      3. Hydroxyzine (Atarax, Vistaril)
    5. Gastrokinetic agents
      1. Metoclopramide (Reglan)
        1. Indicated for partial Small Bowel Obstruction
    6. 5-HT3 Receptor Antagonists
      1. Ondansetron (Zofran)
      2. Granisetron (Kytril)
      3. Dolasetron (Anzemet)
    7. Miscellaneous
      1. Dexamethasone (Decadron)
      2. Dronabinol
      3. Lorazepam (Ativan)
      4. Octreotide (Sandostatin)
  5. References
    1. Ross (2001) Am Fam Physician 64(5):807

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