Clinical picture - potential clinical scenarios

Clinical picture

• Persistent often severe nausea.
• Little relief from vomiting or retching.

Cause

• Chemical stimulation of CTZ.

By

• Drugs, including cytotoxics and opioids (also delay gastric emptying), NSAIDs, syrupy liquids, antibiotics, antidepressants, anticonvulsants, digoxin/cardiac drugs, alcohol.
• Carcinomatosis/chronic inflammation (cytokine induced).
• Metabolic, for example uraemia, hypercalcaemia, hyponatraemia, ketoacidosis, infection, Addison’s disease, circulating toxins, hormone imbalance.

Treatment

• Treat metabolic imbalances.
• Dopamine antagonist, for example QTmetoclopramide(caution in use of prolonged higher doses, monitor for extrapyramidal side effects) 10mg up to four times a day orally or subcutaneously or 30mg to 60mg over 24 hours by continuous subcutaneous infusion (unlicensed use). Specialists may recommend higher doses.

or

• QT†haloperidol 500micrograms to 1.5mg orally at night or twice daily, or 500micrograms to 1mg subcutaneously daily (start with lower doses in renal failure and elderly and frail patients) or 1mg to 5mg over 24 hours by continuous subcutaneous infusion titrated to effect (unlicensed use)
• QT†levomepromazine* 2.5mg to 5mg by subcutaneous injection 12 hourly as needed or 5mg to 15mg in 24 hours by continuous subcutaneous infusion. May need to give subcutaneous injection more frequently initially, for example hourly, to control symptoms. Consider change to oral route if symptoms resolve.
• Cytotoxic/chemotherapy induced – check local policy.

For persistent problems, seek specialist advice. 

Clinical picture

• Intermittent large volume vomit, usually relieves symptoms temporarily.
• Early satiation.
• Reflux, hiccup.
• Often little nausea until immediately prior to vomit. 

Cause

• Gastric stasis.
• Gastric outlet obstruction - pseudo-obstruction - intestinal. 

By

• Autonomic neuropathy (paraneoplastic).
• Drugs (opioid, anticholinergic).
• Metabolic (for example hypercalcaemia).
• Mechanical obstruction, tumour, nodes, enlarged liver (leading to squashed stomach).
• If there is large volume vomiting and/or colicky bowel pain, especially colic caused by a prokinetic agent - exclude complete bowel obstruction – refer to separate guideline.

Treatment - prokinetic

• QTMetoclopramide 10mg orally up to four times a day or 30mg to 60mg/24 hours by subcutaneous infusion (unlicensed route/dose/duration). Specialists may recommend higher doses.

or

• If elderly or at higher risk of extrapyramidal effects, use QTdomperidone 10mg three times a day orally.
• If extrinsic compression, consider corticosteroid – †dexamethasone 4mg to 8mg daily reducing after 3 days, aiming to stop or reduce to lowest maintenance dose, or if appropriate, stent.

Note: prokinetic agents may trigger oesophageal spasm.

For persistent problems, seek specialist advice. 

Clinical picture

• Headache.
• Altered conscious level.
• Vertigo - dizziness with nausea.
• Movement-related sickness. 

Cause

• Raised intracranial pressure (ICP), vestibular nerve or inner ear stimulation. 

By

• Space occupying lesion.
• Base of skull tumour.
• Ototoxicity.
• Middle ear problems. 

Treatment - raised intracranial pressure

• Cyclizine 25mg to 50mg orally or subcutaneously (unlicensed route) three times per day or 50mg to 150mg over 24 hours via subcutaneous infusion (unlicensed route).
• Corticosteroid – †dexamethasone 8mg to 16mg daily reducing after 3 days, aiming to stop or reduce to lowest maintenance dose.
• Second line – levomepromazine* QT3mg to 6mg twice daily orally or QT†2.5mg to 5mg by subcutaneous injection 12 hourly as needed or 5mg to 15mg in 24 hours by continuous subcutaneous infusion. May need to give subcutaneous injection more frequently initially, for example hourly, to control symptoms
• QTprochlorperazine 3mg buccal or 5mg to 15mg orally.

 Treatment - movement related nausea

• Cyclizine 25mg to 50mg orally or subcutaneously (unlicensed route) three times per day or 50mg to 150mg over 24 hours via subcutaneous infusion (unlicensed route) 
• †Hyoscine hydrobromide 150micrograms to 300micrograms orally, 200micrograms to 400micrograms subcutaneously or 1mg/72 hours via transdermal patch. Observe for anticholinergic side effects.
• Cinnarizine 30mg orally initially then 15mg three times a day.
• Second line - levomepromazine* QT3mg to 6mg twice daily orally or QT†2.5mg to 5mg by subcutaneous injection 12 hourly as needed or 5mg to 15mg in 24 hours by continuous subcutaneous infusion. May need to give subcutaneous injection more frequently initially, for example hourly, to control symptoms
• QTprochlorperazine 3mg buccal or 5mg to 15mg orally.

For persistent problems, seek specialist advice. 

Clinical picture

• Worse on eating.
• Exacerbated by sight or smell of food or smells from other sources.
• Reflux symptoms.
• Retching associated with productive cough.

Cause

•  Cranial nerve irritation (vagal and glossopharyngeal).

By

• Tumour.
• Secretions or sputum, stimulating the gag reflex.
• Acid reflux.
• Toxins.
• Inflammation.
• Infection (for example candida, herpes simplex).
• Foreign body (for example stent).
• Smells from wounds, stomas, food or other sources.

Treatment

• Treat reversible causes, for example acid reflux, infection, secretions.
• Cyclizine 25mg to 50mg orally or subcutaneously (unlicensed route) three times per day or 50mg to 150mg over 24 hours via subcutaneous infusion (unlicensed route).
• Anticholinergics, for example †hyoscine hydrobromide 150micrograms to 300micrograms orally, 200micrograms to 400micrograms subcutaneously or 1mg/72 hours via transdermal patch.
• levomepromazine* QT3mg to 6mg twice daily orally or QT†2.5mg to 5mg by subcutaneous injection 12 hourly as needed or 5mg to 15mg in 24 hours by continuous subcutaneous infusion. May need to give subcutaneous injection more frequently initially, for example hourly, to control symptoms.

For persistent problems, seek specialist advice. 

Clinical picture

Treatment

• Consider potential causes and treat appropriately. If nausea and vomiting persists, use levomepromazine* as a broad spectrum anti-emetic.
• levomepromazine* QT3mg to 6mg twice daily orally or QT†2.5mg to 5mg by subcutaneous injection 12 hourly as needed or 5mg to 15mg in 24 hours by continuous subcutaneous infusion. May need to give subcutaneous injection more frequently initially, for example hourly, to control symptoms maintenance dose.
• Consider higher centre origin, for example pain, fear, anxiety.

For persistent problems, seek specialist advice. 

Treatment

• Refer to Pain assessment and Pain management guidelines where appropriate.
• Nausea associated with anticipation or anxiety may respond to a benzodiazepine, for example lorazepam 500 micrograms to 1mg sublingually or diazepam 2mg to 5mg orally. The 500 microgram Lorazepam tablet cannot be absorbed by this route, only the blue 1mg tablets which can be halved (e.g. TEVA, Genus, PVL) can.]

For persistent problems, seek specialist advice.