Nausea & Vomiting Managing a common symptom without becoming sick to your stomach Amanda Sommerfeldt, MD Medical Director, Hospice Southland ...
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Nausea & Vomiting
Managing a common symptom without becoming sick to your
stomach
Amanda Sommerfeldt, MD
Medical Director, Hospice Southland
Objectives 1. Learn the NAUSEA acronym to guide assessment of patients with nausea 2. Learn the VOMIT acronym to identify common causes of vomiting 3. Understand the importance of matching the treatment of nausea and vomiting to the cause of nausea and vomiting 4. Discuss various medications used to palliate nausea and vomiting
Disclosures
• I have no relevant conflicts of
interest to disclose
• I am from the U.S. and I talk
and spell like an American. If I
say something that doesn’t
make sense, please stop me
and ask for clarification
• Evidence for use of anti-
emetic medications in
palliative care is limited –
some of the drugs discussed
are used off label
Image courtesy of www.guff.comTerminology
Nausea Vomit
• Unpleasant sensation • Eject stomach contents through the
• Vaguely referred to epigastrium mouth
(Dorland’s Medical Dictionary)
and abdomen • From the Latin vomere, meaning
• With a tendency to vomit (Dorland’s “spew forth” or “discharge”
Medical Dictionary)
• Medical term for vomitus is
• From the Greek word naus “emesis”, from the Greek emein
(“ship”)
• Reference to seasickness experienced by
sailors
• Nausia (Greek) or Nausea (Latin)What’s so bad about N&V?
• Reduced quality of life
• Uncomfortable or distressing to patient
• Upsetting to family and friends
• Takes away enjoyment of meals
• Can contribute to weight loss and malnutrition
• May be symptoms of serious underlying problem(s)
• It’s common
• 70-85% of pregnant women
• Up to 2% with hyperemesis gravidarum
• 90-100% who receive total body irradiation
• Most prevalent with abdominal, pelvic, or mantle
• 40-60% with advanced malignancy
• Present in up to 55% in last 4 weeks of life
• 16-68% of palliative care patientsKEY POINT
Nausea and vomiting are symptoms of a diagnosis.
They are not the diagnosis.Why are nausea and vomiting difficult to treat?
• Symptoms may not be reported
• Seen as normal or expected by patients with cancer
• Seen as untreatable or “part of life”
• Failure to identify and target the cause
• Medications
• Unrecognized pregnancy
• Constipation
• Brain tumour
• Wrong anti-emetic medication
• Failure to match the treatment to the cause
• Using multiple medications with similar mechanisms of action
• Failure to recognize the cause can change over time
• Patient with cancer who had chemo in the past but now
has N&V from constipationWhy are nausea and vomiting difficult to treat? • Inadequate dose • Medication not given often enough • Fail to increase dose when appropriate • Inappropriate route Oral medication + Vomiting patient = Rectal medication + Frequent Diarrhoea =
Successful management of N&V 1. Assess the patient • History • Physical exam 2. If possible, identify the cause of the nausea/vomiting 3. Direct treatment toward the cause • Fix the cause (if feasible) • Medications • Non-pharmacologic measures 4. Reassess
Step 1 - Assessment
Remember
N–A–U–S–E-AAssessment of N&V
• Nausea history and intensity
• Ordinal scale (like 0-10)
• Description of symptoms
• Duration of symptoms
• Aggravating factors – what makes it worse?
• Food, eating / not eating, drinking, medications, movement, time of day
• qUality of life
• How upsetting is this?
• Symptoms associated with N&V
• Dizziness, fatigue, anxiety, depression, sweating, pain, constipation, diarrhoea, fever, weight
loss
• Episodes of vomiting per 24 hour period
• Alleviating factors – what makes it better?
• Distraction, food, vomiting, medicationsExamining the patient with N&V
• Appearance and vital signs • Abdominal exam
• How does the patient look? • Tenderness
• Pale • Distension
• Jaundiced • Masses
• Acutely ill
• Bowel sounds
• Fever to suggest infection
• Tachycardia
• Rectal exam
• Depends on patient’s prognosis and goals
• Hypotensive
of care
• May be bradycardic and hypotensive
• Constipation
while vomiting
• Bleeding
• Skin and mucous membranes
• Mass
• Hyper salivation
• Sweating
• Skin tenting, dry mouth with dehydrationStep 2 – Identify the cause(s)
Remember
V–O–M–I-TN&V – The Major Players
1. GI tract
2. Vestibular apparatus
• Part of inner ear responsible for sensing motion and body position
3. Chemoreceptor Trigger Zone (CTZ)
• Area postrema on the floor of the 4th ventricle
• Located in the dorsal medulla (brainstem)
• Loose blood-brain barrier
• Chemicals in the bloodstream and CSF can affect the CTZ
4. Cerebral cortex
• Nausea stimulated or suppressed by taste, sight, smell,
emotion, and memoryReceptors Involved in N&V
GI tract CTZ
D2, 5-HT3, also M1,
5-HT3, also M1, H1, H1, NK1
NK1
Vestibular
apparatus Cerebral
H1, M1 Emetic cortex
Centre
M1
Emetic Centre in the
nucleus tractus
solitarius in medullaKEY POINT
When the emetic centre is signalled by the GI tract,
vestibular apparatus, CTZ, and/or cerebral cortex,
vomiting is triggeredV - Vestibular
• Motion sickness
• Benign paroxysmal positional vertigo
• Meniere’s disease
• Tumour
• Inner ear infections or inflammation (labrynthitis)
• Visual cues – spinning, tilting
Stimulation Stimulation
of inner of Activation
Release of
ear or vestibular of the
ACh,
direct nuclei in Emetic
histamine
visual the Centre
stimulus brainstemO – Obstruction of bowel
• Constipation
• Ileus
• Partial or complete bowel obstruction
• Think of a clogged water pipe
Bowel lumen
Dilation of bowel
pressure Release
before the Activation
Blocked rises, bowel of ACh,
blockage and of the
intestinal wall edema, histamine,
decompression Emetic
flow fluid +/-
of bowel past the Centre
secretion, serotonin
blockage
peristalsisM – Motility disorders in upper GI tract
• Diabetes mellitus • Scleroderma
• Neurologic disorders • Small cell lung cancer
• Motor neurone disease
• Acute gastroenteritis
• Parkinson’s
• Stroke • Acid reflux disease
• Medications • Hypo/hyperthyroidism
• TCAs • AIDS
• Opioids
• Lithium
• Psychiatric disorders
• Nicotine • Rumination syndrome
• CCBs
• Clonidine
• some
chemotherapy drugsM – Motility disorders in upper GI tract
Interruption of Activation of
electrical Release of the CTZ then
Medical dopamine,
and/or the Emetic
condition, serotonin,
mechanical Centre, or
medication, or histamine,
processes that direct
injury to vagus ACh, +/-
regulate activation of
nerve substance P
stomach the Emetic
contractions CentreI – Infection / Inflammation
• Bacterial toxins • Brain tumour
• Viral infections • Concussion
• Meningitis • Stroke
• Encephalitis
Release of
dopamine,
serotonin, Activation of
Infection or Activation of
NE, the Emetic
Inflammation the CTZ
enkephalins, Centre
GABA, +/-
substance PT - Toxins
• Metabolic disorders • Medications
• Diabetic ketoacidosis
• Carbidopa/Levodopa
• Uraemia
• Oestrogens
• Hypoxemia
• Opioids
• Hypercalcemia
• D2 mediated
• Oestrogen release of pregnancy • Chemotherapies
• Nicotine • Digoxin
• General anaesthetics
• Ergot alkaloids
Release of Activation of
Activation of
Toxin dopamine +/- the Emetic
the CTZ
serotonin CentreStep 3 – Direct the treatment
toward the cause
Fix when possible. Palliate when a fix
is impossible or not feasibleGeneral management principles
• Treat the cause when possible
• Benefits/burdens of laxative regimen
• Senna stimulates the myenteric plexus in the GI tract
• Docusate without senna is “mush without push”
• Two birds, one stone
• May need more than one medication
• Avoid using multiple medications with similar mechanisms of action
• Limited data to support efficacy of meds used
• Case reports
• Small studies – usually with cancer patients, and usually
receiving chemoMedication Classes • Anticholinergics (block acetylcholine) • Antidopaminergics (block dopamine) • 5-HT3 antagonists (block serotonin) • Antihistamines (block histamine) • Substance P antagonists (particularly NK-1) • Other • Corticosteroids • Cannabinoids • Benzodiazepines
Anticholinergics
• Mechanism
• Block acetylcholine (ACh) at muscarinic (M1) receptors
• Drugs
• Hyoscine HBr– SC, IM, IV, TD
• Meclozine hydrochloride - PO (NS)
• Also acts as an antihistamine
• Uses
• Vestibular N&V (room spinning, inner ear problems)
• Patients who also have secretions
• Renal or biliary colic
• Side effects / Risks
• Blind as a bat, mad as a hatter, dry as a bone,
red as a beet
• Tachycardia, urinary retention, dizzinessAntidopaminergics • Mechanism • Block dopamine at D2 receptors • Drugs • 3 classes • Uses • N&V due to opioids, electrolyte imbalances, migraine, CTZ activation, or unknown cause • Patients who also have agitation, delirium, or psychosis • Metoclopramide specifically if upper GI motility disorders
Classes of dopamine blockers 1. Phenothiazines • Levomepromazine (Nozinan) – PO, injection, infusion • Trifluoperazine HCl (Stelazine) – PO • Chlorpromazine – PO, IM, IV • Prochlorperazine – PO and buccal tabs, PR, IM 2. Butyrophenones • Haloperidol (Haldol) – PO tabs or drops, injection, slow infusion • Droperidol (Droleptan) – injectable (NS) • Domperidone (Motilium (NS), Prokinex (S)) - PO
Classes of dopamine blockers
3. Substituted benzamide
• Metoclopramide – PO, IM, IV
4. Atypical antipsychotics
• Also block 5-HT2A receptors (sleep, mood, fewer extrapyramidal symptoms, weight gain)
• Block H1 receptors (sleep, weight gain, appetite)
• Block α1 and α2 adrenergic receptors (salivation, improved urine flow)
• May block other dopaminergic and 5-HT1A receptors as well
• Drugs
• Olanzapine – PO, ODT, IM
• Quetiapine - PO
• Risperidone – PO, ODTRisks and side effects – antidopaminergics • Common side effects • Sedation, dizziness, dry mouth • Haloperidol is less sedating • Rare and more serious side effects • Extrapyramidal symptoms – tremor, disordered movement, rigidity • Tardive dyskinesia – repetitive, involuntary movements like lip smacking • QT prolongation / torsades de pointes • Blood dyscrasias • Weight gain, hyperglycemia (especially atypicals) • DVT/PE • Elevated prolactin (atypicals)
Contraindications to using dopamine blockers
• Parkinson’s disease and related conditions
• Increased risk of dopamine depletion leading to tardive dyskinesia
or EPS
• Low dose quetiapine may be a consideration if necessary
• Movement disorders
• Caution if prolonged QT, heart disease, history of
arrhythmia or seizure, dementia, elderly5-HT3 antagonists
• Mechanism
• Block serotonin at 5-HT3 receptors
• Drugs
• Ondansetron – PO, ODT, injection
• Tropisetron – injection
• Granisetron - PO
• Uses
• Most data for acute or delayed chemotherapy induced N&V
• Prevent post-operative emesis
• Emesis related to radiation therapy
• Side effects / Risks
• Headache, flushing, dizziness, itching, urinary retention,
constipation, diarrhoea
• Elevated LFTs
• Rare EPS
• Rare QT prolongationAntihistamines
• Mechanism
• Block histamine at H1 receptors
• Many also block acetylcholine (anticholinergic)
• Drugs
• Promethazine (Phenergan) – PO, IM, caution if IV, PR
• Diphenhydramine – PO, (injection)
• Why not use a newer antihistamine like loratadine, fexofenadine, or cetirizine?
• Uses
• Vestibular N&V
• Patients who also have nasal allergies, congestion, respiratory infections, or insomnia
• Side effects / Risks
• Sedation, blurred vision, dizziness, dry mouth, urinary retention,
confusion (especially elderly)
• Extravasation (IV > IM)Substance P antagonists
• Mechanism
• Block Substance P at NK-1 receptors
• Emerging therapy
• Drugs
• Aprepitant (Emend) – PO ($100 for 3 tabs)
• Uses
• Used with serotonin blockers and dexamethasone to prevent delayed N&V from
chemotherapy
• Prevent post-operative N&V
• Side effects / Risks
• Headache, GI upset, elevated LFTs, dizziness,
hiccup, astheniaOther anti-emetics - Corticosteroids
• Mechanism
• Not well understood. May prevent release of arachidonic acid
• Drugs
• Dexamethasone – PO, injection, infusion
• Methylprednisolone PO, injection
• Uses
• Nausea due to inflammation, chemotherapy, or unknown cause
• Patients with concomitant anorexia, fatigue, lethargy
• Side Effects / Risks
• Oedema, insomnia, agitation, psychosis, adrenal insufficiency,
GI upset, headache, elevated blood sugar, infections, muscle weakness,
osteoporosis, avascular necrosis,
hypokalaemia, possible bleedingOther anti-emetics - Cannabinoids
• Mechanism
• Affect cannabinoid receptors near the Emetic Centre
• Drugs
• Natural cannabis and synthetic cannabinoids - illegal
• Dronabinol (Marinol) in U.S. – expensive, limited benefit
• Nabiximols (Sativex) – used only for spasticity due to MS
• Uses
• Limited utility
• Better tolerated and seems more efficacious in younger patients, those who previously
benefited from marijuana
• Side effects / Risks
• Sedation, dizziness, agitation, hallucinations,
seizuresOther anti-emetics - Benzodiazepines • Mechanism • Enhance effects of GABA by binding to benzodiazepine receptors in the brain • Drugs • Lorazepam – PO • Alprazolam – PO • Diazepam – PO, injection, PR • Midazolam – PO, injection, infusion, PR, intranasal, SL • Uses • Limited • Anticipatory or vestibular N&V • Associated anxiety, insomnia, seizures, or spasm • Side effects / Risks • Sedation, dry mouth, dizziness, paradoxical agitation • Dependence, abuse
What if I have no idea what is
causing the nausea or vomiting?
Safety – Efficacy – Simplicity - Cost
effectivenessNon-pharmacologic measures
• Mainly anecdotal evidence
• Ask and educate
• What do you think this means?
• What are your expectations?
• It is not normal to stop moving bowels when oral intake is poor
• Diet
• Small, more frequent meals
• Low-fat and low residue diets if early satiety or delayed gastric emptying
• Avoid strong or noxious odours
• Keep mouth moist and clean
• Progressive relaxation and guided imagery may help prevent CINV
• Hypnosis
• Patient needs to be able to concentrate
• May reduce nausea, vomiting, anxiety, and early satiety
• Music
• Systematic desensitization
• DistractionConclusions
1. Nausea and vomiting are common symptoms associated with a variety of
medical conditions
2. N&V can adversely affect quality of life in a number of ways
3. The NAUSEA acronym is a tool that can aid in assessment of
nausea/vomiting
4. The VOMIT acronym can be used to quickly recall common causes of N&V
5. Management is most likely to succeed when the treatment is matched to the
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http://medical-dictionary.thefreedictionary.com/THANK YOU!
Questions? Comments? Concerns?
Amanda Sommerfeldt
amanda.sommerfeldt@hospicesouthland.org.nzYou can also read
