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antiemetics Flashcards

1
Q

What is a common complaint?

A

N/V

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2
Q

What is nausea?

A
  • the conscious recognition of the imminent need to vomit
  • may or may not result in vomiting
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3
Q

What is nausea mediated by?

A

the autonomic nervous system

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4
Q

What is retching/dry heaves?

A
  • rhythmic & spasmodic movement involving the diaphragm & abdominal muscles
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5
Q

What is retching/dry heaving controlled by?

A

the respiratory center in the brainstem

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6
Q

What is vomiting?

A

The forceful expulsion of gastric contents through the mouth

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7
Q

What are some causes of nausea & vomiting?

A
  • surgery
  • infection
  • constipation
  • malnutrition
  • cancer
  • immunosuppression
  • MI
  • motion sickness
  • depression
  • pregnancy
  • radiation
  • bowel obstruction
  • concomitant medications
  • fluid & electrolyte imbalances
  • liver failure
  • certain meds
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8
Q

What meds can cause nausea & vomiting?

A
  • chemotherapy
  • antibiotics
  • oral hypoglycemics
  • oral contraceptives
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9
Q

What part of the brain contains the vomiting center?

A

the medulla

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10
Q

What happens during the vomiting reflex?

A
  1. relaxation of the lower esophageal sphincter
  2. contraction of the diaphragm & abd muscles
  3. autonomic changes
  4. epiglottis closes
  5. expulsion of food
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11
Q

What are the consequences of untreated N/V?

A
  • decreased quality of life
  • dehydration
  • electrolyte imbalance
  • decreased self care
  • decreased function
  • nutritional deficits
  • taste changes
  • decreased performance status
  • esophageal tears
  • weight loss
  • anorexia
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12
Q

What is acute chemo-induced N/V?

A
  • occurs within minutes to hours after chemo administration
  • depends upon type, dose, route & schedule
  • risk factors: gender, age, stage of disease, alcohol use & comorbidities
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13
Q

What is anticipatory N/V?

A

when a pt thinks they will vomit so vomiting does occur

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14
Q

What is delayed chemo-induced N/V?

A
  • occurs at least 24hrs following chemo administration
  • acute N/V increased risk
  • risk factors: high-dose chemo, certain agents, poorly controlled N/V
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15
Q

What is breakthrough chemo-induced N/V?

A
  • occurs despite standard tx
  • requires further intervention
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16
Q

What is refractory chemo-induced N/V?

A

unrelieved N/V despite standard & breakthrough tx

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17
Q

What medications are the classes of antiemetics?

A
  • anticholinergics
  • antihistamines
  • neurolytics
  • prokinetics
  • 5HT3
  • adjunct medication
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18
Q

What anticholinergic medications act as antiemetics?

A
  • scopolamine
  • dicyclomine (bentyl)
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19
Q

What neurolytic medications act as antiemetics?

A
  • chlorpromazine
  • haldol
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20
Q

What prokinetic medications act as antiemetics?

A
  • metoclopramide
  • cisaprine
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21
Q

What 5HT3 medications act as antiemetics?

A

ondansetron

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22
Q

What are adjunct medications that act as antiemetics?

A
  • corticosteroids
  • benzodiazepines
  • cannabinoids
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23
Q

What are the routes of administration for antiemetics?

A
  • oral
  • sublingual
  • rectal
  • IV
  • IM
  • SQ
  • transdermal
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24
Q

How do anticholinergics work?

A

block acetylcholine at the muscarinic receptors

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25
What can anticholinergics be used to treat?
used to treat motion sickness
26
What are the side effects of anticholinergics?
- dry mouth - urinary rention - blurred vision - exacerbation of narrow-angle glaucoma - skin irritation
27
What do you need to do with an anticholinergic before an MRI?
remove it
28
What medication is an anticholinergic and what is the route of administration?
scopolamine; transdermal patch
29
Where are serotonin receptors?
serotonin receptors (5-HT3 type) are present both peripherally & centrally
30
When are serotonin antagonists given?
- Chemotherapy - radiation therapy - post-op N/V
31
Where are serotonin antagonist metabolized and excreted?
In the liver & excreted in the urine
32
What do serotonin antagonist end in?
setron
33
What drugs are serotonin antagonists?
- ondansetron (zofran) - granisetron (kytril) - dolasetron (anzemet) - palonosetron (aloxi)
34
What are the side effects of serotonin antagonists?
- headache - diarrhea - fever - hypotension - GT prolongation
35
How does ondansetron (zofran) work?
block serotonin in the CTZ
36
What are the routes for ondansetron (zofran)?
- PO - sublingual - IV - IM
37
What are the possible doses for zofran?
- 4 mg - 8 mg
38
What pregnancy category is zofran?
pregnancy category B
39
What are contraindications for zofran?
anticonvulsants
40
What patients should you use caution when giving zofran?
Use the lowest dose in hepatic & renal impairment
41
What are the side effects of zofran?
- headache - diarrhea - constipation - fatigue
42
What are the 3 subtypes of dopamine 2 antagonists?
- piperazine phenothiazine/ antipsychotics; prochlorperazine - metoclopramide (reglan) - butyrophenone derivative/ antipsychotic; doperidol & haloperidol (haldol)
43
What are the indications for dopamine 2 antagonists?
- motion sickness - chemo-induced N/V - post-op N/V
44
What properties do dopamine 2 antagonists have?
antihistamine & anticholinergic properties
45
What medications are considered second-line therapy?
dopamine 2 antagonist
46
What are drugs in the dopamine 2 antagonist class?
- promethazine (Phenergan) - trimethobenzamide (tigan)
47
What class is metoclopramide (Reglan) in?
dopamine 2 receptor antagonist
48
What is metoclopramide (reglan) also classified as?
non-phenothiazine
49
What are the indications for metoclopramide (reglan)?
- GERD - diabetic gastroparesis - N/V
50
What are the routes of administration for metoclopramide?
- oral - IV - IM
51
What is the black box warning for metoclopramide (reglan)?
may cause tardive dyskinesia
52
What pregnancy category is metoclopramide (reglan)?
pregnancy category B
53
What are contraindications for metoclopramide (reglan)?
- bowel obstruction - GI bleeding - pheochromocytoma - epileptic
54
What are the side effects of metoclopramide (reglan)?
- restlessness - drowsiness - extrapyramidal symptoms (EPS) - neuroleptic malignant syndrome (NMS) - suicide ideation
55
What is haloperidol (haldol) derived from?
butyrophenone derivative
56
What are indications for haldol?
- schizophrenia - control of tics & vocal utterances of Tourette's disorder - N/V
57
What is the route of administration for Haldol?
- PO - IV - IM
58
What is the black box warning for haldol?
elderly patients with dementia-related psychosis
59
What pregnancy category is haldol?
pregnancy category C
60
What are contraindications for haldol?
- patients with severe toxic central nervous system depression or comatose states from any cause - hypersensitivity to drug - Parkinson's disease - dementia
61
What are side effects of haldol?
- sedation - EPS - tardive dyskinesia - dystonia - dizziness - QT prolongation
62
phenothiazines are ___________ acting
centrally
63
What are phenothiazines used for?
used for N/V related to: - anesthesia - sever vomiting - intractable hiccoughs
64
What are the routes of administration for phenothiazines?
- oral - suppositories - IM - IV
65
What are contraindications for phenothiazines?
- pts in comas or severe CNS suppression - severe hypo/hypertension - liver dysfunction - severe renal impairment
66
What drugs are phenothiazines?
**- prochlorperazine (compazine)** - chlorpromazine (thorazine) - perphenazine (trilafon) - Thiethylperazine maleate: torecan (IM) or norazine (PO or PR)
67
What are possible adverse effects of phenothiazines?
- decreased CNS stimulation - hypotension - cardiac arrhythmias - autonomic effects - urine may become pink to red-brown in color - endocrine effects - photosensitivity
68
What kind of drug is prochlorperazine (Compazine)?
piperaze phenothiazine
69
What are indications for compazine?
- N/V - schizophrenia - non-psychotic anxiety - morning sickness
70
What are the routes of administration for compazine?
- oral - IV - IM - rectal
71
What is Compazine metabolized and excreted by?
metabolized by the liver & excreted via the urine
72
What are the side effects of compazine?
- drowsiness - hypotension - extrapyramidal sx - tardive dyskinesia - neuroleptic malignant syndrome - dystonia - photophobia - blurred vision
73
What are contraindications for compazine?
- pts taking antipsychotic drugs - children
74
What are H1 receptor antagonists also known as?
anti-histamine
75
What are H1 receptor antagonists used for?
- motion sickness - morning sickness - allergies
76
What other properties do H1 receptor antagonists have?
anticholinergic properties
77
How do H1 receptor antagonists work?
block muscarinic receptors
78
What drugs are in the H1 receptor antagonist class?
- diphenhydramine - meclizine - promethazine - doxylamine succinate
79
What are the side effects of H1 receptor antagonists?
- drowsiness - blurred vision - dry mouth - hypo/hypertension - urinary retention
80
Do corticosteroids help with N/V?
according to the Cochrane report there is a low-degree of evidence for tx of N/V
81
What are indications for corticosteroids for N/V?
used as an adjuvant to tx chemo-induced N/V
82
What is the mechanism of action for corticosteroids?
- precise mechanism of action is not know - suppresses prostaglandin release from hypothalamus which may then inhibit the subsequent process of N/V - anti-inflammatory
83
What corticosteroids are used for N/V?
- dexamethasone (decadron) - prednisone (deltasone)
84
How should you administer corticosteroids for N/V?
administer slowly
85
What are the side effects of corticosteroids?
- insomnia - anxiety - acne - hyperactivity
86
What have cannabinoids been historically used for?
have been used for centuries for a wide variety of ailments
87
What are the types of cannabinoids?
- CB-1 1 receptors: GI tract - CB-2 receptors: inflammatory & epithelial cells
88
What is cannabinoid equally efficient as?
equal in efficacy to ondansetron
89
What drugs are in the cannabinoid class?
** - drobabinol (marinol)** - nabilone (cesamet)
90
What are side effects of cannabinoids?
- sedation - vertigo - euphoria - dry mouth - tachycardia - paranoid reactions
91
What are indications for dronabinol (marinol)?
- anorexia - CINV that has failed standard tx - appetite stimulant
92
What is the Route of administration for dronabinol (Marinol)?
oral
93
What are the possible dosages for Dronabinol (marinol)?
- 2.5 mg - 5 mg - 10 mg
94
dronabinol is highly __________ ____________
protein bound
95
What pregnancy category is dronabinol (marinol)?
pregnancy category C
96
What should you be cautious with when using dronabinol (marinol)?
- elderly pts due to an increased risk of neuropsychoactive effects - patients with a history of alcohol &/or substance abuse - patients with underlying psychiatric disorders (mania, depression, or schizophrenia)
97
What are the side effects of dronabinol (marinol)?
- mood changes - euphoria - depression - insomnia - psychosis (in extreme cases)
98
What class is olanzapine (zyprexa) in?
thienobenzodiazepine
99
What other class of drug is olanzapine (zyprexa) considered?
also an antipsychotics
100
What are indications for olanzapine (zyprexa)?
- depressive episodes related to bipolar I - tx of resistant depression - acute agitation related to schizophrenia & bipolar I mania - N/V
101
What are the routes of administration for olanzapine (zyprexa)?
- PO - IM
102
What is the black box warning for olanzapine (zyprexa)?
elderly patients w/ dementia- related psychosis
103
what are contraindications for olanzapine (zyprexa)?
- elderly patients with dementia-related psychosis - fluoxetine in combination - in combination with lithium or valproate
104
What labs should be monitored when taking olanzapine (zyprexa)?
- CBC - glucose - lipid profile
105
What pregnancy category is olanzapine (zyprexa)?
pregnancy category C
106
What are the side effects of olanzapine (zyprexa)?
- hypotension - weight gain - suicide ideations - neuroleptic malignant syndrome - sedation
107
What neurotransmitters do anxiolytics/ benzodiazepines affect?
affects GABA neurotransmitters
108
What are the indications for anxiolytics/ benzos?
- typically used as an adjunct agent for acute or delayed N/V - anticipatory N/V
109
What do anxiolytics/ benzos act as?
CNS depressants; interferes with afferent nerves
110
What are anxiolytics/benzos drugs used for N/V and their doses/routes?
- alprazolam(xanax); 0.5 to 2 mg PO - lorazepam (ativan): 0.5 to 2 MG PO, SQ or IV
111
What are side effects of anxiolytics/benzos?
- drowsiness - sedation - confusion - agitation - dependence & withdrawal sx - hallucinations
112
What do neurokinin-1 antagonists also inhibit?
also inhibits substance P
113
What are indications for neurokinin-1 antagonists?
to prevent & treat acute & delayed nausea associated with highly emetogenic chemotherapy
114
What are the routes of administration for neurokinin-1 antagonists?
- PO - IV
115
Neurokinin-1 antagonists can be ____________ with other __________
combined; antiemetics
116
neurokinin-1 antagonists are __________ of the __________ system
inducers; cyp450
117
What are drugs in the neurokinin-1 antagonist class?
**-aprepitant (emend)** - fosaprepitant dimeglumine (emend) - rolapitant (varubi)
118
What are the side effects of neurokinin-1 antagonists?
- diarrhea - constipation - gastritis - anorexia - headache - fatigue
119
What is the route of administration & dosage for aprepitant (emend)?
IV; 150 mg
120
What can aprepitant (emend ) cross?
the blood brain barrier
121
What is aprepitant (emend) metabolized & excreted in?
metabolized in liver & excreted in the urine & feces
122
What drugs interact with aprepitant (emend)?
- pimozide - warfarin - oral contraceptives - corticosteroids
123
What are the side effects of aprepitant (emend)?
- liver enzyme elevation - dehydration - hiccups - steven-johnson syndrome
124
What herbal & vitamin supplements are used as antiemetics?
- ginger - pyridoxine (vitamin B6)
125
What medications are used to augment antiemetics?
- diphenhydramine (Benadryl) - lorazepam - megestrol acetate (megace)
126
What should you know about antiemetic use with pediatrics?
- should be used with caution - increase risk for adverse effects
127
What should you know about antiemetic use with adults?
- frequently used for surgery & chemotherapy - pregnancy & lactation; not been studied; many drugs can enter breast milk
128
What should you know about antiemetic use with older adults?
- more likely to experience an adverse effect from drugs - issue of hepatic & or renal impairment
129
What lab studies are important to look at for N/V?
- weight - hydration status - serum electrolytes - creatinine - LFT - I & Os
130
What is extrapyramidal sx (EPS) manifested as?
manifested primarily as acute dystonic reactions
131
What can dystonic reactions include?
- sudden onset of muscular spasms, especially in the head & neck or opisthotonos - other EPS include: laryngospasm, dysphagia, & oculogyric crisis - involuntary spasms of the tongue & mouth may lead to difficulty in speaking & swallowing - may also include akathisia, restlessness, akinesia, & other parkinsonian-like sx
132
What are tx for extrapyramidal sx (EPS)?
- depends on severity of sx - reduce or discontinue drug - anticholinergic drugs can be used to treat acute dystonic reactions
133
What are emetics used for?
- may be given in cases of overdosing or poisoning - used to induce vomiting - no longer recommended for home use
134
Is IPECAC used now?
no; standard of practive prior to 2003 - standard of practice as of today is to dispose of any IPECAC in home & call poison control center
135
What is your priority nursing intervention for N/V?
assess/identify factors contributing to sx of N/V
136
What focused assessments should be performed for N/V?
- skin - cardiac - I & Os - lab studies - s/s of dehydration
137
What should you do when pt has N/V?
administer antiemetic as prescribed
138
What should you monitor for pts on anticholnerigcs?
monitor for side effects
139
What patient education should be given for pts taking antiemetics?
- Drink plenty of fluids - small frequent meals - avoid strong smells
140
What evaluation should done when pt is taking antiemetics?
- did sx improve - good urine output - able to tolerate food

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