Chapter 4 - Nausea And Labrynth Disorders

Question 1

What is the lifestyle advice associated with nausea and vomiting?

Answer 1

Eat smaller, more frequent meals
Remain hydrated (with water, not juice)
Eat as tolerated
Eat light, bland foods 
Ginger may help

Question 2

What is the mechanism of antihistamines in nausea and vomiting?

Answer 2

Block muscarinic receptors

And inhibit cholinergic transmission to the vomiting centre

Question 3

Give some examples of sedating antihistamines

Answer 3

Chlorphenamine
Promethazine
Diphenhydramine 
Cinnarizine
Cyclizine

Question 4

Give some examples of non-sedating antihistamines

Answer 4

Fexofenadine
Cetirizine
Loratadine
Acarvistine

Question 5

List some antimuscarinic side effects associated with antihistamines

Answer 5

Sedation
Dry mouth 
Constipation 
Blurred vision
Urinary retention

Question 6

Which antipsychotics can be used in nausea and vomiting?

Answer 6

Chlorpromazine
Prochlorperazine

In palliative care, haloperidol and levopromethazine

Question 7

When is buccal gem licensed OTC?

Answer 7

Nausea and vomiting associated with previously diagnosed migraine in over 18 year olds

Question 8

What is the mechanism of phenothiazines in nausea and vomiting?

Answer 8

Block the CTZ

They act centrally

Question 9

Give examples of prokinetic agents used in nausea and vomiting

Answer 9

Metoclopramide

Domperidone

Question 10

What is the mechanism of prokinetic agents in nausea and vomiting?

Answer 10

Inhibit the CTZ

Also acts on the GIT

Question 11

Which antiemetic affects the CTZ and the GI system, metoclopramide or prochlorperazine?

Answer 11

Metoclopramide, therefore it can be used in nausea and vomiting associated with gastric, hepatic and biliary disease

Question 12

What is the maximum duration of use of metoclopramide?

Answer 12

5 days

Question 13

Why is the maximum use of metoclopramide 5 days?

Answer 13

Risk of EPSEs

Question 14

What is the minimum age of metoclopramide?

Answer 14

18 years

Question 15

Why doesn’t domperidone act centrally?

Answer 15

It doesn’t cross the BBB

Question 16

At what weight is domperidone unlicensed?

Answer 16

Less than 35kg

Question 17

Which class of antiemetics shouldn’t be co-prescribed with a prokinetic agent?

Answer 17

Antimuscarinics

This increases antimuscarinic side effects
Concurrent use can lead to confusion in the elderly
The GI effects of prokinetics are antagonised by antimuscarinics

Question 18

Give examples of 5HT3 receptor antagonists

Answer 18

Onsansetron

Granisetron

Question 19

When are 5HT3 receptor antagonists used in nausea and vomiting?

Answer 19

Cytotoxic induced nausea and vomiting

Postoperative nausea and vomiting

Question 20

When is dexamethasone used in nausea and vomiting?

Answer 20

Chemotherapy induced nausea and vomiting

Question 21

What are the different classes of antiemetics?

Answer 21

Antihistamines 
Prokinetics
5HT3 receptor antagonists 
Neurokinin 1-receptor antagonists 
Dexamethasone
Nabilone

Question 22

Give examples of neurokinin 1-receptor antagonists

Answer 22

Aprepirant

Fosaprepitant

Question 23

When are neurokinin 1-receptor antagonists used?

Answer 23

Moderately emetogenic chemotherapy

Question 24

What is nabilone and when is it used?

Answer 24

A synthetic cannabinoid

It is used as add on treatment for chemotherapy induced nausea and vomiting

Question 25

When does nausea and vomiting in pregnancy usually resolve?

Answer 25

16-20 weeks

Question 26

Which antiemetics can be used in pregnancy?

Answer 26

Antihistamines e.g. promerhazine, certirizine, chlorphenamine

Question 27

What is the most effective drug for motion sickness?

Answer 27

Hyoscine

Question 28

What options are available for motion sickness?

Answer 28

``` Hyoscine Promethazine Cinnarizine Cyclizine Ginger Acupressure ```

Question 29

Which antiemetics should be used in gastric stasis/drug induced nausea and vomiting?

Answer 29

Metoclopramide | Domperidone if EPSEs are a problem

Question 30

What antiemetic would you give for nausea and vomiting associated with diseases of the inner ear?

Answer 30

Cyclizine

Question 31

What antiemetic is used for the nausea and vomiting associated with tinnitus, vertigo and hearing loss associated with Ménière’s disease?

Answer 31

Betahistine

Question 32

Should betahistine be taken with or without food?

Answer 32

With food

Question 33

What age is cyclizine licensed in?

Answer 33

>6 years old It can be given to >1 month old Don’t give to neonates due to significant antimuscarinic activity

Question 34

Why is cyclizine cautioned in severe heart failure?

Answer 34

It reduces cardiac output, and therefore increases heart rate

Question 35

How does alcohol and cyclizine interact?

Answer 35

The effects of alcohol are enhanced

Question 36

Can patients drive if they have taken nabilone?

Answer 36

Yes, as long it has been taken as prescribed, is within certain limits, and has not impacted the patients driving It is an offence to drive if nibolone has impaired driving

Question 37

What are the indications of domperidone?

Answer 37

Nausea and vomiting in adults and children in >12 years GI pain in palliative care Neonates with GORD - specialist use only

Question 38

What is the maximum duration of domperidone and why?

Answer 38

7 days | Due to the risk of CVD effects (arrhythmia)

Question 39

When are the cardiovascular side effects of domperidone increased?

Answer 39

Over 60 year olds Daily domperidone doses above 30mg Patients taking other drugs that increase QT interval prolongation

Question 40

What is the dose of metoclopramide?

Answer 40

<60kg - 500mcg/kg daily in 3 divided doses >60kg - 10mg TDS

Question 41

When metoclopramide is given by IV injection, how long should it be administered for?

Answer 41

At least 3 minutes

Question 42

How can the risk of EPSEs be reduced in patients taking metoclopramide?

Answer 42

Short term use (5 days max) Max 30mg daily Give the injection over at least 3 mins

Question 43

When taking metoclopramide, which patient groups are at the highest risk of EPSEs?

Answer 43

Women | The very round or very old

Question 44

When do EPSEs usually start after taking metoclopramide?

Answer 44

Within 24h

Question 45

What is the maximum duration of use of ondansetron and why?

Answer 45

5 days | Due to risk of arrhythmias

Question 46

What is the risk associated with taking ondansetron in pregnancy in the first trimester?

Answer 46

Small risk of cleft lip and/or palate

Question 47

Which antiemetics are available as a patch?

Answer 47

Hyoscine - change every 72 hours | Granisetron - change every 10 days

Question 48

What are the indications of hyoscine?

Answer 48

Motion sickness Excess secretions in palliative care Bowel colic pain in palliative care Hypersalivation due to clozapine

Question 49

How is the hyoscine patch used?

Answer 49

Apply behind the ear 5-6 hours before the journey Change patch after 72 hours if needed The patch can be cut if required

Question 50

What are the brand names of hyoscine?

Answer 50

Patch - scopoderm | Tablets - keels, joyrides