Lecture 2 Nausea And Vomiting Flashcards
Motion sickness non Pharm measures
Stable visual point
Avoid visual/no visual stimuli that exacerbate
Acute pressure point
Diet
Increase ventilation
On boat: sit in central
Motion sickness pharmacological measure
Anticholinergic/antihistamines
- Dimenhydrinate, diphenhydramine
- start 60 mins before activity, repeat q4-q6 for - - -immediate release, q8-12 for long acting
- consider promethazine if patient does not respond to Dimenhydrinate
NV of pregnancy
Common in first trimester - 75% of women
Usually peaks at 9 weeks
If worse in am keep crackers at bedside
NV of pregnancy- non pharm
Diet, small, bland meals
Eat at times of the day when nausea is less
Eat cold foods
Drink fluids
Others: acupressure
NV of pregnancy- RX 1st line, 2nd line, 3rd line, 4th line, 5th line
1st: Diclectin- pyridoxine (vitamin B6) doxylamine 10mg delayed release
Dose: 2 tabs qhs then titrate by adding 1 tab in the am and 1 tab afternoon (max 8 tabs per day)
Side effects : drowsiness, disorientation, diarrhea
2nd: Pyridoxine alone can also work
3rd or 4th: Dimenhydrinate, also diphenhydramine or promethazine can be option
5th line: phenothiazines- chlorpromazine,prochlorperazine, metoclopramide
Hyperemesis gravidarum
Extreme persistent NV during pregnancy
Dehydration, electrolyte disturbances can occur
Often requires hospitalization
Management: IV fluids/electrolyte replacement, may consider phenothiazines, metoclopramide, ondansetron, corticosteroids
Ondansetron in pregnancy
May be used clinically for severe/persistent NV or hyperemesis gravidum
NOT RECOMMENDED
Post operative NV (PONV) main risks
4 main risks: female, non smokers, history of PONV/Motion sickness, post-op opioid use
Postoperative NV moderate and severe risk factors
Moderate risk (2 risk factors) - consider 1-2 antiemetics
Severe risk ( >3-4 risk factors)- 2 anti emetics before surgery
PONV prophylaxis therapies
5-HT3
Dexamethasone
Dimenhydrinate
Phenothiazines
NK1 RA
Factors to consider in selection of therapy for PONV
Timing
Consider goal of prevention vs treatment of PONV
Consider side effect profile
Cost and formulary issues
Anticipatory AINV
Occurs before patients receive their next chemo treatment
Considered a conditioned response
Breakthrough AINV
Nausea or vomiting that occurs despite prophylactic treatment and or requires rescue with antiemetics agents
Refractory AINV
Nausea and or vomiting that occurs during subsequent treatment cycles when antiemetic prophylaxis and or resource have failed in earlier cycles
Acute AINV
Occurs within first 24 hours after exposure to Antineoplastic agents
Onset with few minutes to several hours after drug administration
Instensity peaks at 5-6 hours
Resolves in approximately 24hours
Delayed AINV
Onset is 24 hours or more after chemo administration
Common in cisplatin and cyclophosphamide with doxorubicin
Maximal intensity at 48-72hours post chemo and can last 6-7 days
More common than acute
IV HEC
Highly emetogenic IV chemotherapy
IV MEC
Moderately emotogenic IV chemotherapy
What is the most important factor when assessing risk of Antineoplastic induced nausea/vomiting
Emetic risk
Other factors affecting risk of AINV
Women higher risk
High alcohol consumption is associated with less nausea
Younger age associated with higher risk of
Previous treatments or previous cycles of current treatment
Prophylaxis of acute AINV
Highly emetogenic chemo: three or four drugs given pre chemo
Moderately emetogenic chemo- two or three drugs given pre chemo
Low emetogenic chemo- then one drug option dexamethasone, 5HT3RA, prochlorperazine, metoclopramide
Example of regimen for high emetic chemo - three drug prophylaxis
Day 1 pre chemo : 5-HT3RA + NK1-RA + dexamethasone
Day 2: NK1-RA + Dexamethasone
Day 3: NK1-RA + Dexamethasone
Example of regiment for high emetic chemo - four drug prophylaxis
Day 1 pre chemo: 5-HT3 RA + NK1-RA + Dexamethasone + olanzapine
Day 2: NK1-RA + Dexamethasone + olanzapine
Day 3: NK1-RA + Dexamethasone + olanzapine
NK-1 Antagonist/ 5-HT3 receptor antagonist combination
Product: Akynzeo ( netupitant 300mg and palonosetron HCL 0.5mg as single capsule)
1 hour prior to chemo
Not covered by ABC
Treatment of breakthrough NV
Metoclopramide 10mg q4-q6 prn
Prochlorperazine 10mg q6h prn
Olanzapine 2.5-10mg po daily prn
Most common cause of NV in children in …..
Gastroenteritis
Non pharmacological for NV in children
Small meals
Prevent motion sickness in cars - improve ventilation
Use of antiemetics for motion sickness or N/V for children
Dimenhydrinate - recommended for >2 yrs old
Oral: ages 2-6, 12.5-25mg po q6-q8 prn (max 75mg every 24hrs)
Oral : ages 6-12: 25-50 mg po q6-q8 prn ( max 150mg every 24hrs)
Rectal formulation: Ages 2-5, 12.5mg-25mg prn.
