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NAUSEA AND VOMITING Flashcards

(53 cards)

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1
Q

Causes

A

REMEMBER ‘VOMITING’
- vestibular
- opiates
- migraine
- infection
- toxicity with drugs
- Increased ICP
- neurodegenic
- gestation

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2
Q

Types of drugs for N+V

A
  1. Antihistamines
  2. Antimuscarinic
  3. 5HT3 Antagonist
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3
Q

List the antihistamines used for N&V

A
  • Cinnarizine
  • Cyclizine
  • Promethazine hydrochloride
  • Promethazine teoclate
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4
Q

Which causes of N&V are antihistamines used in?

A
  • Vomiting during pregnancy = Promethazine
  • Post-op = Cyclizine
  • N&V in palliative care = Cyclizine
  • Motion sickness
  • Vertigo associated with meniere’s disease
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5
Q

What are the main side effects of
Antihistamines used for N&V?

A

Drowsiness and sedation
* Promethazine =most
* Cyclizine and Cinnarizine = less

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6
Q

List the antimuscarinic used for N&V

A

Hyoscine hydrobromide (NOT BUSCOPAN)
Note buscopan is Hyoscine
butylbromide

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7
Q

When is an antimuscarinic used in N&V?

A
  • N+V associated with motion sickness
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8
Q

Which antimuscarinic is used for motion sickness?

A

Hyoscine hydrobromide
E.g. Kwells

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9
Q

Which antiemetics are
INEFFECTIVE in motion sickness?

A
  • Dopamine antagonists
  • 5HT3-antagonists
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10
Q

Antimuscarinic SEs

A
  • Dry mouth
  • Blurred vision
  • Drowsiness and sedation (not as bad as antihistamines)
  • Urinary retention
  • Tachycardia

BT DUD

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11
Q

List the antimuscarinic used for 5HT3-antagonists

A
  • Granisetron
  • Odansetron
  • Palonesteron
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12
Q

Which types of N&V
can the 5-HT3 antagonists be used in?

A
  • N&V in patients receiving cytotoxic drugs
  • Post-op N&V
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13
Q

Which 5-HT3 receptor antagonist can be found in a combination product with an NK1 antagonist, and which one?

A

Palonesteron can be found in combination with Netupitant
(NK1 antagonist)

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13
Q

What are the side effects of 5HT3 antagonists?

A

Generally well tolerated
- Gl upset
- Headache and flushing
- Most common is constipation
- QT
- SS

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14
Q

List the dopamine antagonists as an antiemetic in N&V

A
  1. Phenothiazines (Typical antipsychotics)
    - Chlorpromazine (most sedating), Prochlorperzine, perphenazine, Trifluoperazine
  2. Other antipsychotics e.g.
    Levomepromazine, Haloperidol (unlicensed)
  3. Metoclopramide
  4. Domperidone
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15
Q

What types of N&V are dopamine antagonists used for?

A
  • Diffuse neoplastic disease
  • Radiation sickness
  • Emesis caused by drugs such as opioids, general anesthetics and cytotoxic drugs
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16
Q
A
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17
Q

Which phenothiazine is the most sedating?

A

Chlorpromazine

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18
Q

What are the side effects of
Phenothiazines?

A

MRS PG B

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19
Q

Which dopamine antagonist may be better in emesis associated with gastroduodenal, hepatic, and biliary disease? And why?

A
  • Metoclopramide
  • Act directly on GI tract so it is more superior then phenothiazines
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20
Q

What are the side effects of
metoclopramide?

A
  • Parkinsonian symptoms
  • Diarrhoea
  • Drowsiness
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21
Q

What is a serious side effect of
Metoclopramide?

Study These Flashcards
A

Neurological SE: dystonia
- particularly in children (esp young girls)

22
Q

Dystonia

Study These Flashcards
A
  • Facial and skeletal muscle spasms would occur
  • Occur shortly after starting treatment and subside within 24 hours of stopping it
  • Procyclidine injected would stop these dystonic attacks
23
Q

What are the guidances by MHRA on Metoclopramide to reduce the risk of neurological side effects?

Study These Flashcards
A
  • Use in 18+
  • Short term (max 5 days)
  • Usual dose 10mg TDS
    These restrictions do not apply to unlicensed use e.g. palliative care
24
What are the cautions for use of Metoclopramide?
- Children due to risk of serious neurological side effects - Parkinson's disease (due to parkinsonian symptoms which would worsen Parkinson's) - Asthma
25
What is the advantage of using domperidone over metoclopramide and phenothiazines?
- Domperidone does NOT BBB - Metoclopramide (and phenothiazines do), which is why you can get sedation and neurological side-effects - You DO NOT get sedation or dystonia with domperidone
26
What are the side-effects of Domperidone?
- Dry mouth (Most common) - QT prolongation
27
What is a serious side effect of Domperidone?
- Serious cardiac side effects - e.g. Arrhythmias, QT interval prolongation and sudden cardiac death
28
What are the guidances MHRA for domperidone in order to reduce the risk of cardiac side effects?
- It should only be used for relief of N&V (so not prophylaxis) - Lowest effective dose and shortest possible duration ( Max 1 week)
29
Domperidone CI
- CI in cardiac disease - QT interval prolongation drugs - Drugs that are CYP inhibitors
30
Is domperidone effective for N&V in patient's aged under 12 years old?
- No - MHRA 2019 guidance suggests that there is no efficacy in children aged under 12 years old
31
What should patients and carers be advised on when taking domperidone?
How to recognise symptoms of arrhythmias e.g. palpitations and syncope
32
Which dopamine antagonist would you only offer to patient's with Parkinson's?
Domperidone - Doesn't cross BBB
33
List the NK1 antagonists used in N&V
- Aprepitant - Fosaprepitamt - Netupitant
34
What are the use of NK1 antagonists?
For prevention of N&V for moderate and highly emotogenic (e.g. Cisplatin) cytotoxic drugs
35
What are the side effects of NK1 antagonists?
- Appetite decreased - Asthenia - Constipation - Headache - Hiccups
36
NK1 antagonists and hormonal contraceptives
- NK1 antagonists can reduce the effectiveness of hormonal contraceptives - Barrier protection or non-hormonal alternatives should be used during treatment and 2 months after stopping
37
When is Nabilone used?
- When no other drug is effective
38
What are the side effects of Nabilone?
- Drowsiness - Dizziness - Dry mouth
39
Which type of N&V is dexamethasone used in?
N&V associated with cancer It can be used on its own or with either: - D2 antagonists - 5HT3 antagonists - NK1 antagonist
40
How do you treat nausea and vomiting during pregnancy?
- If the first trimester, then it's usually mild and does not require drug therapy, offer advice such as oral hydration, rest and ginger etc. - If vomiting is severe, then short-term therapy with pharmacological treatment
41
What antiemetics can be used in pregnancy?
- Chlorpromazine - Cyclizine - Metoclopramide - Prochlorperazine - Promethazine - Ondansetron (avoid in first trimester)
42
What are the risk factors of postoperative nausea and vomiting (PONV)?
- Female gender - Being a **non**-smoker - History of PONV - Use of opiod analgesia - Type of surgery
43
Which anti-emetics are used as prophylaxis for PONV?
Prophylaxis only needed if there is a risk of PONV - Dopamine antagonists - 5HT3 antagonists - Antihistamines Combination of two or more is used if there is a HIGH RISK
44
How is N&V associated with cytotoxic drugs prevented?
- Prophylaxis depends on when symptoms occur (e.g. acute - within 24 hours, delayed - more than 24 hours, and anticipatory - occurring prior to subsequent doses) - Prophylaxis also depends on risk factors e.g. women, - Prophylaxis also depends on the level of emetogenic effect of cytotoxic drugs
45
List some of the cytotoxic drugs according to the level of emesis: MILD
Mild: - Florouracil - Etoposide - Methotrexate (Low dose) - Vinca-alkaloids - Abdominal radiotherapy
46
List some of the cytotoxic drugs according to the level of emesis: MOD
Moderate: - Taxanes - Doxorubicin - Low/intermediate dose of Cyclophosphamide
47
List some of the cytotoxic drugs according to the level of emesis: HIGH
High: - Cisplatin - Dacarbazine - High doses of cyclophosphamide
48
How do you prevent **acute symptoms** of N&V associated with cytotoxic drugs?
Low risk of emesis: - pretreatment with Dexamethasone OR Lorazepam High risk of emesis: - Dexamethasone AND 5-HT3 antagonist and NK-1 antagonist (e.g. arepiprentant)
49
How do you prevent **delayed symptoms** of N&V associated with cytotoxic drugs?
If delayed symptoms are associated with the **moderate** emetogenic drug: - Dexamethasone + 5HT3 antagonist If delayed symptoms are associated with the **highly** emetogenic drugs: - Dexamethasone + aprepitant
50
How do you prevent **anticipatory symptoms **of N&V associated with cytotoxic drugs?
- Good symptom control - But lorazepam may be used for its sedative, amnesic, and anxiolytic effect (so it relieves anxiety which is one risk factor of N&V associated with cytotoxic drugs)
51
Which antiemtics can be used in ménière's disease?
- Antihistamines - Phenothiazines - Betahistine
52
Which antiemetics is used buccally in N&V associated with migraines?
Prochlorperazine 3mg (buccastem)

PR - CNS (61 decks)

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