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PR - CNS > NAUSEA AND VOMITING > Flashcards

NAUSEA AND VOMITING Flashcards

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?

A

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

22
Q

Dystonia

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?

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
Q

What are the cautions for use of
Metoclopramide?

A
  • Children due to risk of serious neurological side effects
  • Parkinson’s disease (due to parkinsonian symptoms which would worsen Parkinson’s)
  • Asthma
25
Q

What is the advantage of using domperidone over metoclopramide and phenothiazines?

A
  • 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
Q

What are the side-effects of
Domperidone?

A
  • Dry mouth (Most common)
  • QT prolongation
27
Q

What is a serious side effect of
Domperidone?

A
  • Serious cardiac side effects
  • e.g. Arrhythmias, QT interval prolongation and sudden cardiac death
28
Q

What are the guidances MHRA for domperidone in order to reduce the risk of cardiac side effects?

A
  • It should only be used for relief of N&V (so not prophylaxis)
  • Lowest effective dose and shortest possible duration ( Max 1 week)
29
Q

Domperidone CI

A
  • CI in cardiac disease
  • QT interval prolongation drugs
  • Drugs that are CYP inhibitors
30
Q

Is domperidone effective for N&V in patient’s aged under
12 years old?

A
  • No
  • MHRA 2019 guidance suggests that there is no efficacy in children aged under
    12 years old
31
Q

What should patients and carers be advised on when taking domperidone?

A

How to recognise symptoms of arrhythmias e.g. palpitations and syncope

32
Q

Which dopamine antagonist would you only offer to patient’s with Parkinson’s?

A

Domperidone
- Doesn’t cross BBB

33
Q

List the NK1
antagonists used in
N&V

A
  • Aprepitant
  • Fosaprepitamt
  • Netupitant
34
Q

What are the use of
NK1 antagonists?

A

For prevention of N&V for moderate and highly emotogenic (e.g. Cisplatin)
cytotoxic drugs

35
Q

What are the side effects of NK1 antagonists?

A
  • Appetite decreased
  • Asthenia
  • Constipation
  • Headache
  • Hiccups
36
Q

NK1 antagonists and hormonal contraceptives

A
  • 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
Q

When is Nabilone used?

A
  • When no other drug is effective
38
Q

What are the side effects of Nabilone?

A
  • Drowsiness
  • Dizziness
  • Dry mouth
39
Q

Which type of N&V is dexamethasone used in?

A

N&V associated with cancer
It can be used on its own or with either:
- D2 antagonists
- 5HT3 antagonists
- NK1 antagonist

40
Q

How do you treat nausea and vomiting during pregnancy?

A
  • 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
Q

What antiemetics can be used in pregnancy?

A
  • Chlorpromazine
  • Cyclizine
  • Metoclopramide
  • Prochlorperazine
  • Promethazine
  • Ondansetron (avoid in first trimester)
42
Q

What are the risk factors of postoperative nausea and vomiting (PONV)?

A
  • Female gender
  • Being a non-smoker
  • History of PONV
  • Use of opiod analgesia
  • Type of surgery
43
Q

Which anti-emetics are used as prophylaxis for PONV?

A

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
Q

How is N&V associated with cytotoxic drugs prevented?

A
  • 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
Q

List some of the cytotoxic drugs
according to the level of emesis: MILD

A

Mild:
- Florouracil
- Etoposide
- Methotrexate (Low dose)
- Vinca-alkaloids
- Abdominal radiotherapy

46
Q

List some of the cytotoxic drugs
according to the level of emesis: MOD

A

Moderate:
- Taxanes
- Doxorubicin
- Low/intermediate dose of
Cyclophosphamide

47
Q

List some of the cytotoxic drugs
according to the level of emesis: HIGH

A

High:
- Cisplatin
- Dacarbazine
- High doses of cyclophosphamide

48
Q

How do you prevent acute symptoms of
N&V associated with cytotoxic drugs?

A

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
Q

How do you prevent **delayed symptoms **of
N&V associated with cytotoxic drugs?

A

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
Q

How do you prevent **anticipatory
symptoms **of N&V associated with cytotoxic drugs?

A
  • 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
Q

Which antiemtics can be used in ménière’s disease?

A
  • Antihistamines
  • Phenothiazines
  • Betahistine
52
Q

Which antiemetics is used buccally in N&V
associated with migraines?

A

Prochlorperazine 3mg
(buccastem)

PR - CNS (61 decks)

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