nausea and vomiting Flashcards
other Sxs associated with NV?
palor, diaphoresis, tachycardia
causes of NV
GI disorders (flu, pathogen, ulcer, GERD, pancreatitis, cholecystitis, obstruction, tumor, DM gastroparesis), CNS disorders (anxiety, tumor, HA), pain (acute* or chronic), excessive intake of anything (food or alcohol), cyclic vomiting syndrome (bouts of severe NV that can last for days, no known cause, associated with migraine HA, may be triggered by stress, children more often than adults), pregnancy (80%, begins week 4-7, resolves week 20, hyperemesis gravidarum (under 1%))
treatment-induced causes of NV
anti-neoplastic agents radiation opioids anesthesia procedures (especially abdominal)
complications of NV
discomfort, dehydration (K+, Na+, Cl-), malnutrition, aspiration pneumonia, anxiety, compromise therapy, decreased QOL
assessment of NV
number of episodes, onset, duration of Sxs, severity (1-10)
questions to ask patients presenting with NV
how long have you had NV?
what color is your vomitus?
how often do you vomit?
is vomiting related to eating? if so, what food and how soon after?
do you have nausea without vomiting?
is the NV associated with … ? (signs of other problems)
site of action of drugs that treat NV
dopamine receptors (D2) histamine receptors (H1 and H2) muscarinic receptors - cholinergic receptors (M) serotonin receptors (5-HT3) neurokinin receptors (NK-1)
non-pcol management of NV
determine cause
put the gut to rest - clear liquid diet and IV hydration
dietary - avoid favorite foods, avoid fatty, fried, sweet and spicy foods, eat food cold or at room temp
physical - avoid unpleasant sights, sounds and odors that may aggravate, get fresh air, avoid sudden movements, dim lights, acupressure, nerve stimulation therapy (relief band? - returns stomach to a normal rhythm)
treatment of nausea secondary to dyspepsia
antacids (maalox, mylanta, tums, peptobismol) H2 antagonists (zantac, pepcid)
antihistamines-anticholinergics to treat NV
limited for mod-severe NV
MOA: block histamine and/or muscarinic receptors in the CTZ and NTS centers
SE: drowsiness**, sedation, dry mouth, constipation, blurred vision
phenothiazines
prochlorperazine, promethazine
MOA: dopamine inhibition at CTZ
SE: dizziness, sedation, dry mouth, hypotension, EPS (children, young adults, elderly)
serotonin antagonists
ondansetron, granisetron, palonosetron
MOA: serotonin inhibition at CTZ, NTS, and GI tract
very effective
SE: mild HA, constipation, dizziness, QT prolongation
advantages/disadvantages of various serotonin antagonists
ondansetron: multiple dosage forms (inc. ODT), generic, low cost
granisteron: multiple dosage forms (patch, inj, SC), generic, low cost
palonosetron: long DOA, brand only, no PO dosage form
NO SUPPOSITORY FOR ANY
granisetron dosage forms
sancuso
patch: apply 24-48 hours before chemo, may be worn up to 7 days, avoid sun exposure to site and for up to 10 days, $$$
sustol
ER injection: acute delayed CINV, polymer-based drug delivery technology, efficacy greater than 5 days, 10 mg SC no more often than q 7 days, administer over 20-30 seconds d/t viscosity, not recommended for use longer than 6 months
butyrophenones
MOA: dopamine inhibition at CTZ
SE: sedation, hypotensoin, EPS*
black box warning: risk of EKG abnormalities (need 12-lead EKG + 2-3 hour post-op monitoring)
droperidol
haloperidol (1-5 mg IM/IV/PO q 1-5 hours)
olanzapine
MOA: blocks D2, 5-HT2c and 5-HT3 receptors - excellent for breakthrough NV, no IV formula
side effects: sedation
NK-1 antagonists
MOA: neurokinin receptor inhibition at CTZ, NTS and GI tract
SE: fatigue, dizziness, HA
aprepitant: for both acute and delayed CINV, not monotherapy, 125 mg day 1, 80 mg day 2 & 3, drug interactions (must decrease dexamethasone by 50%), expensive
fosaprepiant: for acute CINV, not monotherapy, 150 mg IV day 1, expensive
rolapitant: indicated for delayed CINV, not monotherapy, 180 mg as a single dose 1-2 hours before chemo, SE: neutropenia, hiccups, dec appetite, $$$
netupitant and palonosetron: indicated for both acute and delayed CINV, 300/0.5 mg PO 1-2 hours prior to chemo (covers days 1,2,3), used with dexamethasone, SE: headache, asthenia, dyspepsia, fatigue, constipation, $$$
cannabinoid use in NV
dronabinol and nabilone
MOA: binds with cannabinoid or CB1 receptors in the brain
efficacy similar to phenothiazines and metoclopramide
indications: unresponsive NV, wasting in patients with chronic disease, stimulate appetite, some pain management, MS
SE: sedation, dry mouth, euphoria, dysphoria
corticosteroid use in NV
MOA: inhibition of cortical input into vomiting center?
SE: insomnia, agitation, mild euphoria
low risk of ADRs
dexamethasone
benzo use in NV
lorazepam, alprazolam
MOA: inhibition of cortical input into vomiting center
especially useful for anticipating NV - start PO day prior to chemo and IV just prior to chemo
SE: sedation, amnesia
benzamide use in NV
metoclopramide
MOA: dopamine inhibition at CTZ, serotonin inhibition at CTZ, NTS, & GI tract
dose: 20-50 mg
SE: drowsiness, sedation, diarrhea; restlessness, agitation, EPS (use benadryl to prevent EPS)
treating NV associated with severe pain
5HT3 antagonists
scopolamine
apply 6-8 hours before needed
duration = 72 hours
dimenhydrinate
dramamine
50 mg PO taken 30-60 min before needed
meclizine
25 mg PO taken 30-60 min before needed
treating NV during pregnancy
dietary modifications herbal therapy -ginger root (1 gram in divided doses, efficacy similar to B6, onset is 3 days) -ginger gum -peppermint oil -best for mild cases B6 25 mg TID + doxylamine 12.5 TID metoclopramide 5-10 mg TID ondansetron 4-8 mg up to TID meclizine dimenhydrinate promethazine prochloperazine
hyperemesis gravidarum treatment
metoclopramide and ondansetron SQ infusions
similar to using an insulin pump
post-op NV
very common w older inhaled anesthetic agents
patients with multiple risk factors are at highest risk for PONV
most common complication associated with ambulatory surgery
prevention is more effective than treatment
risk factors for PONV
female
non-smoker
Hx of PONV or motion sickness
anesthetic: intra-operative use of volatile anesthetics (less w propofil), use of NO
surgical: duration of surgery, type of surgery (laprascopic, craniotomy, ENT)
treatment of PONV
low risk: 0-1 factors, no prophylaxis, treat PRN
mod-high: 2+ risk factors, prophylaxis with 1-2 antiemetics (1 if using propofol), 5HT3 is DOC, all classes can be used
highest risk: always use 2 agents (5HT3 antagonist + metoclopramide or aprepitant)
breakthrough: use an agent from a different class if within 6 hours
aprepitant in PONV
40 mg 1-3 hours prior to induction of anesthesia
acute emesis CINV
begins within 1-2 hours after administration, symptoms reach maximum intensity after 5-6 hours and resolve within 12-24 hours
delayed emesis CINV
most difficult to treat
follows acute emesis (post 24 hours) - less severe but more bothersome
peak onset 48-72 hours after chemotherapy administration
gradually diminishes over next 1-3 days
may persist up to 1 week after chemotherapy treatment; - may worsen with repeated courses
more common with high-doses of certain agents, especially cisplatin
no clear MOA, but appears to differ somewhat from acute emesis
anticipatory emesis CINV
conditioned response to a conditioned stimuli
usually develops after 4-5 cycles of cehmo
more common in patients with history of severe uncontrolled emesis
generally occurs before treatment begins
factors affecting CINV
female
age (decreased likelihood as age increases)
EtOH intake (less chance in Hx of chronic intake)
prior chemo (increases chance if emesis poorly controlled)
predisposition to NV (motion sickness)
personality (anxious)
emetogenic potential of chemo (cisplatin, cyclophospamide + doxorubin)
dose and dosage regimen (large doses, later in cycles, less with fractionated regimen)
combination therapy
preventing acute CINV
assess the individual situation
assess the emetogenic potential of the agents and regimen
always treat when risk is mod-high
use PO therapy whenever possible
regimen for prevention of acute CINV in high emetic risk patients
5HT3 antagonist -ondansetron 16 mg PO or 8-16 mg IV -granisetron 2 mg PO or 1 mg IV -palonosetron 0.25 mg IV dexamethasone -12 mg IV/PO day 1, then 8 mg daily days 2-4 aprepitant -125 mg PO day 1 then 80 mg days 2-3 \+/- lorazepam 0.5-2 mg IV or PO q46h PRN days 1-4
netupitant: 300 mg PO on day 1
palonosetron: 0.5 mg PO on day 1
dexamethasone: 20 mg PO on day 1, then 8 mg BID on days 2-4
+/- lorazepam: 0.5-2 mg IV or PO q46h PRN days 1-4
olanzapine: 10 mg PO on days 1-4
dexamethasone: 20 mg IV on day 1, then 8 mg BID on days 2-4
palonosetron: 0,25 mg IV on day 1
+/- lorazepam: 0.5-2 mg IV or PO q46h PRN days 1-4
prevention of acute CINV in moderate emetic risk patients
5HT3 antagonist (palonosetron is preffered) dexamethasone: days 1-3
prevention of acute CINV in low emetic risk patients
any of the following: dexamethasone* 12 mg po/IV daily metoclopramide 10-40 mg PO/IV, then q6h prochlorperzine 10 mg PO/IV, then q6h ondansetron 16 mg PO daily granisetron 2 mg PO daily
minimal emetic risk: use agents PRN
breakthrough NV during chemo
difficult to control
give agent from a different* drug class
IV or PR administration often required
ATC rather than PRN dosing
treatment of breakthrough NV during chemo
prochloperazine - 10 mg IV q46h PRN nabilone - 1-2 g PO q12h metoclopramide - 10-40 mg IV q46h prn + benadryl 50 mg IV haloperidol - 0.5-2 mg q46h PRN olanzapine - 10 mg PO daily
delayed NV overview
risk for acute CINV = risk for delayed CINV
complete control may only be 50%
clinicians often over-estimate efficacy of typical PRN regimens for delayed CINV
treatment and prevention of delayed NV
metoclopramide + dexamethasone
ondansetron or granisetron + dexamethasone
palonosetron +/- dexamethasone
olanzapine + 5HT3
aprepitant
add something the patient hasn’t had
carries over from acute treatment….
aprepitant 125 mg 1 hour prior to chemo and then 80 mg on days 2 and 3
plus dexamethsone 4-8 mg x 3-5 days starting on day 2
unresponsive delayed NV
nabilone, dronabinol, medical marijuana
better in young patients
monitoring antiemetic therapy efficacy
volume of vomit frequency and duration of vomiting nausea 0-10 ability to maintain food/liquid # of PRN doses of antiemetics QOL rating
monitoring antiemetic therapy toxicity
sedation/drowsiness dizziness diarrhea headache anticholinergic SE EPS
