Nausea and Vomiting Treatments (Part 2) Flashcards
Motion Sickness
- Non Pharm
Stable visual point
- Clear forward view
- Minimal head movement
Avoid exacerbations (Visual/Non-visual stimuli)
- Reading
- Odours
- Smoking
Acupressure Points
Diet
Increase ventilation
Motion Sickness
- Non Pharm (Diet)
Avoid eating 3 hours within time of travel
Avoid dairy products
Avoid protein/calories/sodium
Motion Sickness
- Non Pharm (Boat)
Sit in central area
Motion Sickness
- Pharm
Short Duration:
1. Dimenhydrinate
2. Diphenhydramine
3. Hydroxyzine
- Use 60 mins before
Long Duration:
1. Scopolamine (No longer available)
- Apply 4 hours before
Alternative:
1. Promethazine
- Use 30-60 mins before
Motion Sickness
- Promethazine
Antihistamine + Anticholinergic + Antidopaminergic
Longer duration of action
- Start 30-60 min before activity
- May take up to 2 hours for onset
Used as an alternative to dimenhydrinate
NV Pregnancy
- When can it occur
Morning sickness can occur at any time of the day
NV Pregnancy
- Non-pharm
Diet
- Small and bland meals
- Cold foods
- Drink fluids
- Eat when nausea is less
Ginger
- 1g divided doses (250mg q6h)
Acupressure
NV Pregnancy
- Pharm (Mild)
Pyridoxine + Doxylamine (Diclectin)
- Does not work, is still recommended
Pyridoxine
- May recommend this one instead
Diclectin
- Adverse Effects
Drowsiness, Disorientation, Diarrhea
NV Pregnancy
- Pharm (Moderate-Severe)
First Line:
1. Pyridoxine
2. Diclectin
3. Ginger
3rd or 4th Line:
4. Dimenhydrinate
5. Diphenhydramine
5. Promethazine
4th or 5th Line:
6. Phenothiazine (Chlorpromazine)
7. Metoclopramide
What is extreme persistient NV during pregnancy
Hyperemesis Gravidarum
- Causes dehydration, electrolyte imbalance, malnutrition
Requires hospitilzation
Hyperemesis Gravidarum
- Treatment
IV Fluids / Electrolyte Replacement
+ One of the following:
- Phenothiazines
- Metoclopramide
- Ondansetron
- Corticosteroids for refractory (Methylprednisone)
NV Pregnancy
- Pharm (Considerations)
Ondansetron should only be used in severe or persistient NV or Hyperemesis Gravidum
- Can cause malformations
PONV
- Risks
- Female
- Nonsmokers
- History of PONV/Motion Sickness
- Post-op Opioid Use
PONV
- Risk Values
Moderate Risk (2 Risk Factors)
- Consider 1-2 antiemetics
Severe Risk (3-4 Risk Factors)
- 2 antiemetics before surgery
PONV
- Treatments
5-HT3 RA
Dexamethasone
Dimenhydrinate
Phenothiazines
NK1 RA
PONV
- 5HT3 RA
Ex. Ondansetron, Granisetron
Timing:
- Can be given at the end of procedure to prevent PONV
- Can be given after procedure to treat PONV
AE:
- Can cause constipation
PONV
- Dexamethasone
Timing:
- Administered after anesthesia to prevent PONV
AE:
- Hyperglycemia
- Infection risk
- Sleep disturbance
PONV
- NK1 RA
Ex. Aprepitant, Fosaprepitant
Timing
- Administered within 3 hours of anesthesia for prevention
Issues:
- Is expensive
- May be restricted (Hospital formulary)
PONV
- Antidopaminergic
Risk of QT prolongation
AINV
- Meaning
Antineoplastic Induced Nausea and Vomiting
AINV
- Acute
Occurs within first 24 hours after exposure to antineoplastic agent
- Intensity peaks after 5-6 hours
- Resolves after 24 hours
AINV
- Delayed
Occurs after the first 24 hours after exposure to antineoplastic agent
- Intensity peaks at 48-72 hours
- Resolves after 6-7 days
- More common than acute
What drugs cause Delayed AINV
Cisplatin
Cyclophosphamide
Doxorubicin
Anticipatory AINV
Occurs before patients receive chemotherapy treatment
- Conditioned response
Breakthrough AINV
NV that occurs despite prophylactic
treatment
- Required rescue with antiemetic agent
Refractory AINV
NV that occurs during subsequent cycles
- Prophylaxis has failed
- Rescue has failed
What does HEC and MEC stand for
Highly Emetogenic Chemotherapy
Moderately Emetogenic Chemotherapy
HEC
High Emetic Risk (Greater than 90%)
- Cisplatin
- Cyclophosphamide > 1500mg/m2
- Anthracycline + Cyclophosphamide
MEC
Moderate Emetic Risk (30-90%)
- Carboplatin or Oxaliplatin
- Cyclophosphamide < 1500mg/m2
- Anthracycline (Doxorubicin, Epirubicin)
Low Emetic Risk
Low Emetic RIsk (10-30%)
- Docetaxel or Paclitaxel
- Fluorouracil
Minimal Emetic Risk
Minimal Emetic Risk (Less than 10%)
- Vincristine, Vinorelbine
AINV
- Risk Factors
- Women are at higher risk
- Low Alcohol consumption is at higher risk
- History of Motion sickness and NVP are at higher risk of CINV
- Younger than 50 years old are at higher risk
- Previous AINV are at higher risk
AINV
- Day 1 Therapy
- 5HT3 RA
- Dexamethasone
- NK1-RA
+/-: Olanzapine
Acute AINV
- Prophylaxis
HEC: 3-4 drugs given pre-chemo
MEC: 2-4 drugs given pre chemo
Low: One drug option: Dexamethasone, 5HT3 RA, Prochlorperazine, Metoclopramide
Delayed AINV
- Prophylaxis
Continued for day 2-4
- NK1-RA
- Dexamethasone
- Olanzapine
Breakthrough AINV
- Treatments
Metoclopramide
Prochlorperazine
Olanzapine
Anticipatory AINV
- Treatments
Benzodiazepines (Lorazepam)
- Before chemotherapy
Behavioural Therapy
Mindfulness
NV Children
- Nonpharm
- Small meals
- Prevent motion sickness in car (Ventilation)
NV Children
- Pharm
Dimenhydrinate (Older than 2 years)
- Younger than 1 = Do not use
- Younger than 2 = Requires physician advice
Diphenhydramine (Older than 6 years)
