Nausea/Vomiting Flashcards
What are the types of non-pharmacologic therapy
Dietary
Physical
Psychological changes
What are dietary therapies for N/V?
Frequent small meals, avoid spicy or fatty foods, eat high-protein snacks
What are dietary therapies for NVP?
Normal dietary therapies plus:
Eat bland/dry foods first thing in the morning
Some evidence that taking a multivitamin at the time of conception may result in less likelihood of seeking medical treatment
What is a natural dietary therapy for motion sickness and dyspepsia?
Peppermint oil
What is a natural dietary therapy for motion sickness and NVP?
Ginger
What are physical therapies for N/V?
Acupuncture
Sea-Band
How do physical therapies work for N/V?
P6 (neiguan) point on the inside of the wrist
Results conflicting
Acupuncture wrist bands may be effective in preventing PONV or motion sickness
What are psychological therapies for N/V?
Hypnosis - may be effective for severe NVP
Psychotherapy - may be effective for hyperemesis gravidum
What are the types of phenothiazines?
Promethazine
Prochlorperazine
What is the MOA of promethazine?
D2 dopaminergic receptor blocker
Muscarinic-1 receptor blocker
Histamine-1 receptor blocker
What are the typical uses of promethazine?
General use
Acute vomiting of central origin (notion sickness, migraine)
What are ADRs of promethazine?
Sedation is common
May cause EPS
Injection site irritation (don’t use SQ)
-IV formulation should be diluted b/c of risk of tissue necrosis
What is the MOA of Compazine?
Mainly D2 dopaminergic receptor blocker
Some Muscarinic-1 and H-1 blockade
What are the typical uses of Compazine?
General use
Acute vomiting of central origin (motion sickness, migraine)
What are the ADRs of Compazine?
May cause EPS
Injection site irritation (don’t use SQ)
What are the serotonin antagonists?
Zofran
Granisetron (Kytril)
Palonosetron (Aloxi)
Dolasetron (Anzemet)
What is the MOA of serotonin antagonists?
5-HT3 receptor antagonist
What are the typical uses for serotonin antagonists?
General use
PONV, CINV, RINV, refractory nausea
What are the ADRs of Zofran and Dolasetron?
Contraindicated with apomorphine
Associated with QT prolongation; correct hypoMG and hypoK
What are the ADRs of granisetron?
Associated with QT prolongation
What are the ADRs of antihistamines
Risk of sedation and anticholinergic effects
What are the butyrophenones?
Haloperidol
Droperidol
What is the MOA of butyrophenones?
D2 dopaminergic receptor blocker
M1 receptor blocker
What is the typical use for butyrophenones?
PONV
What is the typical use for antihistamines?
Motion sickness
What are the ADRs of butyrophenones?
Risk of EPS
BBW for risk of QT prolongation and Torsades
Requirement for baseline ECG and 2-3 hr postdose cardiac monitoring
What are the NK1 antagonists?
Aprepitant (oral) & Fosaprepitant (Injection) (Emend)
Netupitant/palonsetron (Akynzeo)
Rolapitant (Varubi)
What is the typical use of NK1 antagonists?
CINV
What are the ADRs Emend?
Fatigue, hiccups
Reduces efficacy of warfarin and oral contraceptives
Dose-dependent inhibitor of CYP 3A4
What are the ADRs of Akynzeo?
Avoid in severe renal or hepatic disease
What is the antimuscarinic agent?
Scopolamine
What are the typical uses of scopolamine?
Motion sickness
PONV
What are cannabinoids?
Dronabinol (Marinol)
Nabilone (Cesamet)
What are the cannabinoids MOA?
CB1 and CB2 receptor agonists (Antiemetic effect d/t CB1 agonist activity)
What are the typical uses of cannabinoids?
CINV
Refractory vomiting
What are the ADRs of cannabinoids?
May cause appetite stimulation, euphoria, cognitive impairment, hypotension, psychotropic reactions
What is Metoclopramide’s MOA?
D2 receptor blocker
What are the typical uses of metoclopramide?
Prokinetic agent used most often for gastroparesis
Also used for PONV, CINV, RINV
What are the ADRs of Metoclopramide?
BBW for tardive dyskinesia (if used for more than one month)
Restlessness, anxiety, somnolence, EPS, QT prolongation
What are the typical uses of phosphorylated carbohydrate solution?
Upset stomach that occurs with GI virus or food indiscretions
What are the clinical pearls associated with phosphorylated carbohydrate solutions?
Avoid in diabetes and fructose intolerance
Safe in pregnancy
What is MOA of erythromycin?
Motilin receptor agonist
What are the typical uses of erythromycin?
Gastroparesis
What are the ADRs of erythromycin?
GI upset
Diarrhea
N/V
What are the typical uses of medrol and dexamethasone?
CINV
RINV
PONV
What are the ADRs of medrol and dexamethasone?
GI upset
Anxiety
Insomnia
What is the MOA of lorazepam?
GABA agonist
What are the typical uses of lorazepam?
Anticipatory
N/V
What are the ADR of lorazepam?
Sedation
Amnesia
What are the typical uses of antacids/H2RAs?
Nausea associated with gastric acid
What is the MOA of doxylamine/pyridoxine (Diclegis)
H1 receptor blocker
What is the MOA of Sea-Bands?
Stimulates the pericardium (P6) point
What are the typical uses of Sea-Bands?
All types of nausea
What are the common diseases associated with gastroparesis?
Diabetes
Hypothyroidism
What is the 1st step in treatment of gastroparesis?
Diagnosis: 4H gastric emptyping by scintigraphy
What is the 2nd step in treatment of gastroparesis?
Exclude iatrogenic disease:
Dietary: low fat, low fiber diet
Glycemic control among diabetics
What is the 3rd step in treatment of gastroparesis?
Pharmacological Rx:
Prokinetics: metoclopramide, erythromycin, demperidone
Antiemetics: antihistamines, 5-HT3 receptor antagnoists
What is the 4th step in treatment of gastroparesis?
Nutritional support: Enteral formula
What is the 5th step of treatment of gastroparesis?
Non-pharmacological rx: Pyloric injection of botulinum toxin Venting gastrostomy, feeding jejunostomy Parenteral nutrion Gastric eletrical stimulation Pyloroplasty Partial gastrectomy
What will decrease the occurence of NVP if taken at the time of conception?
vitamins
What are the non-pharmacologic therapies for NVP?
Rest
Avoidance of provoking stimuli
Frequent and small meals, avoiding spicy or fatty foods
Powdered ginger capsules 250mh qid
What are the pharmacologic therapies for NVP?
Multivitamins at time of conception Diclegis Phenothiazines (in refractory cases) Corticosteroids (last resort therapy in hyperemesis gravidum) IV hydration Enteral nutrion/TPN Zofran (preg cat B)
Who receives prophylaxis for PONV?
Only necessary with patients at moderate to high risk for PONV
What are risk factors for PONV?
Female Non-smoker h/o motion sickness h/o PONV Volatile anesthetics NO Opioids
What is the treatment for PONV if no prophylaxis was given?
any agent is useful
What is the treatment for PONV if prophylaxis was given?
If < 6 hours post-op: select therapy from a different drug class If > 6 hours post-op: any agent is acceptable except dexamethasone or scopolamine