Nausea & Vomiting

Question 1

Define emesis.

Answer 1

The process of vomiting

• Nausea
• Retching
• Vomiting

Question 2

Briefly describe the pathophysiology of N+V.

Answer 2

Stimulus triggers response in vestibular centre, GI tract or chemoreceptor trigger zone
Vagal afferents activates CTZ
CTZ then activates the vomiting centre
Vomiting centre triggers response in GI tract

Question 3

Give examples of causes of N+V.

Answer 3

Pregnancy
Abdominal conditions
Raised glucose, bilirubin, calcium
Inner ear disorder
Malignancy
Pain
Psychogenic
Drugs

Question 4

Where is the vomiting centre found?

Answer 4

Lower medulla of the brain

Question 5

Name the neurotransmitters involved in N+V at the vestibular centre.

Answer 5

Histamine

ACh

Question 6

Name the neurotransmitters involved in N+V at the CTZ.

Answer 6

Serotonin
Dopamine
Substance P

Question 7

Name the neurotransmitters involved in N+V at the vomiting centre.

Answer 7

Histamine
ACh
Substance P
Serotonin

Question 8

Name the neurotransmitters involved in N+V at the GI tract.

Answer 8

Histamine
ACh
Substance P
Dopamine 
Serotonin

Question 9

Name the neurotransmitters involved in N+V at the vagus nerve.

Answer 9

ACh
Dopamine
Serotonin

Question 10

Name the neurotransmitter involved in N+V at the higher cortical centres.

Answer 10

Histamine

Question 11

Describe the action of antihistamines in N+V.

Answer 11

Primarily inhibit histamine in vestibular centre and GIT so do not stimulate CTZ

Question 12

When are antihistamines useful in N+V.

Answer 12

Motion sickness

Irritants in the stomach

Question 13

What are the cautions of cinnarizine?

Answer 13

Epilepsy
Parkinson’s
Glaucoma

Question 14

What are the uses of cinnarizine?

Answer 14

Motion sickness

Vestibular disorders

Question 15

What are the uses of promethazine?

Answer 15

Motion sickness
Vestibular disorders
Last line in morning sickness

Question 16

What are the cautions of promethazine?

Answer 16

Epilepsy

Glaucoma

Question 17

Describe the action of anticholinergics in N+V.

Answer 17

Inhibit ACh primarly present in vestibular centre and GI tract so do not stimulate CTZ

Question 18

What are the uses of hyoscine?

Answer 18

Motion sickness

Question 19

What are the cautions of hyoscine?

Answer 19

Cardiac conditions including MI

Question 20

What are the contraindications of hyoscine?

Answer 20

Bowel obstruction

UC

Question 21

What are the uses of cyclizine?

Answer 21

For N+V with known cause

Question 22

What are the cautions of cyclizine?

Answer 22

Epilepsy

Glaucoma

Question 23

Describe the action of 5-HT3 antagonists in N+V.

Answer 23

Inhibit serotonin in CTZ and GI tract

Question 24

Give examples of 5-HT3 antagonists.

Answer 24

Ondansetron
Palonosetron
Granisetron

Question 25

What are the uses of 5-HT3 antagonists?

Answer 25

Chemotherapy, post-op and radiotherapy N+V

Question 26

How should ondansetron be given in patients over 65?

Answer 26

Via infusion lasting over 15 minutes

Question 27

What is the major side effect of ondansetron?

Answer 27

QT prolongation

Question 28

Describe the action of D2 antagonists in N+V.

Answer 28

Inhibit dopamine in CTZ

Question 29

Give examples of D2 antagonists.

Answer 29

Metoclopramide Domperidone Haloperidol

Question 30

Describe the use of metoclopramide in N+V,

Answer 30

Given orally or IV Stimulates gut motility Can cause EPSEs as crosses BBB

Question 31

What are the contraindications of metoclopramide?

Answer 31

Parkinson's

Question 32

What is the MHRA alert for domperidone?

Answer 32

Cardiac toxicity risk

Question 33

When is haloperidol used in N+V?

Answer 33

Unresponsive/treatment resistant

Question 34

What is the major side effect of haloperidol?

Answer 34

QT prolongation

Question 35

Describe the action of NK1 antagonists in N+V.

Answer 35

Inhibit substance P in CTZ

Question 36

What is the main benefit of NK1 antagonists?

Answer 36

Show efficacy up to 120 hours after single dose

Question 37

Give examples of NK1 antagonists.

Answer 37

Aprepitant Fosapreitant Netupitant Rolapitant

Question 38

What is nabilone?

Answer 38

Cannabinoid that acts on CTZ via opioid receptors used last line in N+V

Question 39

Describe the use of steroids in N+V. Give an example.

Answer 39

Dexamethasone | Used at supra physiological doses

Question 40

Describe the use of levomepromazine.

Answer 40

Useful in N+V due to wide action however unlicensed | Used in special cases

Question 41

Name 5 drugs that can be used for N+V in pregnancy.

Answer 41

``` Metoclopramide Prochlorperazine Cyclizine Promethazine Ondansetron- hyperemesis gravidarum ```

Question 42

What are the 4 main risk factors for post-op N+V?

Answer 42

Female Non-smoker Previous history of PONV Peri-op opioid analgesia

Question 43

What are the 5 types of chemotherapy induced N+V?

Answer 43

``` Acute Delayed Breakthrough Refractory Anticipatory ```

Question 44

What are the risk factors for chemotherapy induced N+V?

Answer 44

``` Female Age <30 Pre-exisiting N+V Poor control with prior treatment History of N+V Anxiety ```

Question 45

What are the protective factors for chemotherapy induced N+V?

Answer 45

History of high alcohol intake Substance misuse Smoking

Question 46

What is given for anticipatory CINV?

Answer 46

Lorazepam

Question 47

What is commonly given pre-chemo when there is a high risk of N+V?

Answer 47

5-HT3 antagonist Dexomethasone NK1 antagonist

Question 48

What two anti-emetics are used most commonly in a syringe driver?

Answer 48

Cyclizine | Levomepromazine is less irritant and more sedating

Question 49

What anti-emetics may be used in migraine?

Answer 49

Phenothiazine and antihistamine antiemetics Buccal prochlorperazine can be bought over the counter Metoclopramide/domperidone cautioned due to side effects