NV Treatment Approaches Flashcards
commonly used NHPs
- Ginger
- Vitamin B6
Others
• Peppermint oil
• Green tea
• Lemon balm
Ginger
MOA
dose
• MOA: may inhibit serotonin receptors (5HT3) in the gut and CTZ (setron effect)
• Efficacy in nausea/vomiting in pregnancy
– systematic reviews/meta-analysis
• Superior to placebo
– Ginger vs Vitamin B6
• Both decrease N/V – appear equally efficacious
• Dose – 1 gram/day (divided doses BID - QID) – Not more than 1 gram/day in pregnancy • Supplied – Fresh root, dried root, tablets, capsules, tincture, tea, food
ginger AE
– Heartburn, diarrhea
– Mouth irritation –reduced if enteric coated product used
– Dermatitis if used topically
– Thought to inhibit thromboxane synthase and decrease platelet aggregation
• Drug Interactions
– anti-coagulants, antiplatelets – high doses may increase risk of bleeding
• Need to monitor concomitant use, INR
Motion Sickness
Vestibular center – ________ most important
neurotransmitters involved in motion sickness
• Non-pharmacologic
Somethng is mismatched
Actual motion we are sensing in inner air mismatched middle inner ear, not picking up same cues
Ach and histamine
– Stable visual point – e.g. clear forward view, minimum head movements
– Avoid visual stimuli that precipitate motion sickness (e.g. reading), or other stimuli (odors, smoking)
– Diet: avoid eating within 3 hours of travel, avoid dairy products or high in protein/calories or sodium
– Increase ventilation
– If on boat remain in central area with less motion
– Acupressure points (e.g. Seabands) – though not been shown to be effective, however could try if mild symptoms
Slow prolonged motion, waves makes it worse
Fast movements tend to be better
Motion Sickness
• Pharmacologic
type of drugs short vs long duration
Anticholinergic/antihistamines
– Short duration – dimenhydrinate, diphenhydramine (alternate)
• Start 60 min before activity, can repeat q4 – 6 hours
• Consider promethazine if patient does not respond to
dimenhydrinate (note: promethazine longer duration of
action)
– Longer duration – scopolamine patch
• apply at least 4 hours before travel
NV of Pregnancy
which trimester most common
• Common in first trimester – 75% of women – Severity varies among patients – Usually disappears by week 20 – Morning sickness is a misnomer • Hyperemesis gravidarum – only 1 – 3% – Severe NV, requires hospitalization
If severe enough,can continue after first trimester
Women can feel it more in morning haven’t eaen but it can happen anytime of day
cause of NV pregnancy
Cause: unknown, ?high estrogen levels
– NV correlates with human chorionic gonadotropin (hCG)
hCG from placenta to maintain corpus luteum to maintain estrogen, progesterone
Peaks 9-12 weeks
Nausea and vomiting peaks around same level
Hard toknow if its cuz of HCG or increase of estrogen levels at the time
NV of Pregnancy
• Non-pharmacologic – mainstay
– Diet – small, bland meals – Eat at times of the day when nausea is less – Eat cold foods (hot foods may bother with smell) avoid spicy, fatty foods – Drink fluids • Others: – Acupressure – Ginger – mild NVP
NV of Pregnancy
Mild NVP
2 products that can be used
dose?
Mild NVP
• DiclectinTM – Rx
– pyridoxine (vitamin B6) 10mg + doxylamine 10mg delayed
release
doxylamine is antihistamine
– Dose: ii qhs, additionally 1 am and 1 midafternoon (max 8 per day)
Start with 2 tabs at night, bump up the dose every 2-3 days
Add 1 in morning
Then add another 1 in afternoon after another 2-3 days
– Side effects: drowsiness, disorientation, diarrhea
• Pyridoxine alone
– B-natal – pyridoxine 25 mg q8h
dilectin vs vit b6
Controversy, it was not better than Vit B6
Maybe Pyroxidine considered first because it is OTC
both are acceptable
NV of Pregnancy
Moderate-severe NVP
• Dimenhydrinate – usually recommended after Diclectin or pyridoxine has been tried, diphenhydramine or promethazine is also an option
• Also can consider if not responding
– Phenothiazines – chlorpromazine, prochlorperazine
– Metoclopramide
Hyperemesis Gravidarum
• Hyperemesis gravidarum is extreme, persistent NV during pregnancy
management
– dehydration, electrolyte disturbances can occur • If ongoing – nutritional/malnutrition • Often requires hospitalization • Management: – IV fluids/electrolyte replacement – May consider any of the following • Phenothiazines • Metoclopramide • Ondansetron • Corticosteroids for refractory – methylprednisolone
Cleft palates accoiated with cortical steroids in first trimester
Also controversy with ondansetron in pregnancy because of cleft palates in children when used in 1st trimester
Postoperative NV (PONV) 4 main risks
• PONV occurs in 25 – 30% of patients undergoing anesthesia
– and may be as high as 70% in patients at high risk
• Risks:
– 4 main risks: female, nonsmokers, history of PONV/motion sickness, opioid use
– Others:
• anesthetic used (ie nitric oxide)
• type of surgery, longer duration
–abdominal, gynecologic, eye, ear/nose/throat surgeries higher risk
Prophylaxis of PONV
when to use prophylaxis? how amny risk factors = how many antiemetics
Base risk on important risk factors: • > 2 risk factors or history of PONV – Moderate risk (2 risk factors) – consider 1 – 2 antiemetics – Severe risk (>3-4 risk factors) – 2 antiemetics before surgery
Tend to see 5-HT3
Doesn’t matter which combination
Depends on instituion guidelines
name PONV prophylaxis therapies (5)
5-HT3 receptor antagonists Dexamethasone Dimenhydrinate Scopolamine patch Phenothiazine
Antineoplastic Induced Nausea and Vomiting (AINV)
• Five categories of AINV:
acute - Starts within few hours of chemo
- >90% of certain chemo (cisplatin,
cyclophosphamide)
delayed - Starts 24 hours after chemo
- As high as 90% with certain chemo
(cisplatin, cyclophosphamide)
anticipatory - Learned response – 25 -50%
breakthrough - Need rescue antiemetic
refractory - Poor response to multiple antiemetics
• Neurotransmitters most responsible in AINV:
– 5-HT3 receptors
– D2 and NK1 receptors
• Chemotherapy causes large amounts of serotonin to be released in GI
tract through toxic effects on enterochromaffin cells.
Prophylaxis of acute AINV:
when to use prophylaxis? how many antiemetics
– High emetic chemo – three or four drugs*
– Moderate emetic chemo – two or three drugs*
– If low emetic chemo – then one drug options
dexamethasone, 5HT3RA, prochlorperazine, or
metoclopramide
5-HT3 RA \+ NK1-RA \+ Dexamethasone
Prophylaxis of delayed AINV:
which drugs to use?
– 5-HT3 receptor antagonists are inconsistent in effect, therefore not
continued after chemo
– NK1-RA, dexamethasone, or olanzapine continued for day 2 – 4
Example of Regimen for High Emetic Chemo – Three Drugs
4 drugs?
Day 1*
5-HT3 RA + NK1-RA + Dexamethasone
Day 2:NK1-RA + Dexamethasone
Day 3:NK1-RA + Dexamethasone
Dexamethasone may be given day 4 in some regimens
for 4 drugs, add olanzapine for each of 3 days (prechemo)
what is Akynzeo?
Neurokinin-1 Antagonist/5-HT3 Receptor Antagonist combination • netupitant—palonosetron HCl • One dose 1 hour prior to chemotherapy only avail in combo
Treatment of anticipatory
AINV
– More difficult to treat
– May require benzodiazepines such as lorazepam prior to chemotherapy
– Others: behavioral therapy, mindfulness
Anticipatroy is actual ly getting a response from seeing the hospital, difficult to treat
Seeing the nurse causes conditioned respnse and feel naseous
NV in children
usual cause
when to refer (time)
Most common cause of NV in children is viral gastroenteritis
– Natural course
– Prevent dehydration and electrolyte imbalance with oral rehydration
solutions (ORS)
– IF nausea symptoms greater than 24 hours then REFER
NV in children
• Non-pharmacologic as much as possible:
anti-emetics?
– Small meals
– Prevent motion sickness in cars – improve ventilation
– Dimenhydrinate – recommended for >2 years (note: <1 year not
recommended, <2 years under advice of physician)
– Diphenhydramine as alternative (for >6 years)
– Note: some children exhibit paradoxical excitability with the antihistamines
