Nausea and vomiting: Information for clinicians

nausea and vomitingThis information is sourced from NICE, PANG, Sottish Palliative Guidelines, the BMJ and  North West London ICS

Nausea and vomiting are really important symptoms to control. Without effective treatment people can rapidly decline; through an inability to eat resulting in weakness, fatigue and often depression.

Trying to elucidate the cause leads to better success in controlling symptoms. Often there are multiple minor causes that tip the threshold into feeling sick.

Red flags Exclude bowel obstruction
Key clinical features to assess in the community
  • Review underlying diagnosis and recent treatment (e.g. site of tumours, organ failure, recent chemo)
  • Medication review (see table below)
  • Severity eg inability to take usual oral medication
  • Overall condition: signs of dehydration or infection (UTI, chest infection, oral candida) 
  • Abdominal and rectal exam for constipation, masses, bowel sounds, tender epigastrium
  • Assessment of anxiety levels as this can be a cause of nausea
  • Associated symptoms eg headache suggesting a cerebral cause
An initial approach to treatment
  • Stop or reduce dose of offending drugs 
  • Blood tests for a metabolic cause 
  • Urinalysis to exclude infection
  • Antiemetics (metoclopramide is a good first antiemetic to try)
  • Consider more specific treatments according to cause - see table below
  • Nutritional and hydration advice can be very effective 
Top tips
  • Beware worsening colic (or vomiting) with prokinetics - suggests bowel obstruction 
  • Levomepromazine has a broad spectrum of action but is sedating at doses > 12.5mg/24h 
  • Ondansetron can cause constipation
  • Metoclopramide can cause neurological side effects e.g. akathisia/restlessness 
  • 25% cases may need 2 anti-emetics
  • Olanzapine is an alternative broad-spectrum antiemetic starting in doses of 2.5mg OD
  • Prochlorperazine (in buccal form Buccastem) is useful at home if no injections are available
  • Bland food, avoid cooking smells, and some complementary approaches eg Sea Bands may help
Specialist care
  • Advice on combination antiemetics
  • Abdominal CT scan and ultrasound are useful if symptoms persist

Specific treatments according to cause:

Cause

Clinical Features

Initial approach to treatment

Drugs e.g. opioids*, antibiotics, SSRIs, NSAIDs,  steroids, chemotherapy

 

*If dose of opioid is stable, it is unlikely to be the cause of nausea 

Constant background nausea 

 

Stop/reduce dose of offending drugs

Consider gastroprotection with PPI 

Haloperidol Oral/subcutaneous dose: 1.5 mg once or twice daily, up to 5 mg daily (lower starting dose 0.5 mg for frail people). Syringe pump:2.5mg–5 mg/24 hrs

Metoclopramide Oral/subcutaneous dose: 10 mg 3-4 x/24 hrs.   Syringe pump : 30–50 mg /24 hours

Ondansetron for chemo nausea. Oral/subcutaneous dose 4mg-8mg tds

 

Metabolic causes

renal failure, liver failure, hypercalcaemia, hyponatraemia

Co-existent delirium may suggest metabolic cause

 

Haloperidol as above

Hypercalcaemia will need IV hydration and bisphosphonates if appropriate to admit

 

 

Gastric stasis, and severe constipation

Large volume vomit, relief of symptoms after vomiting, oesophageal reflux, hiccups. 

 

Stop/reduce  anticholinergic drugs such as Buscopan, tricycyclic antidepressants, Oxybutinin

Use prokinetic antiemetics: e.g. Domperidone 10mg tds orally or Metoclopramide as above

Treat constipation

Erythromycin 250mg bd may help

 

Physical obstruction (from tumour or external compression) 

Vomiting pattern depends on level of obstruction

 

If possibility of reversal – use prokinetic Metoclopramide in a syringe pump as above. Dexamethasone e.g. 8mg subcutaneously may help nausea and reduce compression.

If likely irreversible – a combination of Cyclizine +/- Haloperidol in a syringe pump

CT may help to identify level/reversibility of blockage

 

Toxins

e.g. ischaemic bowel, tumour products, infection

 

 

Levomepromazine

Oral or subcutaneous dose: 6.25 mg 8 hourly. Syringe pump dose: 12.5 mg-25mg /24 hrs

 

Raised intracranial pressure

Effortless vomiting, often in the morning, associated with headache and papilloedema

 

Cyclizine Oral dose: 25–50 mg up to 150mg/24hrs Subcutaneous dose: 25mg up to 100mg/24 hrs

Syringe pump dose: Up to 100mg /24 hrs

CT head plus Dexamethasone /oncology review

 

Motion-associated nausea

Nausea or sudden vomiting on movement (eg turning in bed) 

For vestibular disturbance (eg diseases of the inner ear and motion sickness): Cyclizine as above

Anxiety-related nausea

Nausea may be triggered by a previous stimulus

CBT may help

Lorazepam 0.5mg orally can be tried

 

Recommended Resources

BMJ: Clinical Review Nausea and vomiting in palliative care

Published 3rd December 2015

PANG Guidelines Physical Symptoms and Signs - Nausea and vomiting

Published 16th October 2016

Scottish Palliative Care Guidelines - Nausea and vomiting

Published 15th April 2021

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Nausea and vomiting: Information for patients and carers

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