Step by step approach to management of nausea and vomiting in palliative care

Last reviewed 1 Jan 2018

1) First line - single agent based on underlying cause. Use regularly and to maximum dose before changing. If one drug is ineffective then use an alternative first line agent.

Cause of Nausea	Suggested Drug	Dose and Route
Drug induced and biochemical	haloperidol	oral: 1.5-3mg od - bd s.c. 2.5-5mg/24hr
Evidence of gastric stasis	metoclopramide	oral: 10-20mg tds before meals s.c. 30-100mg/24hr
	OR domperidone (does not cross the blood brain barrier so fewer side effects)	oral: 10mg tds p.r. 30mg bd or tds
If GI tract involvement or cerebral turmour, or if the above have not worked	cyclizine	oral: 50mg tds s.c. 150mg/24hr

2) Second line - add another first line age (e.g. cyclizine and haloperidol) or change to 'broad spectrum' agent

Cause of Nausea	Suggested Drug	Dose and Route
Broad spectrum anti-emetic useful if multiple possible causes	levomepromazine (acts at multiple receptor sites)	oral: 6mg-25mg nocte s.c. 6.25-25mg/24h

3) Third line - if other drugs are not controlling symptoms try

Suggested drug	Dose and Route
3 day course of 5HT3-receptor antagonist e.g. ondansetron, granisetron or tropisetron	ondansetron - oral: 8mg bd; s.c. up to 24mg per 24 hrs granisetron - oral/s.c. 1-2mg per 24hrs
Nausea and vomiting caused by moderately- to highly- emetogenic chemotherapy neurokinin receptor antagonists for example Aprepitan	Aprepitant 80mg- 125mg OD PO Capsules: 80mg, 125mg
Raised intracranial pressure or intractable nausea and vomiting steroids

Notes:

when changing antiemetics
- ensure the anti-emetic is used regularly, and to a maximum dose before changing
- if first drug is ineffective, change to an alternative first line drug
- if first line drug was partially effective, another anti-emetic drug may be added (see Second line treatment)
- haloperidol with cyclizine is often effective, especially by continuous subcutaneous infusion
- cyclizine and other anticholinergic drugs may antagonise some of the effects of metoclopramide and other prokinetic agents. The combination should therefore be avoided if possible
- re-assess patient

The respective summary of product characteristics must be consulted before prescribing any of the drugs detailed.

Reference:

West Midlands Palliative Care Physicians (2003). Palliative care - guidelines for the use of drugs in symptom control.
West Midlands Palliative Care Physicians (2007). Palliative care - guidelines for the use of drugs in symptom control
West Midlands Palliative Care Physicians (2012). Palliative care - guidelines for the use of drugs in symptom control.

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