Pearls #15 nov 04 nausea.doc

“Pearls”- Nausea in Palliative Medicine November 2004
1) Recognize: Nausea commonly exists without vomiting. Ask about appetite, response to the smell
of food cooking, early satiation when eating. Nausea can interfere significantly with the joy of living and is important to recognize and treat. Nausea is so common with opiates that while vomiting may not be present, the attention to this detail can have a positive effect on quality of life.
2) Prevent the two most common causes of nausea from opiate initiation
a) constipation: see Pearls Nov 2003 b) gastroparesis: add a prokinetic agent (see following chart)
3) Assess : Why does this patient have nausea now?
11 M’s and a P
edications: digitalis, iron preparations, antibiotics, SSRI’s, chemotherapy
induced immediate or delayed, NSAID’s, ASA, opiates Mucosal Irritation: radiotherapy of abdomen, gastritis, gastric/duodenal ulcer
Motility: gastroparesis (opioids), dysmotility syndromes from extensive
Mechanical: bowel obstruction, constipation
Metabolic: hypercalcemia, uremia, liver failure, renal failure
Meningeal Irritation
Movement Related: inner ear, cerebellar involvement
Metastases: intracranial (raised intracranial pressure), abdominal (dysmotility)
Microbes: infections
Mental: anxiety, anticipatory nausea
Myocardial: silent MI’s
4) Correct Reversible Causes
5) Utilize Non-Drug Interventions at the same time as other maneuvers as appropriate
see Windsor and Essex County Care Management Tools
6) Utilize Medications see next page

7) Reassess and modify until nausea is controlled

8) If not improving, reconsider? Have you got the correct cause?

Most commonly used anti-emetics in Palliative Medicine (Stemetil®) so caution when used together Chemoreceptor
trigger zone, D2
raised ICP, or severe liver involvement.
This is not meant to be an e xhaustive reference but rather a simplified approach to nausea.

Prochlorperazine (Stemetil ®) is commonly used as an anti-emetic in oncology. It may be
given po/IM/IV/pr. It cannot be given sc.
Some persons are sensitive to the extrapyramidal side effects; these persons may feel jittery, complain of restless legs. These same persons may be sensitive to the extrapyramidal side effects of metoclopramide. We tend not to use these two drugs together. Domperidone does not share this profile. Please note that dimenhydrinate (Gravol ®) has only a minor indication in palliative medicine: when persons complain of motion sickness nausea not relieved by other medications.
In summary:

Always, always, always watch the bowel and ensure a good bowel protocol is in place and is

The commonest protocol for control of nausea in palliative medicine is either a prokinetic

(domperidone or metoclopramide) or haloperidol alone or in combination. 75% of
prescriptions for nausea in palliative medicine are written for these medications.

A common medication profile with an opiate would be as follows: domperidone 10 mg, 2 tabs (20 mg) qid to prevent/control nausea haloperidol 0.5 mg, 1 tab (0.5 mg) bid to prevent/control nausea lactulose 25 – 30 ml od – bid in juice to prevent constipation bisacodyl 1-2 tabs od – bid to stimulate bowel movement to prevent constipation. C. Jones, MD


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