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Pharmacist to Pharmacist:
A Clinical Care Review for the Pharmacist
This article is brought to you by the makers of
The Pharmacist’s Role in Treating
Nausea and Vomiting
professor of clinical pharmacy at the University of Colorado Denver School Examples of Patient
Referral Requireda
Causes Requiring Referral
given in Table 2. It is important for the son’s life. It has been estimated that Patient Presentations Requiring Referral
and food or drink indiscretions. Several OTC Therapy
• Severe abdominal pain in the middle or ety of underlying causes. Unfortunately, List is not al -inclusive. Always perform a thorough medical and medication history. Pharmacy Times | 09.09
Pharmacist to Pharmacist:
A Clinical Care Review for the Pharmacist
scription Zofran (ondansetron), which recent literature to support the use of Medications Associated
blocks 5-HT (serotonin) receptors in Emetrol is not available. with Nausea and Vomiting
Emetrol has been available for 60 distress subsides, but should not be years.7 According to an article from taken for more than 1 hour or 5 doses. 1953, the preparation was introduced In children aged 2 to 12 years, the into therapeutics by J.E. Bradley for usual dose is 5 to 10 mL, which can the treatment of epidemic vomiting in be repeated every 15 minutes until children.8 It contains a solution of 1.87 distress subsides. Similar to adults, • Digitalis, theophylline, or anticonvul- g dextrose (glucose), 1.87 g levulose children should not take it for more (fructose), and 21.5 mg phosphoric than 1 hour or 5 doses.9 For maximum acid per 5 mL and is clinical y referred effectiveness, Emetrol should not be to as “phosphorated carbohydrate diluted, nor should fluids be taken solution.”7 The hyperosmolar solu- tion with phosphoric acid that makes tion.7 Emetrol is considered safe, but 30 to 60 minutes prior to any activity up Emetrol is thought to work by a few important contraindications do where motion sickness is anticipated. decreasing smooth muscle contrac- Patients taking these agents should be tion and delaying gastric emptying avoid this product, given its high sugar counseled to avoid concurrent alcohol, time through a direct action on the GI content. In addition, individuals with hypnotics, sedatives, and other central wall.2,9 It is considered an antiemetic hereditary fructose intolerance should nervous system depressants, as addi- and is indicated for the relief of nausea avoid Emetrol.7,9 tive drowsiness can occur. Dosing is caused by upset stomach resulting
drug-specific, with certain agents not from intestinal flu, stomach flu, and Role of the Pharmacist in
recommended in children.
uct has also been used off-label for Pharmacists are the front-line health Acid-reducing/neutralizing agents
In 1954, a double-blind study was cal and medication history to identify ated with heartburn or stomach upset performed to evaluate the efficacy underlying causes and to appropriately from the consumption of excessive of Emetrol in 110 patients suffering treat or refer patients with nausea or disagreeable foods or beverages.2 from nausea and vomiting due to a and/or vomiting. When the pharmacist Antacids include calcium carbonate, variety of causes.10 The main objec- aluminum hydroxide, magnesium tive of the study was to determine the ate, several OTC options are available, hydroxide, and others. They neutralize effect of Emetrol within 1 hour using 4 depending on the underlying cause. existing stomach acid by increasing repeated doses of 2 tablespoons every For patients with upset stomach from the pH of the stomach. OTC histamine 15 minutes. In the trial, 37 patients intestinal flu, stomach flu, and food or 2 (H2) receptor antagonists, including had “organic” causes of nausea and drink indiscretions and without con-famotidine, cimetidine, and ranitidine, vomiting, which the authors described traindications, Emetrol, a hyperosmo-inhibit gastric acid secretion in the as stomach cancer, breast cancer, lar solution with phosphoric acid, is a stomach to provide relief of heartburn, diabetes, heart block, and gal bladder safe and effective treatment for adults dyspepsia, and indigestion.2 Again, disease, and 73 patients had “func- and children aged 2 years or older. If 5 dosing is drug-specific, with certain tional” causes of nausea and vomit- ing, which the authors described as resolve the stomach upset, or if the pregnancy, anxiety, constipation in the stomach upset recurs often, patients Ginger (Zingiber officinale)
aged, migraine, and motion sickness. should be instructed to seek further Ginger has been shown to be superior The oral phosphorated carbohydrate medical advice with their primary care to dimenhydrinate for motion sickness solution provided some relief in 8.1% practitioner. ■and beneficial for nausea and vomit- of “organic” cases and some form of  For a list of references and a case presentation, ing in pregnancy.5 The mechanism is relief in 52% of “functional” cases. go to This handout for pharmacists will be available online at
09.09 | Pharmacy Times
Case: Example of Patient
Requiring Referral
Applying the information from Tables 1 and
2, consider the fol owing case example. A
21-year-old patient had knee surgery 10
days ago and has been taking hydro-
codone/acetaminophen and naproxen
500 mg twice daily for pain, along with
aspirin 325 mg daily for postsurgery blood
clot prevention. The patient states that he
has not had a bowel movement in 1 week
and now complains of sharp, intense
epigastric pain and abdominal pain. A
thorough medical history performed by
the pharmacist yields no significant clini-
cal information. Given the medication
history and recent surgery, the patient is
at risk for stomach ulcer from the aspirin
and naproxen. The patient also may be at
risk for bowel obstruction from the opi-
oid pain reliever and should be referred
back to the surgeon or his primary care


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