Nausea and Vomiting

A management approach should be based upon the clinically determined mechanism of nausea and/or vomiting, which can be multifactorial.

The pressure from ascitic fluid may cause gastric compression. The patient may benefit from treatment of ascites alongside a pro-kinetic anti-emetic such as metoclopramide.

Nausea may be secondary to accumulation of toxins and therefore centrally acting anti-emetics, such as haloperidol, may be indicated.

Upper gastro-intestinal bleeding due to portal hypertension may damage enterochromaffin cells, leading to release of the neuro-transmitter serotonin (5HT3) which can cause vomiting. 5HT3 antagonists, such as ondansetron and granisetron, could be tried.

Cyclizine and levomepromazine can also be tried as they are broad-spectrum anti-emetics.

Choices of anti-emetics

Haloperidol, Levomepromazine and Cyclizine

Can be used in normal doses for mild to moderate impairment but can precipitate coma in severe impairment.

Advisable to start with a low dose and titrate slowly in this scenario.

Metoclopramide

Can be used in normal doses in mild to moderate impairment.

However, the half-life can double in severe impairment, so it may be advisable to reduce the daily dose by 50%

Ondansetron

Dose not to exceed 8mg/day in moderate or severe impairment as clearance is significantly impaired.

Granisetron

Can be used in normal doses.

DISCLAIMER

This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.
Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.
While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.