ASSESSMENT AND MANAGEMENT PRINCIPLES

Identify and treat underlying cause

  • Abnormal biochemistry (e.g. hypercalcaemia, uraemia or hyponatremia) – treat where appropriate.
  • Drugs (e.g. opioids, oral bisphosphonates, metronidazole, anticonvulsants) – Anti-emetics may be necessary for a few days when opioid treatment is initiated. Not all patients require this.
  • Exacerbating factors such as severe pain, cough, infection, and anxiety need to be treated.
  • Avoid drugs with anticholinergic effects in patients with gastric stasis (e.g. hyoscine, antidepressants, cyclizine).
  • Constipation – Prevent and treat aggressively.
  • Gastritis – Use a proton pump inhibitor e.g. lansoprazole or ranitidine.
  • Chemotherapy induced nausea & vomiting – A short course of 5HT3-receptor antagonists may be appropriate.
  • Mechanical bowel obstructionSee Section Intestinal Obstruction
  • Raised intracranial pressureSee Chapter: Corticosteroids
  • Anxiety: Psychological care with or without benzodiazepines.
  • Oropharyngeal thrush: a course of antifungal treatment.

Management plan

  • Consider nonpharmacological measures, e.g. advice on posture and diet, acupuncture/acupressure, removal of unpleasant stimuli, complementary therapies, psychological treatments such as anxiety management.
  • Ensure the most appropriate anti-emetic see is used regularly, to a maximum dose and for a sustained period of time (e.g. 24hrs). Section: Anti-emetic Medications
  • Ensure additional PRN anti-emetics are available
  • Remember the oral route is often ineffective when someone has nausea or vomiting in which case alternative route should be considered.

If management is ineffective:

  • Reconsider the likely cause(s),
  • Review the route of administrations
  • Another complementary anti-emetic drug may be added (see second line treatment). For example haloperidol with cyclizine is often effective, especially by continuous subcutaneous infusion.
  • NB. 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.
  • Consider using a Syringe driver: a continuous subcutaneous infusion via a syringe driver/pump may be considered for patients who are vomiting for longer than 24 hours or have nausea unresponsive to appropriate oral anti-emetics or are unable to swallow oral antiemetics. See Chapter: Syringe Driver

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.