Nausea

1
Nausea Vomiting

• made easy

2
First steps

• What is the cause?
• Non-medical treatment
• Medical treatment
• 1st line
• Other options

3
Scale of the problem

• Occurs in 40-70 patients with advanced cancer
• 1/3 will have more than 1 contributing factor
• 1/3 will need more than 1 anti-emetic

4
Non-medical treatment

• Calm environment good ventilation
• Frequent small snacks
• Avoid sight smell of food eg cooking

5
Gastric stasis - causes

• Drugs
• Opioids
• Squashed stomach syndrome
• tumour, enlarged liver, ascites
• Outflow obstruction
• tumour

6
Gastric stasis - symptoms

• Epigastic discomfort
• Fullness
• Early satiety
• Exacerbated by eating / relieved by vomiting
• Large volume vomits (undigested food)

7
Gastric stasis - management

• Prokinetic agent
• metoclopramide 10-20mg tds (oral)
• 40-80/24hrs sc infusion
• Also consider
• Domperidone (less side effects but not sc)
• PPI to reduce acidity
• Steroids 8-12mg dexamethasone for 7 days
• 2nd line
• Cyclizine 50mg tds po/sc (150mg/24hrs sc
  infusion)
• bowel distension

8
Chemically-induced nausea - causes

• Drugs (10-30 on inititation of opioid)
• antibiotics, anticonvulsants, antidepressants,
  cytotoxics, steroids, digoxin, NSAIDs
• Metabolic
• renal or hepatic failure, hypercalcaemia,
  hyponatraemia, ketoacidosis
• Toxins
• ischaemic/obstructed bowel, tumour effect,
  infection

9
Chemically-induced nausea - symptoms

• Constant nausea
• Vomiting is variable in volume timing
• May be other features of drug toxicity

10
Chemically-induced nausea - management

• Haloperidol po/sc 1.5-3mg od/bd
• 2.5-10 mg/24hrs sc infusion
• Also consider
• Correct the correctable
• Metoclopramide (gastric stasis) 10mg tds

11
Raised intracranial pressure causes

• Intracranial tumour
• Cerebral oedema
• Intracranial bleed
• Meningeal infiltration by tumour
• Skull metastases
• Cerebral infection

12
Raised intracranial pressure symptoms

• Nausea worse in the morning
• Headache
• Nausea and/or vomiting provoked by head movement

13
Raised intracranial pressure management

• Cyclizine 50mg tds (oral)
• 150mg/24hr sc infusion
• Also consider
• High dose steroid dexamethasone 16mg od
• Hyoscine hydrobromide
• Kwells 300mcg qds
• 0.8-3.6mg/24hr sc infusion

14
If at first you dont succeed

• Consider adding a second agent
• Different mechanisms of action
• eg haloperidol with cyclizine
• Avoid antagonistic action
• cyclizine counteracts the prokinetic affect of
  metoclopramide
• Consider levomepromazine
• broad spectrum antiemetic
• 6.25-12mg (1/4 -1/2 tablet)po
• or 5-25 mg sc/sc infusion over 24hrs

15
Summary

• Gastric stasis
• metoclopramide
• Chemically-induced
• haloperidol
• Raised intracranial pressure
• cyclizine
• Consider additional or 2nd line treatment
• Dont forget the effect of anxiety pain