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Guidelines for the Management of Nausea and Vomiting in Palliative Care

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Guidelines for the Management of Nausea and Vomiting in Palliative Care GUIDELINES FOR THE MANAGEMENT OF NAUSEA AND VOMITING IN PALLIATIVE CARE 27.1 GENERAL PRINCIPLES Nausea and vomiting are experienced by 50-60% of patients with advanced cancer. 1 Nausea and vomiting are more common in certain groups of patients i.e. <65 years old, females and certain malignancies e.g. gastric and breast cancer. 1 Patients with advanced malignancy may develop nausea and vomiting from causes unrelated to the cancer e.g. gall bladder disease or gastroenteritis. 1 Table 27.1 lists some common causes of nausea and vomiting in patients with advanced cancer. 1, 2 1, 2 Table 27.1 Common causes of nausea and vomiting in advanced cancer Anxiety Gastritis Autonomic neuropathy Hypercalcaemia Biochemical Infection Brainstem / meningeal disease Intestinal obstruction Constipation Pain Cough Radiotherapy Drugs Raised intracranial pressure Functional obstruction Renal failure Gastric outlet obstruction Vestibular disturbance Anti-emetics are neurotransmitter-blocking agents and are effective at different receptor sites (see Figure 27.1). 3 The choice of anti-emetic will be influenced by the cause of vomiting. They may be administered by a variety of routes. The oral or subcutaneous routes are the preferred options in palliative care. 4 27.2 GUIDELINES Table 27.2 lists the pharmacological options for the management of nausea and vomiting in advanced cancer. 3 Table 27.2 Pharmacological options for the management of nausea and vomiting in advanced cancer 1, 2, 3, 5, 6 [Level 4] Drug name Type of drug Indication for Oral dose Parenteral dose Parenteral dose Notes use (subcutaneously over (subcutaneous stat 24 hours via a syringe doses) driver) Cyclizine Antihistamine Central causes. 50mg tds. 100g-150mg 50mg subcutaneous Dilute with water Movement Maximum prn. Side effects include dry mouth, urinary related nausea daily dose is retention and restlessness. Should not be and vomiting. 150mg. co-prescribed with metoclopramide or Bowel domperidone. Avoid in severe cardiac obstruction. failure. Should not be mixed with hyoscine butylbromide in a CSCI. Dexamethasone Corticosteroid Intracranial 8mg-16mg od 8mg-16mg Not applicable. Side effects include insomnia, delerium disease. Exact dose and restlessness. If dose≤ 8mg can give as Bowel determined subcutaneous bolus dose. Use separate syringe driver as does not mix with other obstruction. by cause. (See Guidelines on drugs. Use of Corticosteroids) Domperidone Prokinetic Useful in gastric 10mg-20mg n/a n/a Can be given via rectal route. Does not stasis. tds-qds. cross the blood-brain barrier so less likely D2 receptor antagonist to give extrapyramidal reactions compared to haloperidol. Haloperidol Butyrophenone Chemical causes 1.5mg-5mg 1.5mg-5mg 1.5mg-3mg Risk of extrapyramidal symptoms. Single e.g. opioids. nocte. subcutaneously as daily dose usually sufficient because of (D2 receptor (maximum 10mg daily) required. long half life. Parental administration is antagonist) Metabolic (maximum10 NB: Subcutaneous: oral causes. mg daily) more potent therefore consider starting at potency of haloperidol a lower dose. is 2:1. Continued on next page Table 27.2 (continued) Pharmacological options for the management of nausea and vomiting in advanced cancer 1, 2, 3, 5, 6 [Level 4] Drug name Type of drug Indication for Oral dose Parenteral dose Parenteral dose Notes use (subcutaneously over (subcutaneous stat 24 hours via a syringe doses) driver) Hyoscine Anti-cholinergic Mechanical 300 micro- 1.2mg-2.4mg 400microgrammes May cause paradoxical agitation. Has Hydrobromide obstruction grams - subcutaneously as central anti-emetic activity. Movement-related hourly required nausea and (sublingual) vomiting Levomepromazine Phenothiazine Unknown cause 6.25mg- 6.25mg-25g 6.25mg-12.5mg Side effects include dry mouth, sedation (Methotrimeprazine) of vomiting 25mg od subcutaneously as and hypotension. Usually used as required Parenteral administration is more potent second line therefore consider starting at a lower dose. therapy due to There is a 6mg tablet available sedative effect. (unlicensed). Lorazepam Benzodiazepine Anxiety 0.5mg-1mg n/a n/a Risk of sedation. Often used during Anticipatory sublingually chemotherapy. as required nausea or bd Metoclopramide Prokinetic. Useful in gastric 10mg-20mg 30mg-120mg 10mg-20mg Reduce dose in severe renal failure. Do not stasis/ tds subcutaneously as use in complete bowel obstruction. May D2 receptor antagonist gastroparesis required cause extrapyramidal reactions at higher doses. Prokinetic effect may be reduced if anticholinergic drugs are co-prescribed. Octreotide Somatostatin Reduction of Not 300microgrammes- 50microgrammes– A long acting depot injection is available. analogue gastrointestinal applicable 600microgrammes 100microgrammes secretions subcutaneously as required Ondansetron 5HT3 receptor Chemotherapy 4mg-8mg bd 8mg-24mg 4mg subcutaneously Side effects include constipation. antagonist and radiotherapy or tds as required Dilute with saline. induced nausea and vomiting Figure 27.1 Sites of action of selected anti-emetics 2, 3 [Level 4] CORTICAL STRUCTURES Dexamethasone (reduces raised intracranial pressure but probably not anti-emetic at cortex) VOMITING CENTRE M 5-HT2 H1 (muscarinic) (histamine) - Cyclizine - Levomepromazine - Hyoscine hydrobromide CHEMORECEPTOR VESTIBULAR APPARATUS TRIGGER ZONE H1 M D2 5-HT3 - Cyclizine (dopamine) - Hyoscine hydrobromide - Haloperidol - Metoclopramide - Levomepromazine - Ondansetron VAGAL/SOMATIC AFFERENTS e.g. bowel D2 5-HT3 M - Metoclopramide/Domperidone - Levomepromazine - Ondansetron Patient assessment should include a full history, examination and investigations where appropriate. 1 [Level 4] The history should include details of the volume, content and timing of vomiting. Nausea should be specifically enquired for and rated, along with any diurnal pattern or associated features which may suggest a cause. 1 [Level 4] A biochemical profile, including corrected calcium, should be checked in patients with nausea and / or vomiting unless they are in the dying phase. 1 [Level 4] Reversible causes should be treated where appropriate. These include: drugs, constipation, hypercalcaemia, cough, anxiety and gastric irritation. 3, 4 [Level 4] Non-pharmacological measures which may be useful in the management of nausea and vomiting include: psychological measures, transcutaneous electrical nerve stimulation (TENS), complementary therapies and advice on posture and diet. 1, 3 [Level 4] Anti-emetics may be given via the oral route for patients with nausea. However, if nausea is severe or protracted, early use of the parenteral route should be considered. Gastric stasis can cause nausea and oral anti-emetics may be ineffective in this situation. 1,3 [Level 4] A continuous subcutaneous infusion (CSCI) via a syringe driver should be considered for: − Patients who have vomiting lasting more than 24 hours. 11 − Patients who have nausea unresponsive to oral anti-emetics for more than 24 hours. [Level 4] Various subcutaneous regimens are suggested in Table 27.3. A single stat subcutaneous injection should be given at the same time as setting up the CSCI and breakthrough anti-emetics should always be prescribed. 11 [ Level 4] If using levomepromazine in a syringe driver, the syringe should be shielded from sunlight. 9 [Level 3] In cases of inoperable bowel obstruction, a nasogastric tube or venting gastrostomy may be appropriate for symptom control. (see Guidelines for the Management of Bowel Obstruction). 1,10 [Level 3] Autonomic neuropathy is common in advanced disease and may cause gastroparesis. This may contribute to terminal restlessness. Consider using a nasogastric tube to remove gas and liquid from the stomach. This may restore comfort and the tube can then be withdrawn. 11 [Level 4] If a nasogastric tube is left in-situ, prescribe cyclizine or levomepromazine to alleviate the nausea caused by pharyngeal stimulation. 11 [Level 4] Table 27.3 Suggested antiemetic regimens via CSCI 2, 3, 6, 7, 8 [Level 4] Aetiology First line Second line Cause unknown Cyclizine 100mg-150mg +/- Levomepromazine 6.25mg – 25mg haloperidol 1.5mg-5mg via CSCI over 24 hours, +/- dexamethasone over 24 hours. 4mg–8mg subcutaneously once daily. Bowel obstruction See Guidelines for the Management See Guidelines for the Management of Bowel Obstruction. of Bowel Obstruction. Chemical/ 1.5mg-5mg haloperidol injected Discuss with specialist team Metabolic subcutaneously once daily or via CSCI over 24 hours. Gastroparesis Initial stat subcutaneous injection of Discuss with specialist team metoclopramide 10mg, followed by CSCI of metoclopramide 30mg– 60mg over 24 hours. NB Do not use in complete obstruction. 27.3 STANDARDS 1. Any patient with a history of nausea and vomiting should have a full assessment including a history, clinical examination and appropriate investigations to try and identify a cause for the symptoms. 1 [Grade D] 2. Appropriate anti-emetics should be prescribed on a regular and as required basis. 11 [Grade D] 3. If a patient is vomiting or nauseated for more than 24 hours, anti-emetics should be given via the parenteral route. 11 [Grade D] 4. If combinations of anti-emetics are required, drugs with different but complementary actions should be used. 2, 3 [Grade D] 5. Metoclopramide should not be prescribed if the vomiting is caused by complete intestinal obstruction. 2, 3 [Grade D] 6. Symptoms of nausea and vomiting should be controlled within 72 hours. 11 [Grade D] 27.4 REFERENCES 1. Baines MJ. ABC of palliative
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