1 Causes of Nausea and Vomiting and Drug Classes Used to Control

Causes of nausea and vomiting and Drug Classes used to control nausea and vomiting

Etiology Site affected Neurotransmitters & Anti-emetics by drug class receptors involved GI- Infection or Chemoreceptors and Serotonin (5-HT3) D2 receptor antagonists related (Abdominal/pelvic) radiotherapy mechanoreceptors of Dopamine (D2) Prokinetic agents (D2, 5-HT3, 5HT4) gastrointestinal tract 5-HT3 receptor antagonists Gastric stasis Chemoreceptors and Serotonin (5-HT3) Prokinetic agents (D2, 5-HT3, 5HT4) mechanoreceptors of Dopamine (D2) gastrointestinal tract Biliary duct distension Chemoreceptors and Serotonin (5-HT3) Corticosteroids mechanoreceptors of Dopamine (D2) Prokinetic agents (D2, 5-HT3, 5HT4) gastrointestinal tract Gastric/abdominal neoplasia Chemoreceptors and Serotonin (5-HT3) Prokinetic agents (D2, 5-HT3, 5HT4) Hepatic metastases mechanoreceptors of Dopamine (D2) Corticosteroids Hepatic distension gastrointestinal tract Carcinomatosis Gastric irritation or inflammation Chemoreceptors and Serotonin (5-HT3) Gastroprotective agents, PPI, anti-H2, mechanoreceptors of Dopamine (D2) antacids gastrointestinal tract Constipation Chemoreceptors and Serotonin (5-HT3) Laxatives mechanoreceptors of Dopamine (D2) gastrointestinal tract Bowel obstruction Chemoreceptors and Serotonin (5-HT3) See presentation mechanoreceptors of Dopamine (D2) gastrointestinal tract Visceral pain Chemoreceptors and Serotonin (5-HT3) Treat the pain mechanoreceptors of Dopamine (D2) D2 receptor antagonists gastrointestinal tract Prokinetic agents (D2, 5-HT3, 5HT4) 5-HT3 receptor antagonists

Central: Medication: Opioids Chemoreceptor trigger Dopamine (D2) D2 receptor antagonists Medications zone (CTZ) Serotonin (5-HT3) Prokinetic agents (D2, 5-HT3, 5HT4) Medication: Chemotherapy Chemoreceptor trigger Dopamine (D2) 5-HT3 receptor antagonists zone (CTZ) Serotonin (5-HT3) D2 receptor antagonists Prokinetic agents (D2, 5-HT3, 5HT4) Corticosteroids NK-1 receptor antagonists Medication: Chemoreceptor trigger Dopamine (D2) D2 receptor antagonists Estrogen zone (CTZ) Serotonin (5-HT3) Digoxin Iron Potassium Antibiotics Others Central: Vestibular disorder, local Vestibular apparatus Histamine (H1) Anticholinergics (Achm) Vestibular tumour invasion of cranial and labyrinth Acetycholine (Achm) nerve VIII Opioids Central: Metabolic: Chemoreceptor trigger Dopamine (D2) D2 receptor antagonists Metabolic Renal failure zone (CTZ) Serotonin (5-HT3) Corticosteroids Hypercalcemia If possible, treat underlying cause Uremia Ketoacidosis Hyponatremia Tumoural peptides Central: Psychological stimuli: Cerebral cortex GABA Benzodiazepines High CNS Emotions, Odours, Sounds Vision Central: Intracranial hypertension Cerebral cortex GABA Corticosteroids Raised ICP Cerebral tumour or metastases Carcinomatous meningitis Adapted from Simard M. Nausea and Vomiting. In Néron A, ed. Care beyond cure: Management of Pain and Other Symptoms, 4th ed. Montréal: Association des pharmaciens des établissements de santé du Québec; 2009: Chapter 9.

Drugs used to control nausea and vomiting

Site of action/Receptor Drug class Drug name Chemoreceptor trigger zone (CTZ) Prokinetic agents Domperidone (Motilium®) Metoclopromide (Maxeran®, Reglan®, Metonia®) Chemoreceptor trigger zone (CTZ) Neuroleptics (antipsychotics) Chlorpromazine (Largactil®) Haloperidol (Haldol®) Methotrimeprazine (Nozinan®) Prochloperazine (Stemetil®) Olanzapine (Zyprexa®, Zyprexa Zydis®)

Selective 5HT3 receptor antagonists Setrons Granisetron (Kytril®) Ondansetron (Zofran®)

Vestibular apparatus and Vomiting Dimenhydrinate (Gravol®) Centre Diphenhydramine (Benadryl®) Hydroxyzine (Atarax®) Atropine Scopolamine/hyoscine hydrobromide (Transderm-V®, Scopolamine HCI) Scopolamine butylbromide (Buscopan®)

Unknown Corticosteroids Dexamethasone (Decadron®) Prednisone (Deltasone®)

Cortex Benzodiazepines Lorazepam (Ativan®) Oxazepam (Serax®) Midazolam (Versed®)

Various CNS Cannabinoids Dronabinol (Marinol®) Nabilone (Cesamet®)

Various CNS Neurokinin-I receptor Aprepitant (Emend®) antagonists Others Octreotide (Sandostatin®, Sandostatin LAR®) Adapted from Simard M. Nausea and Vomiting. In Néron A, ed. Care beyond cure: Management of Pain and Other Symptoms, 4th ed. Montréal: Association des pharmaciens des établissements de santé du Québec; 2009: Chapter 9.