Nausea and vomiting medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: {{VVS}

Mainstay of treatment of nausea and vomiting is correcting any electrolyte imbalance, dehydration, malnutrition, and suppression of symptoms while evaluating and treating the underlying cause. Dietary recommendations include a low-fat, low-fiber diet with frequent small meals if able to tolerate oral intake. Liquid diet is recommended in case solid diet is not well tolerated. Medical therapy involves two groups of drugs i.e., antiemetics and prokinetics. Antiemetics suppress nausea and vomiting and typically act centrally. Prokinetics modulate gastrointestinal motility.

• Mainstay of treatment of nausea and vomiting is correcting any electrolyte imbalance, dehydration, malnutrition, and suppression of symptoms while evaluating and treating the underlying cause. ^[1]
• Dietary recommendations include a low-fat, low-fiber diet with frequent small meals if able to tolerate oral intake. Liquid diet is recommended in case solid diet is not well tolerated. ^[2]
• Medical therapy involves two groups of drugs i.e., antiemetics and prokinetics. Antiemetics suppress nausea and vomiting and typically act centrally. Prokinetics modulate gastrointestinal motility.

• Benzodiazepines are used for anticipatory nausea and postoperative nausea and vomiting. Eg., Lorazepam 0.5-2mg oral, SL (sublingual) or IM (intramuscular), Alprazolam 0.25-1mg oral or IV (intravenous). ^[3]
• Serotonin 5-HT3 antagonists are used in postoperative, post-radiation and chemotherapy induced nausea and vomiting. Eg., Ondansetron 4-8mg oral or IV, Granisetron 1-2 mg every 4-8 hours or 0.075mg-0.25mg every 24 hours oral or IV. ^[1]
• Antihistamines are used in motion sickness and labrythitis. Eg., Meclizine 25-50mg every 24 hours oral, Diphenhydramine, Cyclizine, Hydroxazine 25-50mg every 6-8 hours, 25–75 mg every 8 hours, 25–50 mg every 4–6 hours, 25–100 mg every 6–8 hours oral, IM or IV. ^{[2] [4]}
• Anticholinergic agents are used in motion sickness. Eg., Scopolamine 0.3–0.6 mg every 24 hours SL, IV, IM or transdermal. ^{[5] [6]}
• Phenothiazines are antidopaminergics which are effective for migraine, motion sickness, vertigo, postoperative and chemotherapy induced nausea and vomiting. Eg., Prochlorperazine, Promethazine, Chlorpromazine, Perphenazine 5–10 mg every 6–8 hours, 12.5 –25 mg every 4–6 hours, 10–25 mg every 4–6 hours, 4–8 mg every 8–12 hours Oral, IV or IM. ^{[7] [8]}
• Droperidol is a Butyrophenone and a restricted drug used for postoperative and chemotherapy induced nausea and vomiting, 0.625–1.25 mg every 24hours IM or IV ^[5]
• Cannabinoids are used for chemotherapy induced nausea and vomiting. Eg., Dronabinol, Nabilone 2.5–10 mg every 6–8 hours, 1–2 mg every 8–12 hours oral. ^{[8] [9]}
• Corticosteroids are used for acute or delayed chemotherapy induced or postoperative nausea and vomiting. Eg., Dexamethasone 4–8 mg every 4–6 hours Oral, IM or IV. ^{[8] [10]}
• NK-1 Receptor Antagonist is used in acute as well as delayed chemotherapy-induced nausea and vomiting. It has also been used in gastroparesis-associated nausea and vomiting. Eg., Aprepitant 80–125 mg every 24 hours oral. ^{[11] [12] [13]}

• Prokinetic agents are used for only prokinetic activity (eg, Erythromycin) or both prokinetic and antiemetic activity (eg, Benzamides like Metoclopramide and Domperidone are shown to be efficacious in chemotherapy induced vomiting and gastroparesis). Metoclopramide 10–20 mg every 6–8 hours Oral, IM or IV, Domperidone 10mg every 8–24 hours oral, Erythromycin 250–500mg every 8 hours oral or IV. ^{[14] [15]}

• Novel and non-traditional therapies for nausea and vomiting include Tricyclic antidepressants (TCAs), Gabapentin and Olanzapine. Gabapentin is shown effective in life-threatening refractory emesis following posterior fossa surgery. TCAs (Amitriptyline, Nortriptyline, Doxepin, Desipramine, Imipramine) 10–100 mg/day oral, Gabapentin 300–900 mg three times daily oral, Olanzapine 5–10 mg/day oral. ^{[16] [17] [18] [19] [20]}
• Ginger has some efficacy to reduce postoperative nausea and vomiting, morning sickness and motion sickness. ^{[21] [22]}
• Gastric electric stimulation(GES) is a surgical procedure used in refractory gastroparesis. ^[23]
• Transcutaneous electrical nerve stimulation (TENS) with a wrist band is used to control symptoms postoperatively. ^[24]
• Alternative approaches include hypnosis, acupressure and acupuncture. ^{[25] [26]}

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