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Nausea and vomiting due to opioids alone usually resolves in 5-7 days, so a trial with an antiemetic is advisable if this is thought to be the cause. It is often sensible to ensure a when required supply of antiemetic (e.g. metoclopramide) when patients are first started on regular strong opioids.
Treat potentially reversible and exacerbating factors if possible and appropriate, such as:
Prescribe the appropriate anti-emetic regularly and as required, to be given before meals.
Review every 24 hours:
Use syringe driver or other parenteral route:
Consider converting to oral route if good control after 72 hours.
Metoclopramide MHRA safety advice: Although there has been a recent MHRA safety update about the use of high doses of metoclopramide which cautions its use, the risks of neurological effects in the Palliative Care setting may be justified in the context of improved symptom control in the final phase of life. Dose titration should be carefully assessed for benefit. Please discuss with your local Specialist Palliative Care provider if you have concerns
Ondansetron is rarely of value in palliative care due to its limited range of activity – consider for post-operative and chemotherapy induced nausea and vomiting only.
If symptoms are not resolving seek advice from specialist palliative care team.
Consider using dexamethasone 8mg – 16mg daily in cancer patients (if liver metastases or extrinsic compression from tumour is likely), see section 6.3 Corticosteroids.
Adjunct: Omeprazole (See section 1.3.5 Proton pump inhibitors (PPI))
Key clinical feature is nausea at the sight and smell of food
Consider using dexamethasone 4mg daily for cancer patients only, see section 6.3 Corticosteroids.