16.3 Nausea and vomiting in palliative care

• Ginger preparations may be effective for nausea in some patients – consider trial but discontinue if lack of benefit
• Accupressure wrist bands e.g. Sea bands® purchased by the patient may be helpful in movement-related sickness – consider trial but discontinue if lack of benefit
• Strong smells can trigger nausea

Prescribe the appropriate anti-emetic regularly and as required, to be given before meals.

Review every 24 hours:

• If good control, continue the ant-emetic unless the causes has resolved
• If there is some response increase the first choice anti-emetic and consider adding or changing to a second choice
• If no benefit reassess the cause. Consider a second choice or alternative first choice, and consider an alternative route

Use syringe driver or other parenteral route:

• If patient is vomiting or oral route is in doubt,
• In cases of persistent nausea, when absorption of oral medications may be poor

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.

Gastric stasis / outlet obstruction

Metoclopramide

• 10-20mg oral 3 x daily or 30-60mg SC 24 hourly in infusion
• Start with low doses, titrate only if required, and monitor closely
• Metoclopramide should not be used in patients with Parkinson's disease because of the central anti-dopaminergic effect

Domperidone

• Up to 10mg oral 3 x daily
• Domperidone is safer in patients with Parkinson's disease as the drug does not cross the blood-brain-barrier
• If there is colic or no response, seek advice from the 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.

Gastric irritation / radiotherapy

Metoclopramide

• 10-20mg oral 3 x daily or 30-60mg SC 24 hourly in infusion
• Start with low doses, titrate only if required, and monitor closely.
• Metoclopramide should not be used in patients with Parkinson's disease because of the central anti-dopaminergic effect.

Adjunct: Omeprazole (See section 1.3 Antisecretory drugs and mucosal protectants)

Chemical / metabolic

Key clinical feature is nausea at the sight and smell of food

Levomepromazine

• 6.25mg orally at night (quartering a 25mg tablet resulting in off-label use), or 6.25mg -12.5mg SC 24 hourly infusion

Haloperidol

• 500 microgram 12 hourly orally recommended as starting dose
• Haloperidol may be less sedating

Intra-cranial disease / treatment in cancer patients

Cyclizine

• oral 50mg three times a day, or 100mg – 150mg SC 24 hour infusion (plus dexamethasone 8mg – 16mg daily if raised intra-cranial pressure)

Levomepromazine

• 6.25mg – 12.5mg SC 24 hour infusion

Movement related (often including vertigo)

Cyclizine

• oral 50mg three times a day, or 100mg – 150mg SC 24 hour infusion

Levomepromazine

• 6.25mg orally at night (quartering a 25mg tablet resulting in off-label use), or 6.25mg – 12.5mg SC 24 hourly infusion

Consider:

Betahistine

• oral 8 – 16mg three times daily

Hyoscine hydrobromide

• patches 1mg/72 hours

Prochlorperazine

• Buccal prochlorperazine 3mg twice daily

Cause unclear / multiple causes

Metoclopramide

• 10-20mg oral three times daily or 30-60mg SC 24 hourly in infusion

Levomepromazine

• 6.25mg orally at night (quartering a 25mg tablet resulting in off-label use), or 6.25mg – 12.5mg SC 24 hourly infusion

Consider using dexamethasone 4mg daily for cancer patients only, see section 6.3 Corticosteroids.