4.6 Drugs used in nausea and vertigo

Drugs used for nausea and labyrinth disorders not listed below:

Vomiting is a complicated process mediated by a central coordinating 'vomiting center', which is located in the brain stem. The vomiting center receives input via the nervous system from many sources, including the chemoreceptor trigger zone (CTZ), the pharynx, the gastrointestinal tract, pain receptors and the vestibular apparatus. CTZ activity is modified by a variety of receptors, including histaminic, muscarinic and serotonergic. Most antiemetic drugs have antagonist activity at one or more of these receptors.

Anti-emetics should be prescribed only when the cause of vomiting is known, particularly in children, otherwise the symptomatic relief that they produce may delay diagnosis. Anti-emetics are unnecessary and sometimes harmful when the cause can be treated e.g. diabetic ketoacidosis, or in excessive digoxin or anti-epileptic dosage.

Antihistamines

Cinnarizine
  • Tablets 15mg (£9.14 = 30mg three times daily)

Indications

  • Vestibular disorders, such as vertigo, tinnitus, nausea and vomiting in Ménière's disease
  • Motion sickness

Dose

  • Vestibular disorders, 30mg 3 times daily
  • Motion sickness, 30mg 2 hours before travel then 15mg every 8 hours during journey if necessary
Cyclizine
  • Tablets 50mg (£6.12 = 50mg three times a day)
  • Injection 50mg/ml (£2.71 = 1ml amp)

Indications

  • Nausea, vomiting, vertigo, motion sickness, labyrinthine disorders

Dose

  • Oral, cyclizine hydrochloride 50mg up to 3 times daily
  • Intramuscular or intravenous injection, 50mg 3 times daily

Notes

  1. Avoid cyclizine in patients with severe heart disease. Cyclizine may be associated with tachycardia.

Phenothiazines and related drugs

Prochlorperazine
  • Tablets 5mg (£0.35 = 10 tablets)
  • Buccal tablets 3mg (£8.62 = 10 tablets)
  • Injection 12.5mg/ml (£0.52 = 1ml amp)

Indications

  • Nausea and vomiting

Notes

  1. Prochlorperazine buccal tablets have been included only for use as an alternative to injection in certain circumstances (e.g. GP call out). They should be prescribed in small quantities not exceeding 10 tablets
  2. Severe reactions to prochlorperazine should be treated with procyclidine injection, 5mg to 10mg given IM, repeated if necessary after 20 minutes, maximum of 20mg daily. In children, the dose range is as follows: Age 1-2yrs, 500 micrograms to 2mg, age 2-12yrs 2mg to 5mg, and age 12-18yrs 5mg to 10mg. Subsequent oral doses may be needed for the next 2 or 3 days.
  3. Prochlorperazine should not be prescribed for patients with Parkinson's disease and should be used with caution in the elderly
  4. Balance disorders can be exacerbated, in part, by the use of labyrinthine sedatives. These drugs, when used for acute vertigo, should only be given for a maximum of two weeks.
Droperidol
  • Injection 2.5mg/ml, 1ml ampoule

Domperidone and metoclopramide

Domperidone
  • Tablets 10mg (£0.50 = 7 days treatment)
  • Suspension 5mg/5ml (£13.43 = 200ml)

Indications

Dose

  • Adult and child over 12 years and body-weight over 35kg, 10mg up to 3 times daily; maximum 30mg daily

Notes

  1. Domperidone does not readily cross the blood-brain barrier and is therefore the preferred option for Parkinson's patients. It may also be useful in reducing the side effects of levodopa and bromocriptine.
  2. MHRA Drug Safety Update - Domperidone is associated with a small increased risk of serious cardiac side effects.
    1. Domperidone is now restricted to use in the relief of nausea and vomiting
    2. It should be used at the lowest effective dose for the shortest possible time. Maximum treatment duration should not usually exceed one week
    3. Patients currently receiving long-term treatment with domperidone should be reassessed at a routine appointment to advise on treatment continuation, dose change, or cessation
  3. Domperidone is now contraindicated in people:
    1. with conditions where cardiac conduction is, or could be, impaired
    2. with underlying cardiac diseases such as congestive heart failure
    3. receiving other medications known to prolong QT interval or potent CYP3A4 inhibitors
    4. with severe hepatic impairment
  4. Patients with these conditions should have their treatment reviewed at their next routine appointment and be switched to an alternative treatment if required
Metoclopramide
  • Tablets 10mg (£2.16 = 10mg three times a day)
  • Oral solution 5mg/5ml (£19.77 = 150ml)
  • Injection 5mg/ml (£0.33 = 2ml ampoule)

Indications

Dose (see Notes below)

  • For adults, the maximum dose in 24 hours is 30 mg (or 0.5 mg per kg bodyweight)

Notes

  1. MHRA Drug Safety Update - Metoclopramide: risk of neurological adverse effects - restricted dose and duration of use (August 2013). The benefits and risks of metoclopramide have been reviewed by the European Medicines Agency's Committee on Medicinal Products for Human Use, which concluded that the risk of neurological effects such as extrapyramidal disorders and tardive dyskinesia outweigh the benefits in long-term or high-dose treatment. To help minimise the risk of potentially serious neurological adverse effects, the following restrictions to indications, dose, and duration of use have been made:
    1. In adults over 18 years, metoclopramide should only be used for prevention of postoperative nausea and vomiting, radiotherapy-induced nausea and vomiting, delayed (but not acute) chemotherapy-induced nausea and vomiting, and symptomatic treatment of nausea and vomiting, including that associated with acute migraine (where it may also be used to improve absorption of oral analgesics);
    2. Metoclopramide should only be prescribed for short-term use (up to 5 days);
    3. Usual dose is 10 mg, repeated up to 3 times daily; max. daily dose is 500 micrograms/kg;
    4. Intravenous doses should be administered as a slow bolus over at least 3 minutes;
    5. Oral liquid formulations should be given via an appropriately designed, graduated oral syringe to ensure dose accuracy.

5HT3-receptor antagonists

Ondansetron
  • Tablets 4mg, 8mg (£1.58 = 8mg twice daily, 5 days treatment)
  • Oral solution sugar free 4mg/5ml (£38.34 = 50ml bottle)
  • Injection 4mg/2ml, 8mg/4ml

Indications

  • Nausea and vomiting induced by cytotoxic chemotherapy and radiotherapy
  • Prevention and treatment of post-operative nausea and vomiting
  • Nausea and vomiting in pregnancy and Hyperemesis Gravidarum (unlicensed indication)

Notes

  1. MHRA Drug safety update (August 2012): Ondansetron (Zofran): important new intravenous dose restriction
    1. A single dose of intravenous ondansetron given for the management of chemotherapy-induced nausea and vomiting (CINV) in adults must not exceed 16 mg (infused over at least 15 minutes)
    2. Ondansetron should be avoided in patients with congenital long QT syndrome
    3. Caution must be used if administering ondansetron to patients with risk factors for QT interval prolongation or cardiac arrhythmias. These include: electrolyte abnormalities; use of other medicines that prolong the QT interval (including cytotoxic drugs) or may lead to electrolyte abnormalities; congestive heart failure; bradyarrhythmias; and use of medicines which lower the heart rate
    4. Hypokalemia and hypomagnesemia should be corrected prior to ondansetron administration
  2. MHRA Drug Safety update (July 2013): Ondansetron for intravenous use: dose-dependent QT interval prolongation
    1. In patients age 75 years or older a single dose of intravenous ondansetron for the prevention of CINV must not exceed 8 mg (infused over at least 15 minutes)
    2. In adult patients younger than 75 years a single dose of intravenous ondansetron for prevention of CINV must not exceed 16 mg (infused over at least 15 minutes)
    3. Dilution and administration in patients age 65 years or older:
      • all intravenous doses for prevention of CINV should be diluted in 50–100 mL saline or other compatible fluid and infused over at least 15 minutes
    4. Repeat dosing in all adults (including elderly patients):
      • repeat intravenous doses of ondansetron should be given no less than 4 hours apart
Granisetron
  • Tablets 1mg (£4.07 = 1mg dose)
  • Injection 1mg/ml (£1.60 = 1ml amp)

Hyoscine

Hyoscine hydrobromide
  • Tablets 300 micrograms (£1.67 = 12 tablets)
  • Patches 1mg/ 72 hours (£4.97 = 2 patches)
  • Injection 400 micrograms in 1ml

Notes

  1. For motion sickness: Give 30 minutes before travel, followed by two subsequent doses

Other drugs for Meniere's disease

Betahistine dihydrochloride
  • Tablets 8mg, 16mg (£1.39 = 16mg three times daily)

Indications

  • Ménière's disease

Dose

  • Initially 16mg 3 times daily, preferably with food; maintenance 24–48mg daily

 

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