“Pearls”- Nausea in Palliative Medicine November 2004
1) Recognize: Nausea commonly exists without vomiting. Ask about appetite, response to the smell
of food cooking, early satiation when eating. Nausea can interfere significantly with the joy of living
and is important to recognize and treat. Nausea is so common with opiates that while vomiting may not be present, the attention to this detail can have a positive effect on quality of life.
2) Prevent the two most common causes of nausea from opiate initiation
a) constipation: see Pearls Nov 2003 b) gastroparesis: add a prokinetic agent (see following chart)
3) Assess : Why does this patient have nausea now? 11 M’s and a P Medications: digitalis, iron preparations, antibiotics, SSRI’s, chemotherapy
induced immediate or delayed, NSAID’s, ASA, opiates
Mucosal Irritation: radiotherapy of abdomen, gastritis, gastric/duodenal ulcer Motility: gastroparesis (opioids), dysmotility syndromes from extensive Mechanical: bowel obstruction, constipation Metabolic: hypercalcemia, uremia, liver failure, renal failure Meningeal Irritation Movement Related: inner ear, cerebellar involvement Metastases: intracranial (raised intracranial pressure), abdominal (dysmotility) Microbes: infections Mental: anxiety, anticipatory nausea Myocardial: silent MI’s 4) Correct Reversible Causes 5) Utilize Non-Drug Interventions at the same time as other maneuvers as appropriate
see Windsor and Essex County Care Management Tools 6) Utilize Medications see next page
7) Reassess and modify until nausea is controlled
8) If not improving, reconsider? Have you got the correct cause?
Most commonly used anti-emetics in Palliative Medicine
(Stemetil®) so caution when used together
Chemoreceptor trigger zone, D2 receptor
raised ICP, or severe liver involvement.
This is not meant to be an e xhaustive reference but rather a simplified approach to nausea. Notes
Prochlorperazine (Stemetil ®) is commonly used as an anti-emetic in oncology. It may be given po/IM/IV/pr. It cannot be given sc.
Some persons are sensitive to the extrapyramidal side effects; these persons may feel jittery, complain of restless legs. These same persons may be sensitive to the extrapyramidal side effects of metoclopramide. We tend not to use these two drugs together. Domperidone does
not share this profile. Please note that dimenhydrinate (Gravol ®) has only a minor indication in palliative medicine: when persons complain of motion sickness nausea not relieved by other medications.
In summary: Always, always, always watch the bowel and ensure a good bowel protocol is in place and is effective. The commonest protocol for control of nausea in palliative medicine is either a prokinetic (domperidone or metoclopramide) or haloperidol alone or in combination. 75% of prescriptions for nausea in palliative medicine are written for these medications.
A common medication profile with an opiate would be as follows:
domperidone 10 mg, 2 tabs (20 mg) qid to prevent/control nausea
haloperidol 0.5 mg, 1 tab (0.5 mg) bid to prevent/control nausea lactulose 25 – 30 ml od – bid in juice to prevent constipation
bisacodyl 1-2 tabs od – bid to stimulate bowel movement to prevent constipation.
www.palliativedrugs.com www.albertapalliative.net C. Jones, MD [email protected]
Shun Lee Catholic Secondary School Biology (S6) Scheme of work (2011/2012) Laboratory safety and evacuation Level Test Summer Tutorial Class ( 37 periods/~22 hours) Bk E1 Ch 1 Regulation of water content Time allocation Learning target Practical Assignment Exercise Teaching resources (No. of periods) 1.1 Importance of • To identify the m
Drugs & Supplements: Vitamin B12 (Print Version) Vitamin B12 URL of this page: http://www.nlm.nih.gov/medlineplus/druginfo/natural/patient-vitaminb12.html Background Vitamin B12 is an essential water soluble vitamin that is commonly found in a variety of foods such as fish, shellfish,meats, and dairy products. Vitamin B12 is frequentl
“Pearls”- Nausea in Palliative Medicine November 2004