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16.3 Nausea and vomiting in palliative care
A logical approach to the use of anti-emetics depends on knowledge of the cause of the symptoms.
Assess the patient with regard to the cause and wherever possible this cause should be addressed.
Consider
- Drugs
- where possible, stop / change drugs which are causing nausea (e.g. NSAID, opioids, antidepressants, iron supplements)
- in patients with gastric stasis avoid drugs with anticholinergic effects (e.g. hyoscine, antidepressants, cyclizine)
- antiemetics may be necessary for a few days when opioid treatment is initiated
- Abnormal biochemistry:
- hypercalcaemia, renal failure, hyponatraemia
- Constipation:
- prevent and treat
- Gastritis/gastro-oesophageal reflux:
- treat with a PPI
- Raised intracranial pressure:
- treat with corticosteroids
- Psychosomatic factors e.g. anxiety, fear:
- treat with psychological approaches and pharmacological treatments
- Malignant gastrointestinal obstruction
- Pain
General principles
- Ensure the anti-emetic is used regularly and to maximum dose before changing. If the first drug is ineffective, change to a drug from another pharmacological group
- If the first drug is partially effective, add a drug from another pharmacological group
- Metoclopramide with levomepromazine is often effective
- Cyclizine and other anticholinergic drugs antagonise some of the effects of metoclopramide and other prokinetic agents. The combination should be avoided if possible
- Give the antiemetic by an appropriate route i.e. if absorption may be compromised; give antiemetic by continuous subcutaneous infusion (CSCI).
Please refer to: 4.6 Drugs used in nausea and vertigo
MHRA advice regarding the use of metoclopramide and domperidone
The MHRA has issued drug safety updates relating to the use of metoclopramide and domperidone.
MHRA Drug Safety Update (August 2013): Metoclopramide: risk of neurological adverse effects
MHRA Drug Safety Update (December 2019): Domperidone for nausea and vomiting: lack of efficacy in children; reminder of contraindications in adults and adolescents
The British National Formulary has provided clarification regarding the use of metoclopramide in the palliative care setting stating that the advice from the MHRA does not apply to unlicensed uses e.g. palliative care (see link to BNF).
In summary:
- Metoclopramide and domperidone can continue to be used in palliative care patients as standard practice indicates.
- Patients should be monitored for undesirable side effects. If metoclopramide or domperidone need to be discontinued because of side effects, an alternative antiemetic should be provided.
- Minimise long term use of metoclopramide and domperidone where possible e.g. could be discontinued if initiated to cover a course of palliative chemotherapy
- The prescriber must consider the need to provide information to patients about use of "off-licence" drugs.
Drug induced and biochemical causes
Metoclopramide
- oral 10mg 8 - 6 hourly
- 30 – 60mg/24 hours via CSCI
Haloperidol
- oral 1 – 3mg once or twice daily
- 2.5 – 5mg/24 hours via CSCI
- lower doses may sometimes be used e.g. 1mg/24 hours via CSCI
Levomepromazine
- oral 6– 25mg at night
- 6.25 – 25mg/24 hours via CSCI
- lower doses may sometimes be used e.g. 2.5mg/24 hours via CSCI
Cyclizine
- oral 50mg 8 hourly
- 100 - 150mg/24 hours via CSCI
'Squashed stomach syndrome' e.g. ascites, hepatomegaly & gastric stasis (often drug induced)
Metoclopramide
- oral 10mg 8 - 6 hourly
- 30 – 60mg/24 hours via CSCI
Domperidone
- does not cross the blood brain barrier so fewer side effects
- oral 10 – 20mg 8-6 hourly
Stimulation of GI receptors (vagal afferents) e.g. local tumour, oropharyngeal candida, bowel obstruction
Levomepromazine
- oral 6 – 25mg at night
- 6.25 – 25mg/24 hours via CSCI
- lower doses may sometimes be used e.g. 2.5mg/24hours via CSCI
Cyclizine
- oral 50mg 8 hourly
- 100 - 150mg/24 hours via CSCI
Central causes e.g. raised intracranial pressure, vestibular/motion related
Cyclizine
- oral 50mg 8 hourly
- 100 - 150mg/24 hours via CSCI
Hyoscine hydrobromide patch
- 1mg/72 hours
5HT3 antagonists
The place of 5HT3 antagonists in non-chemotherapy induced nausea and vomiting is not yet clear. They may be useful in drug or biochemical induced emesis and stimulation of GI receptors. Generally we would advise caution in palliative patients as they have significant constipating effects.
Corticosteroids can sometimes be helpful in the management of nausea (see section 6.3 Corticosteroids)
