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4.6 Drugs used in nausea and vertigo

First Line
Second Line
Specialist
Hospital Only

Drugs used for nausea and labyrinth disorders not listed below:

See also Chapter 16 - Palliative Care, anti-nausea drugs (including haloperidol) should be prescribed prophylactically when giving opioid analgesics.

Anti-emetics should be prescribed only when the cause of vomiting is known because otherwise they may delay diagnosis, particularly in children. The underlying cause of the nausea should be treated before starting treatment with an anti-emetic wherever possible.

Cyclizine or prochlorperazine are first line in post-operative nausea and vomiting. If ineffective after 30-60 minutes use ondansetron 4mg. If symptoms return, and it is more than 6-8 hours since last dose of 1st line agent, repeat the dose. Maximum doses for cyclizine and prochlorperazine eight hourly and ondansetron twelve hourly.

NHS England (NHSE) has published new prescribing guidance for various common conditions for which over the counter (OTC) items should not be routinely prescribed in primary care (quick reference guide). These conditions include infrequent migraine and travel sickness.

Many of these products are cheap to buy and are readily available OTC along with advice from pharmacies. Some self-care medicines are available from shops and supermarkets. Please click here for further information, exceptions, and a patient leaflet.

Antihistamines

Cinnarizine
  • Tablets 15mg (£10.00 = 30mg three times daily)

Indications

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

Dose

  • Vestibular disorders, 30mg three times daily
  • Motion sickness, 30mg 2 hours before travel then 15mg every 8 hours during journey if necessary
Cyclizine
  • Tablets 50mg (£3.32 = 50mg three times a day)
  • Solution for injection 50mg/1ml (£1.61 = ampoule)

Indications

Dose

  • Oral: 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.
Doxylamine / pyridoxine
  • Gastro-resistant tablets 10mg/10mg (£39.90 = 10mg/10mg four times a day for one week)

Indications and dose

  • Nausea and vomiting in pregnancy in adults over 18 years of age:
    • two tablets once daily at bedtime for 2 days,
    • increased on day 3 if necessary to one tablet in the morning and two tablets at bedtime,
    • further increased on day 4 if necessary to one tablet in the morning, one tablet mid-afternoon and two tablets at bedtime. (Maximum four tablets per day).

Notes

  1. Doxylamine/pyridoxine is considerably more expensive than other antiemetics that have long been used off-label for nausea and vomiting in pregnancy (NVP) but is the only licensed product for NVP in the UK.
  2. Doxylamine/pyridoxine should be administered on an empty stomach with a glass of water.
  3. Doxylamine/pyridoxine has anticholinergic properties and therefore should be used with caution in specific patient groups, refer to SmPC.
  4. Concomitant treatment with MAOIs is contraindicated (anticholinergic effects prolonged and intensified by MAOIs).
  5. Continued need should be reassessed as the pregnancy progresses. To prevent a sudden return of NVP symptoms, the SmPC recommends a gradual tapering dose at the time of discontinuation.

Phenothiazines and related drugs

Prochlorperazine
  • Tablets 5mg (£0.61 = 10 tablets)
  • Intramuscular solution for injection 12.5mg/1ml (£0.52 = ampoule)
  • Buccal tablet 3mg (£1.67 = 10 tablets)

Indications and dose

  • Nausea and vomiting:
    • Adult: acute attack:
      • Oral tablets: Initially 20 mg for 1 dose, then 10 mg for 1 dose, to be given 2 hours after first dose.
      • Deep intramuscular injection: 12.5 mg as required, to be followed if necessary after 6 hours by an oral dose.
    • Adult: prevention:
      • Oral tablets: 5-10mg two to three times a day.
      • Deep intramuscular injection: 12.5 mg as required, to be followed if necessary after 6 hours by an oral dose.
  • Nausea and vomiting in pregnancy and hyperemesis gravidarum (second line) (off-label):
    • Oral tablets: 5-10mg up to three times a day.
    • Buccal tablets: 3-6mg twice daily.

Notes

  1. Prochlorperazine buccal tablets have been included only for use as an alternative to injection in certain circumstances (e.g. GP call out, nausea and vomiting in pregnancy/hyperemesis gravidarum). They should be prescribed in small quantities.
  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.

Domperidone and metoclopramide

Metoclopramide
  • Tablet 10mg (£3.24 = 10mg three times a day)
  • Oral solution sugar free 5mg/5ml (£13.24 = 150ml)
  • Solution for injection 10mg/2ml (£0.54 = 2ml ampoule)

Indications and dose

Notes

  1. MHRA Drug Safety Update (August 2013) Metoclopramide: risk of neurological adverse effects—restricted dose and duration of use. The benefits and risks of metoclopramide have been reviewed and 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 10mg, repeated up to 3 times daily; maximum 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.
  2. Metoclopramide is not as effective as prochlorperazine or cyclizine for the treatment of postoperative nausea and vomiting.
  3. Metoclopramide (and to a lesser degree prochlorperazine) is associated with a high risk of dystonias and oculogyric crises particularly in children, young adults and the elderly. It is not licensed for use in people less than 20 years of age. Other anti-emetics are preferred for these groups of patients.
  4. Severe reactions to metoclopramide should be treated with procyclidine injection, 5mg to 10mg given intra-muscularly, repeated if necessary after 20 minutes, maximum of 20mg daily. In children, the dose range is as follows: Age 1-2 years, 500 micrograms to 2mg, age 2-12 years 2mg to 5mg, age 12-18 years 5mg to 10mg. Subsequent oral doses may be needed for the next 2 or 3 days.
  5. Metoclopramide should not be prescribed for patients with Parkinson's disease.
Domperidone
  • Tablet 10mg (£0.46 = 10mg three times daily, 7 days treatment)
  • Oral suspension sugar free 1mg/ml (£49.32 = 200ml)

Indications

Dose

  • Adults and adolescents 12 years or older and weighing 35kg or more, 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 (December 2019): Domperidone for nausea and vomiting: lack of efficacy in children; reminder of contraindication in adults and adolescents
    1. Change of indication:
      1. domperidone is now authorised for the relief of symptoms of nausea and vomiting only in adults and adolescents 12 years of age or older and weighing 35 kg or more
      2. consider alternative treatments to domperidone in children younger than 12 years of age who need relief of symptoms of nausea and vomiting
    2. Treatment duration:
      1. Domperidone should be used at the lowest effective dose for the shortest possible duration. Maximum treatment duration should not usually exceed 1 week
    3. Domperidone is contraindicated in patients:
      1. with moderate to severe hepatic impairment
      2. with known existing prolongation of cardiac conduction intervals (particularly QTc)
      3. with underlying cardiac diseases such as congestive heart failure
      4. with significant electrolyte disturbances
      5. receiving QT-prolonging drugs (for considerations with regard to apomorphine (see Drug Safety Update April 2016)
      6. receiving potent CYP3A4 inhibitors (regardless of their QT-prolonging effects)
      7. with hypersensitivity to domperidone
      8. with a prolactin-releasing pituitary tumour
      9. in which stimulation of the gastric motility could be harmful (for example, in patients with gastro-intestinal haemorrhage, mechanical obstruction, or perforation)

5-HT3 antagonists

5HT3 antagonists should only be used 2nd line in post-operative nausea and vomiting where prochlorperazine/cyclizine is not effective.

Ondansetron
  • Tablets 4mg, 8mg (£2.89 = 8mg twice daily, 5 days treatment)
  • Oral solution sugar free 4mg/5ml (£23.16 = 50ml bottle)
  • Solution for injection ampoules 4mg/2ml, 8mg/4ml
  • Suppository 16mg

Indications

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:
      1. 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):
      1. repeat intravenous doses of ondansetron should be given no less than 4 hours apart.
  3. MHRA Drug Safety Update (January 2020): Ondansetron: small increased risk of oral clefts following use in the first 12 weeks of pregnancy.
    1. Patients must be counselled regarding the benefits of ondansetron together with the small increase in risk of orofacial cleft following use in the first 12 weeks of pregnancy. The background risk for orofacial cleft is 11 per 10,000 pregnancies. The risk of orofacial cleft is 14 per 10,000 pregnancies following ondansetron use in the first trimester. This equates to an additional 3 cases of orofacial cleft per 10,000 pregnancies exposed to ondansetron.
Granisetron
  • Tablet 1mg
  • Sterile solution for dilution and use as either infusion or injection 1mg/1ml, 3mg/3ml

Notes

  1. For use in University Hospitals Plymouth NHS Trust
Palonosetron
  • Solution for injection vials 250micrograms/5ml

Notes

  1. For use in Torbay and South Devon NHS Foundation Trust
Akynzeo

(Palonosetron and netupitant)

  • Capsules 300mg/0.5mg

Indications

  • Prevention of acute and delayed nausea and vomiting associated with moderately emetogenic cancer chemotherapy after aprepitant has failed

Notes

  1. For use in Torbay and South Devon NHS Foundation Trust.
    1. To be used in accordance with the trust policy for the management of nausea and vomiting in patients receiving chemotherapy and radiotherapy.
  1. Prescribe by brand (to aid identification where products contain multiple ingredients, or to prevent confusion where multiple brands contain similar ingredients).

Neurokinin receptor antagonist

Aprepitant
  • Capsules 80mg, 125mg

Cannabinoids

Nabilone
  • Capsule 1mg

Notes

  1. Nabilone is only used for nausea and vomiting caused by cytotoxic chemotherapy that is unresponsive to conventional anti-emetics.

Hyoscine

Hyoscine hydrobromide
  • Tablets 150micrograms, 300micrograms (£1.84 = 12 tablets)
  • Patches 1mg/72hours (£12.87 = 2 patches)
  • Solution for injection 400micrograms/1ml (£4.00 = 1ml ampoule)

Indications

Notes 

  1. MHRA Drug Safety Update (July 2023): Hyoscine hydrobromide patches (Scopoderm 1.5mg Patch or Scopoderm TTS Patch): risk of anticholinergic side effects, including hyperthermia
    1. Be alert to the potential for anticholinergic side effects in patients, particularly if used outside the licence. 
    2. Children and elderly patients are more susceptible to anticholinergic toxicity. Serious effects can include hyperthermia, urinary retention, delirium, hallucinations, seizures, coma, and respiratory paralysis.
    3. In hospital or residential care settings, monitor patients for signs and symptoms of anticholinergic side effects and manage promptly.
    4. If used at home, counsel patients, parents, and carers on side effects to be aware of and what to do if they occur (see the safety update).

Vertigo and nausea associated with Ménière's syndrome and middle ear surgery may be difficult to treat. Hyoscine, antihistamines, and phenothiazines (such as prochlorperazine) are effective in the prophylaxis and treatment of such conditions. In the acute attack prochlorperazine may be given rectally or by intramuscular injection or cyclizine may be given by intramuscular injection.

Other drugs for Meniere's disease

Betahistine is of benefit solely in treatment of Ménière's syndrome and prescribers should ensure that betahistine is not being prescribed to treat side effects of other medication.

Betahistine dihydrochloride
  • Tablet 8mg, 16mg (£4.48 = 16mg three times daily)

Indications

  • Vertigo, tinnitus and hearing loss associated with Ménière's disease

Dose

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