4.6 Drugs used in nausea and vertigo

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.

Pregnancy: Nausea in the first trimester of pregnancy does not usually require drug therapy. On rare occasions, if vomiting is severe, short-term treatment with an antihistamine may be required. Promethazine is the preferred treatment, see www. cks.nice.org.uk/nauseavomiting-in-pregnancy. Prochlorperazine or metoclopramide may be considered as second line treatments. If symptoms do not settle in 24 to 48 hours then specialist advice should be sought.

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.

Antihistamines

Cinnarizine
  • Tablet 15mg (£9.30 = 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
  • Tablet 50mg (£5.24 = 50mg three times a day)
  • Injection 50mg in 1ml (£2.71 = ampoule)

Indications

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
  • Tablet 5mg (£0.26 = 10 tablets)
  • Syrup 5mg in 5ml (£3.34 = 100ml)
  • Intramuscular injection 12.5mg in 1ml (£0.52 = ampoule)
  • Buccal tablet 3mg (£10.35 = 10 tablets)

Indications

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 (£1.65 = 10mg three times a day)
  • Syrup 5mg in 5ml (£19.77 = 150ml)
  • Injection 10mg in 2ml (£0.33 = 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 (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 to10mg 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 (£0.67 = 10mg three times daily, 7 days treatment)
  • Suspension 5mg in 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.

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 (£1.58mg = 8mg twice daily, 5 days treatment)
  • Oral solution sugar free 4mg/5ml (£38.24 = 50ml bottle)
  • Injection 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:
      • 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
  • Tablet 1mg
  • Sterile solution for dilution and use as either infusion or injection, 1mg, 3mg

Notes

  1. For use in Plymouth Hospitals NHS Trust
Palonosetron
  • Injection 50 micrograms/ml

Notes

  1. For use in South Devon Healthcare Foundation NHS Trust

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 150 micrograms, 300 micrograms (£1.67 = 12 tablets)
  • Patches 1mg/ 72 hours (£8.58 = 2 patches)
  • Injection 400 micrograms in 1ml (£4.72 per ampoule)

Indications

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.

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.

Other drugs for Meniere's disease

Betahistine
  • Tablet 8mg, 16mg (£7.35 = 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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