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Nausea and Vomiting in Palliative Care @Keeley_2020

  • N+V is common in patients with cancer - About 70% of patients

  • Often increases as disease progresses.

  • Causes can be:

    • Drugs:
      • Chemo
      • Non Chemo
    • Disease:
      • Metabolic:
        • Hypercalcaemia
        • Uraemia
      • Intracranial
      • GI irritation
      • Cough/Retching
      • Hepatomegaly
      • Constipation
      • Obstruction
      • Psychogenic (fear)

  • Approaching Patient:

    • What's the likely mechanism?:
      • What are the likely receptors?
  • History:
    • Drugs/Timings of Drugs
    • Gastric Discomfort/Dyspepsia
    • Constipation/Obstruction
    • Neuro Sx (Headache/Confusion)
  • Assessment:
    • Mouth/Pharynx - Thrush - Dehydration
    • Hepatomegaly/Masses
    • Distension
    • Bowels Sounds
    • PR
    • Cranial Nerve/Neuro Exam
  • Investigations:
    • FBC
    • CRP
    • U&Es
    • Ca2+
    • LFTs
    • Imaging:
      • Abdo film/CT
      • CT Head

Antiemetic Drugs

  • Metoclopramide:
    • Prokinetic:
      • Increasing peristalsis (upper gut)
      • Dopamine (D2) Antagonist
      • Serotonin (5HT4) agonist
    • Give for:
      • Gut Stasis
    • 30-80mg in 24/hrs
  • Cyclizine:
    • Antihistamine:
      • Acts on vestibular/vomiting centres
      • Histamine (H1) receptor antagonist
    • Give for:
      • Intestinal obstruction
      • Vestibular Causes (Middle ear/Cranial Nerve VIII tumours)
    • 150mg in 24hrs
  • Haloperidol:
    • Butyrophenone:
      • Dopamine (D2) Antagonist in Chemoreceptor Trigger Zone
    • Give for:
      • Chemical/Drug/Metabolic Causesi
      • Hiccough
    • 1.5-10mg in 24hrs
  • Levomepromazine:
    • Phenothiazine:
      • Dopamine (D2 - Potent) and Serotonin Receptor Antagonist in CTX
      • Most receptors apart from 5HT-3
    • Give for:
      • Most Causes - Broad Spectrum
      • Does sedate also
    • 6.25-50mg in 24hrs
  • Ondansetron:
    • Antiserotoninergic:
      • 5HT3 receptors in CTZ and Gut
    • Give For:
      • N+V related to chemo/surgery/radiotherapy
    • 8-16mg in 24hrs
  • Dexamethasone:
    • Corticosteroid:
      • Reducing inflammatory oedema
      • Acting non-specifically centrally
    • Give for:
      • Raised ICP/Chemo Related N+V
    • 8-16mg in 24hrs
  • Hyoscine Butylbromide:
    • Anticholinergic:
      • Reducing GI Secretions and Motility
    • Give for:
      • Intestinal Obstruction
    • 60-300mg in 24hrs
  • Octreotide:
    • Somatostatin Analogue:
      • Reduces gut secretions
      • Somatostatin receptor agonist
    • Give for:
      • Intestinal obstruction
    • 250-750micro in 24hrs