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Effective Anti-emetics for Nausea Relief

This document discusses rational use of antiemetics for nausea and vomiting. It reviews the mechanisms and indications of metoclopramide, prochlorperazine, cyclizine, and ondansetron. Metoclopramide is safe in pregnancy but not recommended for breastfeeding. Prochlorperazine can cause extrapyramidal side effects and interactions. Cyclizine is recommended as a first-line oral option. Ondansetron is widely used off-label but may increase birth defects. The author recommends metoclopramide for migraine and in pregnancy over 20, and considers age, drugs, and condition when choosing an antiemetic.

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10 views14 pages

Effective Anti-emetics for Nausea Relief

This document discusses rational use of antiemetics for nausea and vomiting. It reviews the mechanisms and indications of metoclopramide, prochlorperazine, cyclizine, and ondansetron. Metoclopramide is safe in pregnancy but not recommended for breastfeeding. Prochlorperazine can cause extrapyramidal side effects and interactions. Cyclizine is recommended as a first-line oral option. Ondansetron is widely used off-label but may increase birth defects. The author recommends metoclopramide for migraine and in pregnancy over 20, and considers age, drugs, and condition when choosing an antiemetic.

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Rational Use of Antiemetics

Dr Gill Davidson
May 2015

Dopamine &
Serotonin are the
key transmitters

Metoclopramide (Maxolon)
Anti-dopaminergic
Also a GI prokinetic
ED Indications:
Nausea and vomiting associated with infectious
disease
Migraine
Side effects
Extrapyramidal symptoms from restlessness and mild
agitation to oculogyric crisis
Children & young adults up to 20 and older people (due
to renal impairment)
Avoid in depression and parkinsonism as symptoms
may worsen

Metoclopramide
Safe to use in pregnancy
Not recommended in breastfeeding
CI: GI obstruction, perforation /
haemorrhage
Interactions:
Increases absorption of alcohol, aspirin
& paracetamol
CNS toxicity with SSRIs

Prochloperazine (Stemetil)
Phenothiazine
Centrally acting anti-dopaminergic (D2)
ED indications:
Vertigo & labrynthitis
Severe vomiting
Side effects:
Similar EPS to Metoclopramide
Can have anti-cholinergic effects urinary
retention
Can cause Neuroleptic malignant syndrome
(rare)

Prochloperazine (Stemetil)
Do not use if had:
Alcohol sedative effect
Tramadol risk of convulsions
Metoclopramide extrapyramidal effects
Risk of arrythmias
Amiodarone
Citalopram/Escitalopram
Disopyramide
Risperidone
Methadone
Avoid in pregnancy BNF
Clinical knowledge summary oral can be used 2 nd
line

Cyclizine
Histamine H1 receptor antagonist acting centrally
(CTZ)
ED indications:
Nausea & vomiting
Vertigo / labyrinthitis / motion sickness
Side effects
Antihistamines can cause drowsiness
Tachycardia
Hypotension (IV dose)
Hallucinations
Interactions:
None specific, but similar to other antihistamines
BNF - Avoid in pregnancy and breastfeeding
CKS June 2013 use it as 1st line

Ondansetron
Serotonin (5-HT) receptor antagonist; centrally and
peripherally (gut)
Mediated through the chemoreceptor trigger zone
ED indications
No specific licensed ED indications (chemo / post
op)
Still widely used
Side effects
Risk of QT prolongation
Headache
Constipation (diarrhoea in children)

Ondansetron
Pregnancy
BNF says no info so avoid
BMJ article says ondansetron increasingly used
with few side effects reported and no reports of
teratogenicity to date
Clinical knowledge summary (2013) oral
Ondansetron as 2nd /3rd line
Recent study in Amer J O&G Dec 2014 2x
increase birth defects
Avoid in breast feeding
Interactions:
Effect of tramadol antagonised
Increased serotonergic effect with SSRIs

Cost
IV

Oral

Other

Metocloprami 0.32
de
(10mg)

0.97 for 28 Oral


tablets 3.5p solution
19.42 /
150ml

Prochloperazi 0.52
ne
(12.5mg)

1.03 for 28
tablets 3.5p

Cyclizine

0.65
(50mg)

11.26 for
100 tablets
1p

Ondansetron

1.00
(4mg)

5.37 for 30 Oral film


tablets
28.50 for
(4mg) 18p 10

My Bottom Line
In pregnancy Metoclopramide if >20yrs
Migraine Metoclopramide
Gastroenteritis any but drug depends
on:
age: young and old likely Ondansetron
drugs patient taking; Cyclizine seems to
have least interactions

Vertigo / labrynthitis Cyclizine /


Prochlorperazine

References
BNF
BMJ 2014;349:g4714 Drug Treatment
of adults with Nausea and vomiting
in primary care
Google

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