FACTSHEET 10 ON PALLIATIVE CARE NAUSEA & VOMITING

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1 FACTSHEET 10 ON PALLIATIVE CARE NAUSEA & VOMITING (EXCLUDING OBSTRUCTION refer to FACTSHEET 11) Any advancing disease may be accompanied by nausea and vomiting. Often metabolic disturbance (electrolyte imbalance/organ failure) will cause nausea the resultant anorexia and poor oral intake can cause dehydration which results in increased nausea sometimes accompanied by vomiting. Nausea and vomiting are frequent symptoms in patients with cancer. In the earlier stages of disease this is often caused by chemotherapy and/or radiotherapy; it is well documented that the anxiety patients experience in relation to treatment at this early stage can lead to anticipatory nausea. This anxiety may well recur at a later stage if the patient experiences nausea/vomiting due to other causes. Plan to: Identify probable cause(s). Common causes of nausea and vomiting in palliative care: Gastric stasis Blood in the stomach e.g. due to GI bleeding Intestinal obstruction. ( refer to Factsheet 11) Drugs (new or increased dose, interaction) e.g. opioids, NSAIDs, digoxin, antidepressants, amiodarone, antibiotics and chemotherapeutic agents Biochemical abnormality hypercalcaemia, renal failure, hepatic dysfunction. Raised intracranial pressure Treatment related e.g. radiotherapy Anxiety Unknown/multifactorial Begin by addressing anxiety: discuss and explain the situation Choose an antiemetic appropriate for suspected cause. Choose route and frequency of administration of antiemetic appropriate to situation i.e. an actively vomiting patient needs parenteral medication, nausea may be treated with oral medication. Investigate and treat any reversible causes. IF IN DIFFICULTY SEEK SPECIALIST ADVICE Page 1 of 5 Factsheet 10

2 Assessment should include: History how and when the problem began (e.g. insidious onset may suggest development of metabolic upset sudden onset may occur in obstruction refer to Factsheet 11) relationship of the nausea and vomiting to recently introduced treatment e.g. NSAIDs, opioids (refer to Factsheet 6), hormonal therapy, anti-depressants; recent radiotherapy Pattern aggravating/relieving factors response to medication already tried (if partially effective does dose need increasing?) nausea relieved by vomiting, consider gastric stasis (possibly opioids, possibly outflow obstruction) vomiting shortly after meals, consider oesophageal/gastric obstruction sudden unpredictable vomit, possibly worse on waking, consider raised intracranial pressure Quantifying colour, nature and frequency of vomit e.g. frequent large amounts suggest high intestinal obstruction small infrequent vomit with persistent nausea may be metabolic large quantities of undigested food at the end of the day suggests gastric outflow obstruction Enquire about bowel habit constipation aggravates nausea; absent bowel activity or absence of passage of flatus suggests obstruction. Examination General appearance anxiety can be a potent cause of nausea and vomiting. Eyes possible jaundice. Oral cavity (exclude candida infection) Examine fundi for possible papilloedema Abdomen signs of distension/ascites Presence or absence of bowel sounds Hepatomegaly (signs and symptoms of) PR may be appropriate if constipation/obstruction suspected Rectal examination Page 2 of 5 Factsheet 10

3 Treatment Any readily reversible causes should be addressed. Treatment of more complex problems e.g. hypercalcaemia or obstruction should be discussed with a specialist. Non-pharmacological Discussion and explanation, this will help to relieve the patient s anxiety. Remove environmental stimuli promoting emesis e.g. cooking smells. Encourage sips of fluid. Consider use of sea bands or acupuncture as adjuvant therapy. Relaxation techniques may relieve associated anxiety. Pharmacological If there is any question of medication not being absorbed due to vomiting, parenteral administration either as subcutaneous bolus or subcutaneous infusion should be used, until condition settles sufficiently to re-establish oral route. Any cause of blood in the stomach must be treated concurrently, as antiemetics alone will not relieve vomiting if blood present in stomach. Choice of Antiemetic The most commonly used first line antiemetics are:- Haloperidol useful for drug induced nausea or when metabolic or chemical abnormality is the probable cause e.g. hypercalcaemia, hepatic dysfunction. Dose 1.5mg orally at night (additional morning dose if necessary); or 2.5mg subcutaneously once daily or twice daily; or 2.5mg to 5mg over 24 hours as continuous subcutaneous infusion. Metoclopramide useful in any situation requiring prokinetic agent e.g. gastric stasis, intestinal stasis. AVOID IN COLIC/OBSTRUCTION (refer to Factsheet 11). Dose 10mg orally three times per day or 10mg subcutaneously as bolus and 30mg to 60mg over 24 hours continuous subcutaneous infusion. Where higher doses have been necessary, reduce to effective minimal dose as soon as possible. Caution in young people under the age of 30, consider domperidone see below. Cyclizine useful in raised intracranial pressure, motion related sickness and mechanical bowel obstruction (refer to Factsheet 11). Dose 25mg to 50mg three times daily orally or subcutaneously; or 100mg to 150mg over 24 hours continuous subcutaneous infusion. (Refer to Factsheet 4 for compatibility). NB cyclizine (as a static agent) and metoclopramide/domperidone (as prokinetic agents) should not be combined as their actions counteract each other. Page 3 of 5 Factsheet 10

4 Response to Treatment Patients/families can be encouraged to record results of treatment to aid re-assessment and ongoing management. Ongoing Management If, after 24 hours of regularly administered medication, the problem persists, reassess: If likely cause unchanged, has the prescribed medication been absorbed? Is a higher dose required? If additional/other cause likely consider alternative antiemetic or discuss possible combination with a specialist. SEEK SPECIALIST ADVICE FOR COMBINING MEDICATION Alternatives Levomepromazine (Nozinan ) is a phenothiazine with potent sedative effect. At low dose (i.e. 6.25mg to 12.5mg orally once daily, or 5mg subcutaneously once or twice daily) it is a powerful broad-spectrum antiemetic often used where first line antiemetics have been unsuccessful. Domperidone 10mg to 20mg three times per day orally or 30mg to 60mg twice daily per rectum. a prokinetic antiemetic with no central effects i.e. an alternative to metoclopramide (therefore not to be used in mechanical bowel obstruction refer to Factsheet 11). Dexamethasone as a short course: often prescribed to prevent chemotherapy emesis or to break a cycle of vomiting (long-term use may be required in raised intracranial pressure consult a specialist). The following are rarely prescribed for use in Palliative Care: The 5HT 3 antagonist: Ondansetron, is used when 5HT 3 is the cause of emesis during chemotherapy, and/or abdominal radiotherapy. Prochlorperazine is generally less effective in the relief of emesis in palliative patients, and is not suitable for subcutaneous use. Reassess regularly until satisfactory control obtained. Once nausea and vomiting is controlled conversion from subcutaneous infusion to oral medication can be considered. Antiemetics should be continued indefinitely whilst underlying cause remains. Page 4 of 5 Factsheet 10

5 IF TREATMENT UNSUCCESSFUL SEEK SPECIALIST ADVICE General palliative care references include: Palliative Care Formulary, Fourth Edition (PCF4) Edits: Robert Twycross and Andrew Wilcock available via Palliativedrugs.com Palliative Adult Network Guidelines Third Edition (also available as an App) Edits: Max Watson, Caroline Lucas, Andrew Hoy, Ian Back, Peter Armstrong Page 5 of 5 Factsheet 10