Term
| Chlorpromazine (Thorazine) |
|
Definition
10-25mg every 4-6hr
25-50mg every 4-6h
Tab, liquid
IM/IV |
|
|
Term
| Prochlorperazine (Compazine) |
|
Definition
5-10mg every 3-4h
5-10mg every 3-4h
2.5-10mg every 3-4h
25mg twice daily
Tab, liquid
IM
IV
Supp |
|
|
Term
|
Definition
12.5-25mg every 4-6h
Tab, liquid, IM, IV, supp |
|
|
Term
| Cyclizine (Marezine, Cyclovert, Bonine for kids) |
|
Definition
50mg 30min before travel, then 50mg every 4-6h (max 200mg)
25mg every 6-8h (max 75mg)
Not recommended |
|
|
Term
| Dimenhydrinate (Dramamine, Travel-EZE) |
|
Definition
50-100mg every 4-6h (max 400mg)
25-50mg every 6-8h (max 150mg)
12.5-25mg every 6- |
|
|
Term
| Diphenhydramine (Benadryl, and many others) |
|
Definition
25-50mg every 4h (max 300mg)
12.5-25mg every 4h (max 150mg)
6.25mg every 4h (max 37.5mg) |
|
|
Term
|
Definition
25-50mg 1h before travel (max 50mg)
Not recommended
Not recommended |
|
|
Term
| Hydroxyzine (Vistaril, Atarax) |
|
Definition
25-100mg every 4-6h
Pill, capsule, liquid, suspension |
|
|
Term
|
Definition
25-50mg 1hr before travel
tab |
|
|
Term
| Scopolamine (Transderm Scop) |
|
Definition
1.5mg every 72h
Transdermal patch |
|
|
Term
| Trimethobenzamide (Tigan) |
|
Definition
300mg 3-4 times daily
200mg 3-4 times daily
Cap
IM/supp |
|
|
Term
| Diphenhydramine (Benadryl) |
|
Definition
25-50mg every 4-6h
10-50mg every 2-4h
Cap, tab, liquid |
|
|
Term
|
Definition
MOA: thought to block dopamine receptors at the CTZ
Most useful for long term use in simple N/V
Side effects:
Extrapyramidal reactions
Excessive sedation
Hypotension
Possible liver dysfunction
Anticholinergic side effects
Drug interactions: other sedating medications, alcohol
Warnings: use caution in older adults with dementia, Parkinson's disease
Contraindications: Pregnant women in the last trimester |
|
|
Term
|
Definition
MOA: thought to block dopamine receptors at the CTZ
Most useful for long term use in simple N/V
Side effects:
Extrapyramidal reactions
Excessive sedation
Hypotension
Possible liver dysfunction
Anticholinergic side effects
Drug interactions: other sedating medications, alcohol
Warnings: use caution in older adults with dementia, Parkinson's disease
Contraindications: Pregnant women in the last trimester |
|
|
Term
| Ondansetron (Zofran, Zofran ODT) |
|
Definition
Dose in adults post-op for prevention of N/V (PONV)
Dose for adult prophylaxis of chemotherapy induced N/V (CINV)
4mg IV at the end of surgery
8-12mg IV or 16-24mg orally |
|
|
Term
|
Definition
Dose in adults post-op for prevention of N/V (PONV)
Dose for adult prophylaxis of chemotherapy induced N/V (CINV)
12.5mg IV at the end of surgery
100mg IV or orally or 1.8mg/kg IV |
|
|
Term
| Granisetron (Granisol, Sancuso) |
|
Definition
Dose in adults post-op for prevention of N/V (PONV)
Dose for adult prophylaxis of chemotherapy induced N/V (CINV)
0.35-1.5mg IV at the end of surgery
1mg IV or 0.01mg/kg IV or 2mg orally or 34.3mg transdermal patch |
|
|
Term
|
Definition
Dose in adults post-op for prevention of N/V (PONV)
Dose for adult prophylaxis of chemotherapy induced N/V (CINV)
0.075mg IV at induction of surgery
0.25mg IV |
|
|
Term
| 5HT3 – receptor antagonists |
|
Definition
MOA: Block serotonin receptors in the gut wall
Use: most useful in treating the acute phase of chemotherapy induced N/V (CINV), post-operative N/V (PONV), and radiation induced N/V (RINV)
Side effects: constipation, headache, weakness
Drug interactions: Apomorphine, other medications that prolong QT interval
Warnings: Use caution in patients with prolonged QT |
|
|
Term
|
Definition
2.5mg; additional 1.25mg may be given
IM, IV |
|
|
Term
|
Definition
1-5mg every 12h PRN
Tab, liquid, IM, IV |
|
|
Term
|
Definition
MOA: Block dopaminergic stimulation at the CTZ
Use: Neither is first-line treatment, Haldol is sometimes used in palliative care situations, Droperidol is not used clinically much due to QT prolongation events
Side effects: QT prolongation, drowsiness/sedation, Extrapyramidal reactions, Tardive dyskinesia
Drug interactions: Other medications that can prolong the QT, CNS depressants, anticholinergic medications, alcohol
Warnings: Older patients with dementia, Parkinson’s disease |
|
|
Term
|
Definition
MOA: Complex effects on the CNS and neural tissue receptors (cannabinoid receptors)
Use: Not first line - Refractory CINV
Side effects: tachycardia, euphoria, dizziness, somnolence, confusion, abdominal pain, weakness
Drug interactions: other medications with CNS affects, alcohol
Warnings: Cautious use in the elderly and patients with history of drug abuse |
|
|
Term
|
Definition
5-15mg/m2
Every 2-4h PRN
Cap (C-III) |
|
|
Term
|
Definition
1-2mg twice daily
Cap (C-II) |
|
|
Term
| Metoclopramide (Reglan) for delayed CINV |
|
Definition
20-40mg 3-4 times daily
tab |
|
|
Term
| Olanzapine (Zyprexa) for breakthrough N/V following prophylaxis |
|
Definition
|
|
Term
|
Definition
| MOA: Both block dopamine at the CTZ Use: Neither are first-line options, generally used to treat breakthrough N/V along with other agents Side effects: drowsiness, dizziness, EPS, anticholinergic side effects (Olanzapine) Drug Interactions: Other CNS active drugs, other antipsychotics, anti-Parkinson’s medications Warnings: Use caution in the elderly and those with Parkinson’s disease |
|
|
Term
|
Definition
125mg orally
80mg days 2 and 3 after chemotherapy
40mg orally within 3h of induction |
|
|
Term
| Fosaprepitant (Emend injection) |
|
Definition
115mg IV
Not FDA approved
N/A |
|
|
Term
| Substance P/NK1 receptor antagonists |
|
Definition
MOA: Substance P (a neurotransmitter) is thought to mediate the acute phase of CINV along with serotonin. It is thought to be the primary mediator of the delayed phase. Aprepitant blocks the actions of Substance P by antagonizing it’s receptor NK1.
Use: First line for prophylaxis of CINV (acute and delayed) when using mod-highly emetic chemotherapy regimens
Side effects: fatigue, weakness, constipation, hiccups
Drug interactions: MANY – induces CYP3A4 and CYP2C9 – remember oral contraceptives and warfarin
Warnings: Not approved for use in children, use with caution in hepatic impairment, not recommended during lactation, not studied for use in existing N/V (chronic use) |
|
|
Term
|
Definition
5 categories: Acute, delayed, anticipatory, breakthrough, and refractory
Prophylaxis for acute and delayed N/V is based on the emetic risk potential of the chemotherapy regimen
High risk: 5HT3RA + dexamethasone+aprepitant
Moderate risk: 5HT3RA + dexamethasone (consider aprepitant if certain chemotherapy agents are used)
Low risk: Dexamethasone, prochlorperazine, metoclopramide, diphenhydramine, and/or lorazepam |
|
|
Term
| Prophylaxis of Delayed CINV |
|
Definition
Use of acute phase prophylaxis and appropriate prophylaxis for the delayed N/V
Aprepitant, dexamethasone, and metaclopramide have been shown to be effective
5HT3RA’s are not consistant – the only one with evidence is palonosetron
Prophylaxis should always be given with highly emetic chemotherapy regimens: aprepitant + dexamethasone on days 2, 3 and dexamethasone on day 4
Moderately emetic regimens consider based on the medication used: dexamethasone, 5HT3RA, lorazepam, H2 blocker, or PPI days 2-3. |
|
|
Term
|
Definition
Usually only occurs if the patient received chemotherapy before without adequate prophylaxis
Difficult to manage
Behavioral therapy may work
Benzodiazepines like lorazepam and alprazolam may lessen anxiety and the N/V |
|
|
Term
|
Definition
Occurs in 10-40% of patients despite adequate prophylaxis
All patients should be prescribed rescue medication for breakthrough N/V regardless of emetic potential
Consider prochlorperazine, promethazine, lorazepam, metoclopramide, haloperidol, 5HT3RA, dexamethasone, dronabinol, or olanzapine for adults.
Chlorpromazine, lorazepam, and dexamethasone recommended in pediatrics |
|
|
Term
| Treatment of Refractory N/V |
|
Definition
Upgrade to the next level of prophylaxis
Add another agent from a different class
Consider a non-oral route of administration
Corticosteroids, haloperidol, olanzapine, and nabilone on alternating schedules/routes are recommended |
|
|
Term
| Post-operative N/V (PONV) |
|
Definition
Occurs in about ¼ of all adults undergoing surgical procedures requiring anesthesia
Occurs from 2-24h post-operatively
Most patients do not require prophylaxis
Use prophylactic anti-emetics in those patients with high risk
Other options include regional instead of systemic anesthesia, and avoiding nitrous oxide and other volatile anesthetics |
|
|
Term
|
Definition
For patients who received prophylaxis:
Use an anti-emetic from a different drug class
Repeating the agent used for prophylaxis within 6h of surgery is not effective
After 6h treatment can include repeat of prophylactic medication except dexamethasone and scopolomine
For patients who did not receive prophylaxis:
5HT3RA at a low dose
Dexamethasone IV
Droperidol or promethazine IV |
|
|
Term
|
Definition
The most important predictors are Hx of PONV or motion sickness, female gender, non-smoking, and use of post-op opiods
0-1 risk factor = low risk
2 risk factors = moderate risk
3-4 risk factors = high risk
Patients at moderate risk should receive prophylaxis with 1-2 antiemetics
High risk patients should receive two antiemetics as prophylaxis. |
|
|
Term
|
Definition
Aprepitant 40mg within 3h of induction of anesthesia
Dexamethasone 4-5mg IV at induction of anesthesia
5HT3RA IV doses at the end of surgery
Others: haloperidol IM or IV, Prochlorperazine IM/IV at end of surgery, Promethazine IV at induction, Scopolamine patch the evening before surgery
Droperidol is very effective but use is limited by concerns regarding torsades de pointes |
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