Professional Documents
Culture Documents
Antonius NW Pratama
Department of Clinical and Community Pharmacy
Faculty of Pharmacy
Universitas Jember
Reference
• DiPiro, NV. 2007. Nausea and Vomiting. in
DiPiro, JT, et al. (Eds.). Pharmacotherapy: A
Pathophysiologic Approach. 7th ed. NY:
McGraw-Hill
KEY CONCEPTS
• Nausea and/or vomiting may be a part of the
symptom complex for a variety of
gastrointestinal, cardiovascular, infectious,
neurologic, metabolic, or psychogenic
processes.
• Nausea or vomiting may be caused by a
variety of medications or other noxious
agents.
KEY CONCEPTS
• The overall goal of treatment should be to
prevent or eliminate nausea and vomiting
regardless of etiology.
• Treatment options for nausea and vomiting
include drug and nondrug modalities such as
relaxation, biofeedback, and selfhypnosis.
KEY CONCEPTS
• The primary goal with chemotherapy-induced
nausea and vomiting (CINV) is to prevent nausea
and/or vomiting. Optimal control of acute nausea
and vomiting positively impacts the incidence
and control of delayed and anticipatory nausea
and vomiting.
• The emetic risk of the chemotherapeutic regimen
is the primary factor to consider when selecting
prophylactic antiemetics for CINV.
KEY CONCEPTS
• Patients at high risk of vomiting should receive
prophylactic antiemetics for postoperative
nausea and vomiting (PONV).
• Patients receiving single-exposure, high-dose
radiation therapy to the upper abdomen or
receiving total or hemibody irradiation, should
receive prophylactic antiemetics for radiation-
induced nausea and vomiting (RINV).
ETIOLOGY
• Associated with a variety of clinical presentations
(see tables)
• In children
– vomiting in newborn suggests upper digestive tract
obstruction or an increase in intracranial pressure.
– other illnesses associated: pyloric stenosis, duodenal
ulcer, stress ulcer, adrenal insufficiency, septicemia,
and diseases of the pancreas, liver, or biliary tree.
– Reye syndrome: hepatocellular failure profound
cerebral edema persistent emesis.
PATHOPHYSIOLOGY
3 phases of EMESIS
Different from
regurgitation (acid reflux)
CLINICAL PRESENTATION
Simple or
complex
TREATMENT
Desired Outcomes
• Overall goal: to prevent or eliminate nausea
and vomiting
– without adverse effects or with clinically
acceptable adverse effects
– appropriate cost issues, particularly in the
management of chemotherapy-induced and
postoperative nausea and vomiting
TREATMENT
General Approach
• Options: drug and non-drug
• Varied depending on the associated medical situation.
• Most patients receive a medication at some point
• For simple nausea and vomiting:
– do nothing or
– to select from a variety of nonprescription drugs (OTC).
• If symptoms are worse or associated with serious
medical problems:
– prescription antiemetic drugs
– However, some patients will never be totally free of
symptoms (eg: receiving chemotherapy of moderate or
high emetic risk)
TREATMENT
Nonpharmacologic Management
• a variety of dietary, physical, or psychological changes
consistent with the etiology of symptoms.
• For patients with simple complaints, perhaps resulting
from excessive or disagreeable food or beverage
consumption, avoidance or moderation in dietary
intake may be preferable.
• Patients suffering symptoms of systemic illness may
improve dramatically as their underlying condition
resolves.
• Finally, patients in whom these symptoms result from
labyrinthine changes produced by motion may benefit
quickly by assuming a stable physical position.
TREATMENT
Pharmacologic
• Most often recommended: Antiemetic drugs
(nonprescription and prescription)
• Factors that enable the clinician to discriminate
among various choices include:
– the suspected etiology of the symptoms;
– the frequency, duration, and severity of the episodes;
– the ability of the patient to use oral, rectal, injectable,
or transdermal medications; and
– the success of previous antiemetic medications.
TREATMENT
Pharmacologic
• Simple emesis: minimal therapy
– Both nonprescription and prescription drugs usually
effective in small, infrequently administered doses.
– Minimal side effects and toxic effects
• Prescription medications can be either as single-
agent therapy or in combination depending on px
conditions
• Complex nausea and vomiting (eg: px with
cytotoxic chemotherapy) combination therapy.
TREATMENT
Pharmacologic
• In combination regimens, the goal is to
achieve symptomatic control through
administration of agents with different
pharmacologic mechanisms of action.
TREATMENT
Pharmacologic
ANTACIDS
• Single or combination nonprescription antacid
products
• magnesium hydroxide, aluminum hydroxide,
and/or calcium carbonate gastric acid
neutralization
• Common regimens: one or more 15 to 30 mL
doses of single- or multiple-agent products
TREATMENT
Pharmacologic
ANTACIDS
• Potential adverse effects:
– magnesium salt (osmotic diarrhea)
– aluminum/calcium salts (constipation)
• Generally, however, when used occasionally
for acute episodic relief of nausea and
vomiting, antacids do not produce serious
toxicities.
TREATMENT
Pharmacologic
TREATMENT
Pharmacologic
H2-RECEPTOR ANTAGONISTS
• Low doses to manage simple emesis
associated with heartburn or
gastroesophageal reflux.
• Individual dosages of cimetidine 200 mg,
famotidine 10 mg, nizatidine 75 mg, or
ranitidine 75 mg may be used for brief
periods.
• Potential drug interactions: cimetidine
TREATMENT
Pharmacologic
ANTIHISTAMINE–ANTICHOLINERGIC DRUGS
• Interrupt various visceral afferent pathways that
stimulate nausea and vomiting for simple nausea
and vomiting.
• Adverse reactions: drowsiness, confusion, blurred
vision, dry mouth, and urinary retention, and possibly
tachycardia, particularly in elderly patients.
• Patients with narrow-angle glaucoma, prostatic
hyperplasia, or asthma are at greater risk of
complications from the anticholinergic effects of these
drugs.
TREATMENT
Pharmacologic
TREATMENT
Pharmacologic
PHENOTHIAZINES
• Phenothiazines have been the most widely
prescribed antiemetic agents and appear to block
dopamine receptors, most likely in the CTZ.
• Most useful in adult patients with simple nausea
and vomiting
• Most practical for long-term treatment and are
inexpensive in comparison with newer drugs.
TREATMENT
Pharmacologic
PHENOTHIAZINES
• Many dosage forms, none of which appears to be more
efficacious than another.
– Rectal: in patients not feasible with oral or parenteral
administration
– Intravenous: quicker and more complete relief with less
drowsiness