Nausea

Short Answer

A. Incorrect. If the morphine dose is drastically reduced, pain is likely to become uncontrolled. Treating the nausea with a drug such as metoclopramide is likely to be more helpful.

B. Incorrect. Since the patient already has daily bowel movements, constipation is less likely to be the cause of his nausea. Metoclopramide may be more helpful to stimulate gastric motility.

C. Correct! Metoclopramide is most appropriate in patients with early satiety, and is often helpful in opioid-related nausea.

D. Incorrect. There is no good evidence that lorazepam helps nausea when used as a single agent, and anxiety does not appear to be the cause here. Metoclopramide may be more helpful.

E. Incorrect. Since this patient's nausea may be related to his opioid use, promethazine would not be helpful. Metoclopramide is a better choice.


Long Answer

The correct answer is C. Metoclopramide, 10 mg po qac.

As with dyspnea, the management of nausea and vomiting requires an understanding of the likely cause of symptoms, an initial choice of treatment, and consideration of other causes if symptoms persist. Causes are often multifactorial. The potential benefits of invasive diagnostic tests or treatments need to be weighed against potential risks and discomfort in light of the patient's prognosis and goals. The underlying cause may not be treatable, especially in advanced cancer. However, the symptoms can often be managed by understanding common contributors and pharmacology. Always assess for constipation and treat this first. Dysmotility is a common and underappreciated cause of nausea, and can be caused by opioids, ascites, disease involving the gastrointestinal tract, or a combination of factors. Early satiety, rather than constant nausea, is a sign of possible dysmotility. Metoclopramide is often most effective in nausea due to dysmotility.


Use the VOMIT mnemonic to remember the causes and treatments of nausea and vomiting in palliative care.


Nausea Cause...Treatment

Vestibular (associated with motion)...Scopolamine 1 patch q72h, promethazine 25 mg bid prn

Obstruction (e.g., constipation). Mechanical obstruction. See section on constipation treatment under question four....Evaluate for surgical/radiation treatment if appropriate given patient's goals.

Motility of upper gut (dysmotility)...Metoclopramide 10mg po/pr/iv qid ac (Don't use in bowel obstruction)

Infection, Inflammation (such as viral gastroenteritis, systemic infection)...Promethazine 25 mg po bid prn

Toxins (usually opioids; also in hepatic or renal failure) Dopamine antagonists such as prochlorperazine 25 mg pr q12h prn or 10 mg po q6h prn, haloperidol 1mg po bid-tid prn


Opioids are a common cause of nausea. Prochlorperazine is the drug of first choice for opioid-induced nausea. Dopamine antagonists such as prochlorperazine and haloperidol are most helpful for this type of nausea. Haloperidol or chlorpromazine may be less sedating, if somnolence is a problem. Sometimes, fluctuating opioid levels can worsen nausea, and using long-acting agents can help; this patient is already on a long-acting preparation. Occasionally, opioid-induced nausea has a vestibular component (is associated with movement). Transdermal scopolamine or promethazine may be effective in this situation. However, since promethazine is an anticholinergic, it will worsen dysmotility, and since it is a weak antidopaminergic, it is ineffective for most opioid-related nausea. For chronic or severe nausea, around-the-clock dosing or combinations of medications (such as ABHR suppositories--ativan, benadryl, haloperidol, and reglan) may be necessary.

Other common causes may require different interventions. Promethazine is often effective in nausea associated with infection. Benzodiazepines may be helpful if anxiety is a component. Antacids may be helpful in gastroesophageal reflux. In patients with possible cerebral metastases, increased intracranial pressure may cause nausea, and steroids would be the best initial choice. For irreversible extraluminal obstruction, try to manage fluids, and it may be necessary to inhibit secretions with octreotide or scopolamine.

Last update: 7/13/02; 3:54:42 PM.