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Flashcards in Anti-emetic Deck (12)
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1

ANTICHOLINERGIC

Examples
Mechanism of Action
Uses
S/E
Contraindications
Considerations

-Scopalamine (Patch)

-It works by antagonizing the M1 muscarinic receptor [vestibular system]

-It is predominantly used to treat motion sickness or prophylactically in the perioperative setting.

-Side effects are typically mild but include dry mouth, vision changes, or drowsiness.

- Known hypersensitivity, narrow-angle glaucoma

-Consider --> 4 hours before or night before; caution in elderly

2

ANTIHISTAMINE (1st/2nd Gen)

Examples
Mechanism of Action
Uses
S/E
Contraindications
Considerations

-- 1st gen [worse side effects]
--> diphenhydramine, dimenhydrinate, doxylamine, meclizine

--2nd gen [lack CNS depressant - not effective]
--> Cetirizine and Fexofenadine

-antagonize H1 and muscarinic cholinergic receptors [vestibular]

- prevent and treat n/v due to motion sickness, vertigo, or migraine

-Sedation

-Known hypersensitivity

3

DOPAMINE ANTAGONIST
-->Three Main Groups

Examples
Mechanism of Action
Uses
S/E
Contraindications
Considerations -- avoid in children under 2 or <9kg
+ other considerations

-Phenothiazines
-->promethazine, prochlorperazine, chlorpromazine
--->antagonize D2 receptor in CTZ
----> motion sickness/vertigo, gastritis, NVP, PONV, CINV
---->sedation, orthohypotension, **EPS [dystonia, tardive dyskinesia, akathisia)
---> dilute IV -- especially intraarterially

-Butyrophenones
-->Droperidol and Haloperidol
---> Central acting (CTZ ?)
----> PONV, some CINV
---> *Black box warning for QT prolongation and torsades
---> 12-lead EKG

-Prokinetics
--> Metoclopramide
---> d2 receptor antagonist in CTZ and peripherally GI
----> PONV, CINV, gastroparesis, GERD
----> crosses BBB** --> EPS, somnolence
--->**young children and elderly avoid

4

CORTICOSTEROIDS

Examples
Mechanism of Action
Uses
S/E
Contraindication

dexamethasone & methylprednisone
-release of serotonin & decrease inflammation
-- combination therapy; PONV, CINV
--- GI upset, anxiety, insomnia, hyperglycemia
-Hypersensitivity, systemic fungal infections.

5

Cannabinoids

Examples
Mechanism of Action
Uses
S/E

Nabilone and dronabinol

- unknown / central acting
- CINV
-drowsiness, euphoria, vision change

6

Benzodiazepines

Examples
Uses
S/E
Contraindications
Considerations

Lorazepam (ADJUNCT antiemetic)

-CINV
- Sedation and amnesia, respiratory depression
- dont use with alcohol

7

Serotonin Antagonists

Examples
Mechanism of Action
Uses
S/E
Contraindications
Considerations

Dolasetron, Granisetron, Ondansetron, Palonsetron

- 5-HT antagonist is GI tract and CTZ
-CINV and PONV
-headache, somnolence, diarrhea, constipation, *QT changes
-Palonsetron = 40 hour half-life (acute and delayed CINV)
--> granisetron degrades by light (patch)

8

NK-1 Receptor Antagonist

Examples
Mechanism of Action
Uses
S/E
Contraindications
Considerations

-Aprepitant (fosaprepitant IV), rolapitant, netupitant
-preventing the release of substance-P, which is an inducer of vomiting
-acute and delayed CINV (**with -setron and corticosteroid); PONV
- fatigue hiccups, h/a

9

Olanzapine

Examples
Mechanism of Action
Uses
S/E
Contraindications
Considerations

- Olanzapine (anti-psych)
- dopamine and serotonin receptors
- combo therapy for severe CINV
- sedation on day 2 on s/e

10

CHEMO - INDUCED Nausea and Vomiting
-Acute/delayed/anticipatory
-Risk Factors for CINV & anticipatory
-Emogenic Potential
--- minimal, Low, moderate, High examples and treatment

--Acute - within 24 hours
--delayed - more than 48 hours
-- anticipatory - prior to chemo when n/v happened in past

-CINV Risk Factors- poor emetic control with prior tx, female, low chronic alcohol intake, younger age
-Anticipatory Risk Factors- Poor prior control of tx and hx of motion sickness or NVP
-minimal- no tx

-Low -->
Day 1 (acute) - Dexamethasone OR 5HT3 Antagonist

-Moderate --> lower cyclophoshamide, isosfamide, carboplatin
Day 1 (acute) - 5-HT3 antagonist PLUS dexamethasone
--> Day 2-4 (Delayed) -- dexameth day 2-3

- high --> cisplatin and high dose cyclophosphamide + AC
Day 1 (Acute) - NK1 Receptor antagonist + 5HT3 antagonist + dexamethasone + olanzapine

11

PONV
risk factors
Pre vs Post treatment
Treatment method (Combination) and breakthrough

- 1 patient factors (female sex, nonsmoking, history of PONV) and 2) anesthesia factors (opioids and gases) and 3) Surgical factors (duration and type)

-PRE -- aprepitant, palonosetron, dexamethasone
-POST- droperidol, 5-ht3 Receptor antagonist
Scopalamine (evening prior or 2 hours prior)

-use combo of method (zofran plus dexameth)
-- use separate class med if one class fails
--- if no class used, low dose 5HT3

12

NVP
Consideration
Lines of tx
hyperemesis gravidarum and tx

- 1) teratogenic potential of therapy 2) severity of n/v
-Pyridoxine (b6) 10-25mg 4x daily alone or w/ antihistamine = first line
-Zofran second line

-treat gravidarum with methylprednisolone AFTER 10 WEEKS (oral cleft)