Nausea and Vomiting Treatments (Part 2)

Question 1

Motion Sickness
- Non Pharm

Answer 1

Stable visual point
- Clear forward view
- Minimal head movement

Avoid exacerbations (Visual/Non-visual stimuli)
- Reading
- Odours
- Smoking

Acupressure Points

Diet

Increase ventilation

Question 2

Motion Sickness
- Non Pharm (Diet)

Answer 2

Avoid eating 3 hours within time of travel

Avoid dairy products

Avoid protein/calories/sodium

Question 3

Motion Sickness
- Non Pharm (Boat)

Answer 3

Sit in central area

Question 4

Motion Sickness
- Pharm

Answer 4

Short Duration:
1. Dimenhydrinate
2. Diphenhydramine
3. Hydroxyzine
- Use 60 mins before

Long Duration:
1. Scopolamine (No longer available)
- Apply 4 hours before

Alternative:
1. Promethazine
- Use 30-60 mins before

Question 5

Motion Sickness
- Promethazine

Answer 5

Antihistamine + Anticholinergic + Antidopaminergic

Longer duration of action
- Start 30-60 min before activity
- May take up to 2 hours for onset

Used as an alternative to dimenhydrinate

Question 6

NV Pregnancy
- When can it occur

Answer 6

Morning sickness can occur at any time of the day

Question 7

NV Pregnancy
- Non-pharm

Answer 7

Diet
- Small and bland meals
- Cold foods
- Drink fluids
- Eat when nausea is less

Ginger
- 1g divided doses (250mg q6h)

Acupressure

Question 8

NV Pregnancy
- Pharm (Mild)

Answer 8

Pyridoxine + Doxylamine (Diclectin)
- Does not work, is still recommended

Pyridoxine
- May recommend this one instead

Question 9

Diclectin
- Adverse Effects

Answer 9

Drowsiness, Disorientation, Diarrhea

Question 10

NV Pregnancy
- Pharm (Moderate-Severe)

Answer 10

First Line:
1. Pyridoxine
2. Diclectin
3. Ginger

3rd or 4th Line:
4. Dimenhydrinate
5. Diphenhydramine
5. Promethazine

4th or 5th Line:
6. Phenothiazine (Chlorpromazine)
7. Metoclopramide

Question 11

What is extreme persistient NV during pregnancy

Answer 11

Hyperemesis Gravidarum
- Causes dehydration, electrolyte imbalance, malnutrition

Requires hospitilzation

Question 12

Hyperemesis Gravidarum
- Treatment

Answer 12

IV Fluids / Electrolyte Replacement
+ One of the following:
- Phenothiazines
- Metoclopramide
- Ondansetron
- Corticosteroids for refractory (Methylprednisone)

Question 13

NV Pregnancy
- Pharm (Considerations)

Answer 13

Ondansetron should only be used in severe or persistient NV or Hyperemesis Gravidum
- Can cause malformations

Question 14

PONV
- Risks

Answer 14

1. Female
2. Nonsmokers
3. History of PONV/Motion Sickness
4. Post-op Opioid Use

Question 15

PONV
- Risk Values

Answer 15

Moderate Risk (2 Risk Factors)
- Consider 1-2 antiemetics

Severe Risk (3-4 Risk Factors)
- 2 antiemetics before surgery

Question 16

PONV
- Treatments

Answer 16

5-HT3 RA
Dexamethasone
Dimenhydrinate
Phenothiazines
NK1 RA

Question 17

PONV
- 5HT3 RA

Answer 17

Ex. Ondansetron, Granisetron

Timing:
- Can be given at the end of procedure to prevent PONV
- Can be given after procedure to treat PONV

AE:
- Can cause constipation

Question 18

PONV
- Dexamethasone

Answer 18

Timing:
- Administered after anesthesia to prevent PONV

AE:
- Hyperglycemia
- Infection risk
- Sleep disturbance

Question 19

PONV
- NK1 RA

Answer 19

Ex. Aprepitant, Fosaprepitant

Timing
- Administered within 3 hours of anesthesia for prevention

Issues:
- Is expensive
- May be restricted (Hospital formulary)

Question 20

PONV
- Antidopaminergic

Answer 20

Risk of QT prolongation

Question 21

AINV
- Meaning

Answer 21

Antineoplastic Induced Nausea and Vomiting

Question 22

AINV
- Acute

Answer 22

Occurs within first 24 hours after exposure to antineoplastic agent
- Intensity peaks after 5-6 hours
- Resolves after 24 hours

Question 23

AINV
- Delayed

Answer 23

Occurs after the first 24 hours after exposure to antineoplastic agent
- Intensity peaks at 48-72 hours
- Resolves after 6-7 days
- More common than acute

Question 24

What drugs cause Delayed AINV

Answer 24

Cisplatin
Cyclophosphamide
Doxorubicin

Question 25

Anticipatory AINV

Answer 25

Occurs before patients receive chemotherapy treatment - Conditioned response

Question 26

Breakthrough AINV

Answer 26

NV that occurs despite prophylactic treatment - Required rescue with antiemetic agent

Question 27

Refractory AINV

Answer 27

NV that occurs during subsequent cycles - Prophylaxis has failed - Rescue has failed

Question 28

What does HEC and MEC stand for

Answer 28

Highly Emetogenic Chemotherapy Moderately Emetogenic Chemotherapy

Question 29

HEC

Answer 29

High Emetic Risk (Greater than 90%) - Cisplatin - Cyclophosphamide > 1500mg/m2 - Anthracycline + Cyclophosphamide

Question 30

MEC

Answer 30

Moderate Emetic Risk (30-90%) - Carboplatin or Oxaliplatin - Cyclophosphamide < 1500mg/m2 - Anthracycline (Doxorubicin, Epirubicin)

Question 31

Low Emetic Risk

Answer 31

Low Emetic RIsk (10-30%) - Docetaxel or Paclitaxel - Fluorouracil

Question 32

Minimal Emetic Risk

Answer 32

Minimal Emetic Risk (Less than 10%) - Vincristine, Vinorelbine

Question 33

AINV - Risk Factors

Answer 33

- Women are at higher risk - Low Alcohol consumption is at higher risk - History of Motion sickness and NVP are at higher risk of CINV - Younger than 50 years old are at higher risk - Previous AINV are at higher risk

Question 34

AINV - Day 1 Therapy

Answer 34

- 5HT3 RA - Dexamethasone - NK1-RA +/-: Olanzapine

Question 35

Acute AINV - Prophylaxis

Answer 35

HEC: 3-4 drugs given pre-chemo MEC: 2-4 drugs given pre chemo Low: One drug option: Dexamethasone, 5HT3 RA, Prochlorperazine, Metoclopramide

Question 36

Delayed AINV - Prophylaxis

Answer 36

Continued for day 2-4 - NK1-RA - Dexamethasone - Olanzapine

Question 37

Breakthrough AINV - Treatments

Answer 37

Metoclopramide Prochlorperazine Olanzapine

Question 38

Anticipatory AINV - Treatments

Answer 38

Benzodiazepines (Lorazepam) - Before chemotherapy Behavioural Therapy Mindfulness

Question 39

NV Children - Nonpharm

Answer 39

- Small meals - Prevent motion sickness in car (Ventilation)

Question 40

NV Children - Pharm

Answer 40

Dimenhydrinate (Older than 2 years) - Younger than 1 = Do not use - Younger than 2 = Requires physician advice Diphenhydramine (Older than 6 years)