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4.6 Drugs used in nausea and vertigo

Aprepitant capsules (oncology use only – mod-severely emetogenic chemo regimens)
Betahistine tablets
Chlorpromazine tablets, syrup
Cinnarizine tablets
Cyclizine tablets, injection
Dexamethasone tablets, injection
Domperidone tablets, suspension, suppositories - see note
Droperidol injection (third line agent for post-operative nausea and vomiting) - see note
Haloperidol capsules, tablets, elixir, injection
Hyoscine hydrobromide sublingual tablets, injection, transdermal (post auricular) patch 1mg/72hr - see note 7 below
Levomepromazine  tablets, injection (palliative care only)
Lorazepam tablets (for anticipatory nausea and vomiting)
Metoclopramide tablets, elixir, injection - short term use only (up to 5 days); max dose 0.5 mg/kg/day - see note
Netupitant / palonosetron (Akynzeo) (oncology use only – mod-severely emetogenic chemo regimens)
Ondansetron tablets, syrup, injection, suppositories - see note
Prochlorperazine tablets, elixir, injection, buccal   

Note:

1. Metoclopramide and domperidone have similar modes of action but domperidone is less likely to cause extrapyramidal side effects. It is therefore preferable for use in patients with Parkinsonism.

2. Domperidone is preferred in patients where the risk of dystonic reactions is high i.e. young women and children, the elderly, and those with Parkinson's disease. However, it is associated with a small increased risk of serious cardiac side effects, and so its use is now restricted to the relief of nausea and vomiting. Max recommended dose: 30 mg/d. Max Duration: 7 days. See MHRA Drug Safety Update May 2014

Other Documents

Domperidone: new restrictions in use
Revised dosing for domperidone use in babies and children

Derbyshire Position Statement for off-license use of domperidone - see link:

3. Metoclopramide in young adults is more likely to cause dystonic reactions. In children, metoclopramide should only be used as a second-line option for prevention of delayed chemotherapy-induced nausea and vomiting and treatment of established PONV. It is no longer recommended for use in gastroparesis, dyspepsia, or GORD (but see Gastroenterologists' Position Statement). See also EMA recommendation and MHRA Drug Safety Update.

The dose and duration of metoclopramide are now restricted to help minimise the risk of potentially serious neurological adverse effects.For adults, the maximum dose in 24 hours is 30 mg (0.5 mg/kg). In children age 1 year or older, the recommended dose is 0.1–0.15 mg per kg bodyweight, repeated up to three times a day; the maximum dose in 24 hours is 0.5 mg per kg bodyweight. The drug is contraindicated in children under one year of age. Metoclopramide should only be prescribed for short-term use (up to 5 days). Intravenous doses of metoclopramide should be given as a slow bolus over at least 3 minutes to reduce adverse effects.

4. Haloperidol is recommended for the control of opiate induced vomiting in a dose of 1.5mg orally once or twice daily or 2.5mg IM to stop active vomiting.

5. Prochlorperazine should be avoided in the elderly if possible because of extrapyramidal effects.

6. Prochlorperazine - buccal for post operative nausea and vomiting in critical care areas only.

7 Hyoscine hydrobromide is useful for prevention of motion sickness and for drying secretions in sialorrhoea, drooling and death rattle, especially in terminal care. The transdermal patch only has travel sickness in it's product licence. Therefore, this should be specialist initiated if used for control of secretions (head & neck cancer, palliative care and neurology).

8. Ondansetron. There is new guidance for intravenous use of ondansetron in relation to:

repeat dosing for all adults;

dosing for prevention of chemotherapy-induced nausea and vomiting in patients age 75 years or older;

and dilution and administration for prevention of chemotherapy-induced nausea and vomiting for patients age 65 years or older.

See Drug Safety Update July 2013.

9. Droperidol is reserved for third-line management of post-operative nausea and vomiting. It is contraindicated in known or suspected prolonged QT interval, hypokalaemia, hypomagnesaemia, and bradycardia. Continuous pulse oximetry should be performed for 30 mins following a single iv dose in patients with identified or suspected risk of ventricular arrhythmia.

 

For link to BNF section: 4.6 Drugs used in nausea and vertigo