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Antiemetics in palliative care

Cyclizine 1st generation antihistamine – piperazine class anti-cholinergic and antiemetic starts working within 2 hrs and duration of action about 4 hrs. bowel obstruction central causes as space occupying lesions , base of skull tumour , raised ICP movement related nausea and vomiting ( e.g Meniere’s disease ) radiotherapy related n/v ( particularly in breast cancer as it does not cause a rise in prolactin ) N/V caused by narcotic analgesics and post operative N/V 50 mg tds maximum dose is 150 mg Can be used PO, IV , IM/ SC , PR Suppository by special order Inj to be diluted with water SEs include dry mouth , urinary retention and restlessness Not to be used along with metoclopramide ( blocks prokinetic effect ) or domperidone Do not use in severe cardiac failure


Corticosteroids mechanism of action as an antiemetic is not known proposed to act centrally with possible mechanisms as depletion of gamma aminobutyric acid stores in medulla , reduction of blood-brain barrier permeability to emetic toxins and inhibition of enkephalin release in the brainstem intracranial disease malignant bowel obstruction – a typical dose of 4-16 mg 
( S/C or IV ) can be used & response to treatment reviewed in 5 days 2nd line in chronic nausea of advanced cancer Dexamethasone 1 mg is about equivalent of prednisolone 7 mg usual dose of dexamethasone is 4-8 mg / day in chronic nausea to upto 16mg / day in malignant bowel obstruction or raised ICP


SEs include- fluid and electrolyte imbalance ( e.g ↓ potassium ) , BP elevation , increased blood glucose , glaucoma , insomnia , delirium , restlessness , ulcerogenic Dexamethasone levels are reduced by rifampicin , carbamazepine , phenobarbital and phenytoin Risk of sepsis in patients on palliative chemotherapy Monitor INR closely in those taking warfarin as the action of anticoagulants may be reduced or less often enhanced


Domperidone -anti-emetic bowel motility stimulant specific dopamine blocker – speeds GI peristalsis , causes prolactin release and has anti-emetic , gastrokinetic and galactagogue activities anti-emetic activity due to dopamine blocking at both the CTZ and at the gastric levelgastric stasis little evidence base for use in palliative care can be used rectally 10 mg to 20 mg 3 to 4 times a day before meals Domperidone does not cross the blood brain barrier so only acts at peripheral dopamine receptors -hence extrapyramidal SE’s are much less likely Beware SEs which include colic and cardiac conduction disturbance , QTc prolongation Domperidone is safe to use in Parkinson’s disease Contraindicated in GI obstruction


Haloperidol -phenylbutylpiperidines derivative with antipsychotic , neuroleptic and antiemetic activities dopamine receptors in the CTZ accounts for its anti-emetic activity known for broad spectrum of activity antiemetic doses are 1.5 mg – 5mg bd or tds orally 0.5 to 2mg IV every 8 hrs used in low doses in a palliative care setting SEs are unusual SEs are similar to those of phenothiazines but it causes less sedation and hypotension Can cause extrapyramide SEs and patient with Parkinson’s disease can be more sensitive to its adverse effects – best avoided Reduce dose in severe hepatic impairment Can exacerbate narrow angle glaucoma


Hyoscine -pure anticholinergic relax smooth muscles and reduce GI secretions via blockade of muscarinic receptors please see section secretion management for a further discussion agents in anti-emetic dose range include
 hyoscine butylbromide 80 mg to 120 mg via s/c infusion hyoscine hydrobromide orally 0.1 to 0.4 micrograms 4 hrly can be used transdermally , s/c or IV


Levomepromazine potent 5HT2 antagonist with no activity at 5HT3 , 5HT4 recepors resembles chlorpromazine and promethazine in pharmacology has anti-emetic , antihistamine and anti-adrenaline activity with strong sedative effects used as 2nd or 3rd line in refractory nausea and vomiting in palliative care can be used orally but generally used via S/C broad spectrum anti-emetic -also has analgesic properties severe delirium /agitation in the last days of life doses less than 12.5 day mg are well tolerated can be used IM or IV after diluting with an equal volume of normal saline or by continuous S/C infusion with an appropriate amount of N saline consider lower dose for nausea / vomiting and higher doses for delirium/ agitation has a long 1/2 life ie once or twice s/c inj can be used as an alternative to continuous s/c infusion shares problems as with other dopamine antagonists as anticholinergic effects, confusion , hallucinations and dystonic reactions sedative ( particularly at doses of 25 mg or more/24 hrs ) and likely to cause postural hypotension use with caution in renal and hepatic impairment avoid in Parkinson’s disease as may cause extrapyramidal symptoms s/c route may cause skin irritation


Lorazepam short acting benzodiazepine spectrum of activities include anxiolytic , anti-anxiety , anti-convulsant , anti-emetic and sedative little anti-emetic effect of its own but may enhance the effectiveness of other anti-emetic regimens due to its sedative , anxiolytic and amnesia properties


Metoclopramide – substituted benzamide and a derivative of PABA that is structurally related to procainamide with gastroprokinetic and anti-emetic properties antagonizes dopamine ( D2 receptors in CTZ ) mediated effect on GI smooth muscles action closely related to control of parasympathetic regulation of the upper GI tract – encourages normal peristaltic action by stimulating activity and restoring normal co-ordination and tone may also strengthen the lower oesophageal sphincter and prevent acid reflux impaired gastric emptying gastric paresis chemotherapy induced emesis consider dose reduction in moderate to severe renal impairment can accumulate in patients with liver cirrhosis most common SEs are restlessness , drowsiness and fatigue risk of neurological effects – extrapyramidal disorders and tardive dyskinesia contraindicated if suspected small bowel obstruction or gastric outlet obstruction , Parkinson’s disease.


Octreotide-synthetic long acting cyclic octapeptide with pharmacological activity which mimicks that of somatostatin inhibits several hormones as growth hormone , glucagon , insulin , LH response to gonadotrophin-releasing hormone , reduces splanchic blood flow , inhibits release of serotonin , gastrin , vaso-active intestinal peptide ,secretin , motilin , pancreatic polypeptide and thyroid stimulating hormone.


malignant bowel obstruction particularly in cases of high output vomiting not repsonding to other agents -here it works by reducing secretions of fluids by the intestine , pancreas , reduces GI motility and causes vasoconstriction unresectable hormone secreting tumours ( e,g carcinoid ) common SEs include local skin reactions ( pain stinging burning ) and GI effects as cramps , nausea / vomiting , diarrhoea or constipation and gallstones headache , hypothyroidism and cardiac toxicity use with caution in people with diabetes , other endocrinopathies , renal failure and hepatic impairment


Ondansetron -oldest highly specific and selective 5HT3 receptor antagonist carbazole derivative newer available agents include granisetron , tropisetron , dolasetron & palonosetron vomiting due to radiation therapy or chemotherapy bowel obstruction renal failure constipation dose dependent headache use with caution if taken with other drugs that prolong QRc interval and reduce dose in severe hepatic impairment max 8 mg / day


A few newer agents -Aprepitant -high affinity substance P antagonist ( Neurokinin -1 NK-1 receptor ) with antiemetic properties for post-operative or cancer chemotherapy related N/V Cannabinoids -little clinical evidence of efficacy & role is limited to management of breakthrough chemotherapy related N/V , only available via specialists


  1. Palliative care – nausea and vomiting Palliative care – nausea and vomiting | Health topics A to Z | CKS | NICE
  2. Nausea and vomiting Scottish Palliative Care Guidelines Scottish Palliative Care Guidelines – Nausea and Vomiting
  3. Nausea and vomiting in palliative care BMJ 2015 ; 351:h6259 Nausea and vomiting in palliative care (
  4. Guidelines for the management of nausea and vomiting in palliative care Nausea_and_Vomiting.pdf (
  5. Glare, Paul et al. “Treating nausea and vomiting in palliative care: a review.” Clinical interventions in aging vol. 6 (2011): 243-59. doi:10.2147/CIA.S13109 Treating nausea and vomiting in palliative care: a review (
  6. Pubchem various topics via PubChem (
  7. EMC various topics via Home – electronic medicines compendium (emc)
  8. Useful medications Palliative Care Guidelines via Palliative Care Guidelines Plus (


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