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 Formulary Chapter 4: Central nervous system - Full Chapter
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04.06  Expand sub section  Drugs used in nausea and vertigo
 note 
  • Anti-emetics should only be prescribed when the cause of nausea or vomiting is known. If an anti-emetic is indicated, the drug should be chosen according to the aetiology.
  • Metoclopramide, prochlorperazine and haloperidol may cause extrapyramidal side effects, particularly in children and young adults. Domperidone is much less likely to cause these. Acute dystonias may be treated with procyclidine injection.
  • Sickness in pregnancy is best left untreated unless severe. Specialist advice should be sought before using an antiemetic in pregnancy.
  • Dexamethasone, Lorazepam and Levomepromazine are also used in nausea and vomiting associated with cytotoxic therapy.
  • Levomepromazine tablets are available as 25mg strength and also as a 6mg (unlicensed) strength to assist administration of smaller doses. Take care when prescribing that the correct strength is specified.
  • For further information on prescribing of anti-emetics in malignancy see 'Nausea and Vomiting' section (page 18) of Leicestershire guidance.
  • Hyoscine patches are occasionally used by specialists in palliative care or neurology for treatment of hypersalivation.
  • For further information regarding the use of anti-emetics in palliative care please see the LOROS guidance on symptom management.
Metoclopramide Hydrochloride
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First Choice
Green
For symptoms associated with gastro-duodenal, hepatic and biliary disease because it acts directly on the gastro-intestinal tract.
Can cause dystonic reactions in young adults.
The MHRA have advised that the maximum dose in adults in 24 hours is 30mg. The usual dose is 10mg up to three times a day. Treatment should be limited to a maximum of 5 days. 
Prochlorperazine
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First Choice
Green
Nausea associated with vertigo.
Avoid in the elderly during very hot or very cold weather (risk of hyper- or hypothermia)
 
Domperidone
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Second Choice
Green
Acts at the chemoreceptor trigger zone; used for the relief of nausea and vomiting associated with cytotoxic therapy. It is less likely to cause central effects (e.g. sedation and extrapyramidal reactions) because it does not readily cross the blood-brain barrier. It is preferred for patients with Parkinson’s disease or those with a high risk of dystonias.
Also has a place in the treatment of non-ulcer dyspepsia.
The MHRA has advised that there is a small risk of serious ventricular arrhythmia and sudden cardiac death with domperidone. See link below 
Link  MHRA Advice: Domperidone: risks of cardiac side effects— indication restricted to nausea and vomiting, new contraindications, and reduced dose and duration of use
Link  UKMI Advice: Domperidone: new restrictions in use
   
Cyclizine
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Restricted Drug Restricted
Green
If nausea or vomiting is unresponsive.
Cyclizine has antihistaminic and anticholinergic actions, which may be additive to the other agents listed. Sedative at higher doses.
 
   
Haloperidol
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Restricted Drug Restricted
Green
Nausea or vomiting induced by opioids in palliative care. There have been shortages recently of haloperidol and also of the alternatives recommended. Therefore check LMSG statement below for alternatives.

The statement does not apply to treatment of delirium on ITU at UHL. Relevant clinicians will receive appropriate guidance as required.  
Link  Leicestershire Guidance: Treatment of Nausea and Vomiting in Palliative Care
   
Cinnarizine + Dimenhydrinate  (Arlevert®)
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Restricted Drug Restricted
Amber Simple
For dizziness in Meniere's Disease use only when other medical therapies have failed 
Link  Leicestershire Evaluation: Arlevert® in Menieres
Link  Simple Amber List
   
Ondansetron
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Restricted Drug Restricted
Green

Green for nausea. Long term administration for chemotherapy or continuation for delayed emesis not recommended.
Melts remain restricted as they have significantly higher cost than tablets - "Films" preferred if unable to swallow tablets.
IV Monograph available through 'Injectable Medicines Guide' link on front page of INsite.
The new maximum single intravenous dose of ondansetron for the management of chemotherapy-induced nausea and vomiting (CINV) in adults is now 16 mg (infused over at least 15 minutes)- See MHRA advice via link below

 
Link  MHRA Advice: Ondansetron (Zofran): risk of QTc prolongation – important new intravenous dose restriction
   
Droperidol
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Restricted Drug Restricted
Red
Specialist anaesthetics use at UHL as a 3rd line option after cyclizine and ondansetron  
Link  Leicestershire Evaluation: Droperidol in PONV
   
 ....
 Non Formulary Items
Dolasetron Mesilate

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Non Formulary
Black
Link  Leicestershire Evaluation: Dolasetron in PONV
 
Granisetron

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Non Formulary
Black
 
Nabilone

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Non Formulary
Black
 
Xonvea®  (Doxylamine & pyridoxine)

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Non Formulary
Black

Not reviewed in Leicestershire

 
  
Key
note Notes
Section Title Section Title (top level)
Section Title Section Title (sub level)
First Choice Item First Choice item
Non Formulary Item Non Formulary section
Restricted Drug
Restricted Drug
Unlicensed Drug
Unlicensed
Track Changes
Display tracking information
click to search medicines.org.uk
Link to adult BNF
click to search medicines.org.uk
Link to children's BNF
click to search medicines.org.uk
Link to SPCs
SMC
Scottish Medicines Consortium
High Cost Medicine
High Cost Medicine
Cancer Drugs Fund
Cancer Drugs Fund
NHSE
NHS England
Homecare
Homecare
CCG
CCG

Traffic Light Status Information

Status Description

Black

Drugs not recommended for use in the Leicestershire Health Community because of lack of evidence of clinical effectiveness, cost prioritization or concerns over safety. All new drugs will be black until they have been through the appropriate approval process - then they will appear as a specific entry   

Red

Drugs which should be prescribed only by hospital specialists (clinical review by specialist as appropriate and annually as a minimum).  

Amber SCA

Drugs which would initially be prescribed by a hospital specialist and then by a GP where full agreement to share the care of each specific patient has been reached under a LMSG Shared Care Agreement (SCA). Specific patient monitoring or intervention required.   

Amber Simple

Drugs suitable to be initiated and prescribed in primary care only after specialist assessment and recommendation. A shared care agreement is not required.  

Green Conditional

Drugs for which GPs are able to take full responsibility for prescribing and monitoring subject to specified conditions e.g. prescribing in line with agreed LMSG guidance or able to demonstrate suitable competence see comments under individual entries.   

Green

Drugs for which GPs would normally take full responsibility for prescribing and monitoring. Drugs included in this list have been specifically considered by LMSG.   

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