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 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.
Nausea associated with vertigo.
Avoid in the elderly during very hot or very cold weather (risk of hyper- or hypothermia)
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
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.
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.
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
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
Drugs which should be prescribed only by hospital specialists (clinical review by specialist as appropriate and annually as a minimum).
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.
Drugs suitable to be initiated and prescribed in primary care only after specialist assessment and recommendation. A shared care agreement is not required.
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.
Drugs for which GPs would normally take full responsibility for prescribing and monitoring. Drugs included in this list have been specifically considered by LMSG.