Treatment Nausea and Vomiting

Treatment Nausea and Vomiting - Nausea and vomiting are common complaints among many individuals with gastrointestinal (GI) disorders. However, because of the variable etiologies of these problems, management can be quite simple or detailed and complex, essentially innocuous or associated with therapy-induced adverse reactions. This chapter  provides an overview of nausea and vomiting, two multifaceted problems. Nausea and vomiting may be associated with a variety of clinical presentations. In addition to GI diseases, either or both may accompany cardiovascular, infectious, neurologic, or metabolic disease processes. Nausea and vomiting may be a feature of such conditions as pregnancy, or may follow operative procedures or administration of certain medications, such as those used in cancer chemotherapy.

Psychogenic etiologies of these symptoms may be present, especially in young women with an underlying emotional disturbance. Anticipatory etiologies may be involved, such as in patients who have previously received cytotoxic chemotherapy. Table below lists specific etiologies associated with nausea and vomiting. In addition to identifying conditions associated with nausea and vomiting, it is important to address the specific causative medical problems. For example, nausea and vomiting may occur in as many as 70% of patients with inferior myocardial infarction or diabetic ketoacidosis. Eighty percent to 90% of patients with an Addisonian crisis, acute pancreatitis, or acute appendicitis may present with nausea and vomiting.

The etiology of nausea and vomiting may vary with the age of the patient. For example, vomiting in the newborn during the first day of life suggests upper digestive tract obstruction or an increase in intracranial pressure. Other illnesses associated with vomiting in children include pyloric stenosis, duodenal ulcer, stress ulcer, adrenal insufficiency, septicemia, and diseases of the pancreas, liver, or biliary tree. Also, the hepatocellular failure seen in Reye syndrome may lead to profound cerebral edema followed by persistent emesis.

A common etiology of vomiting in children is viral gastroenteritis caused by rotavirus. Vomiting in infants may be associated with something as simple as overfeeding, rapid feeding, inadequate burping, or lying down too soon after feeding. These types of vomiting are usually indicative of minor problems and may be altered by changing the approach to feeding.

General Approach to Treatment

Treatment options for nausea and vomiting include drug and nondrug modalities. The treatment of nausea and vomiting is quite varied depending on the associated medical situation. Even though a number of potentially effective measures are available, most patients receive a medication at some point in their care. For simple nausea and vomiting, patients may choose to do nothing or to select from a variety of nonprescription drugs. As symptoms become worse or are associated with more serious medical problems, patients are more likely to benefit from prescription antiemetic drugs. When prescribed according to reliable clinical information, these agents often provide acceptable relief; however, some patients will never be totally free of symptoms. 

This lack of relief is most disabling when it is associated with an unresolved medical problem or when the necessary therapy for this condition is the cause of the nausea or vomiting, as in the case of patients who are receiving chemotherapy of moderate or high emetic risk.

Nonpharmacologic Management

Nonpharmacologic management of nausea and vomiting may include a variety of dietary, physical, or psychological changes consistent with the etiology of symptoms. For patients with simple complaints, perhaps resulting from excessive or disagreeable food or beverage consumption, avoidance or moderation in dietary intake may be preferable. Patients suffering symptoms of systemic illness may improve dramatically as their underlying condition resolves. Finally, patients in whom these symptoms result from labyrinthine
changes produced by motion may benefit quickly by assuming a stable physical position.

Cancer patients who are undergoing chemotherapy may experience nausea and/or vomiting despite receiving prophylactic antiemetics. Anticipatory nausea or vomiting rarely occurs unless the patient has previously experienced posttreatment nausea or vomiting, suggesting that the mechanism for anticipatory nausea and vomiting is a learned process involving elements of classic conditioning. This conditioning model may also be important in understanding the development of pregnancy-related nausea. Nonpharmacologic interventions are classified as behavioral interventions and include relaxation, biofeedback, self-hypnosis, cognitive distraction, guided imagery, and systematic desensitization.

The management of psychogenic vomiting is greatly dependent on psychological intervention. However, because the underlying problems are so complex and intertwined in personal relationships, psychological therapy may require lengthy, in-depth treatment. Pharmacologic therapy offers only minimal benefit in these patients. Surgery, such as gastroenterostomy, is of no value.

Presentation of Nausea and Vomiting

Depending on severity of symptoms, patients may present in mild to severe distress
Simple: Self-limiting, resolves spontaneously and requires only symptomatic therapy
Complex: Not relieved after administration of antiemetics; progressive deterioration of patient secondary to fluid–electrolyte imbalances; usually associated with noxious agents or psychogenic events
Simple: Patient complaint of queasiness or discomfort 
Complex: Weight loss; fever; abdominal pain
Laboratory tests
Simple: None
Complex: Serum electrolyte concentrations; upper/lower GI evaluation
Other information
Fluid input and output
Medication history
Recent history of behavioral or visual changes, headache, pain, or stress
Family history positive for psychogenic vomiting

Pharmacologic therapy

Although many approaches to the treatment of nausea and vomiting have been suggested, antiemetic drugs (nonprescription and prescription) are most often recommended. These agents represent a variety of pharmacologic and chemical classes, as well as dosage regimens and routes of administration. With so many treatment possibilities available, factors that enable the clinician to discriminate among various choices include (a) the suspected etiology of the symptoms; (b) the frequency, duration, and severity of the episodes; (c) the ability of the patient to use oral, rectal, injectable, or transdermal medications; and (d) the success of previous antiemetic medications. Table below gives information concerning commonly available antiemetic preparations.

The treatment of simple nausea and vomiting usually requires minimal therapy. For these symptoms, patients may choose from a lengthy list of nonprescription products. Both nonprescription and prescription drugs useful in the treatment of simple nausea and vomiting are usually effective in small, infrequently administered doses. Side effects and toxic effects in these settings are also usually minimal. Although suitable for occasional simple nausea and vomiting, nonprescription agents are often abandoned by the patient as symptoms continue or become progressively worse. As the patient’s condition warrants, prescription medications may be chosen, either as single-agent therapy or in combination.

The management of complex nausea and vomiting, for example, in patients who are receiving cytotoxic chemotherapy, may require combination therapy. In combination regimens, the goal is to achieve symptomatic control through administration of agents with different pharmacologic mechanisms of action.


by Umaee

Source: Pharmacotherapy 7th
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