Palliative Care
in Dumfries and Galloway
Staff Area
Click on each link below to take you to the relevant page from the Scottish Palliative Care Guidelines. Some of the medications are used off-lisence here – see
the SPCG for more information.
There are multiple reasons why people experience nausea and vomiting. As with pain, a good history, examination and investigations are important. Constipation and hypercalcaemia are common, potentially treatable causes of nausea and vomiting in the palliative care population. Polypharmacy and medication for symptom control such as analgesia can also contribute to nausea and vomiting.
Similarly to pain, psychosocial factors can be important. Mouth examination and care is also required. For more information please see SPCG.
Where appropriate, refer to dietetics if supplements are indicated.
The guidelines below are in the form of “clinical pictures”, to help inform antiemetic choice. Non-drug therapies should also be used, such as acupuncture and avoidance of triggers unless unavoidable.
If someone has severe nausea or is vomiting, oral medication is unlikely to work, and antiemetics should be given parenterally until symptoms have improved.
Try to avoid combinations of a pro-kinetic and antagonists of bowel contractility (eg) avoid metoclopramide and cyclizine.
For detailed dosing advice and pharmacology, see SPCG, BNF or PCF.
- Headache
- Confusion
- Vertigo or movement related nausea
Cause
- Cerebral irritation / raised ICP
- Vestibular disorder
- Due to tumour, benign vestibular problems, pre-existing condition.
Treatment
- Imaging helpful (CT +/- MRI) of brain
- If cerebral metastases / primary brain tumour, steroids and cyclizine
- If other cause raised ICP, cyclizine alone
- If predominantly vestibular, try cinnarazine
- If no response, try prochlorperazine or levomepromazine
- Feel full quickly
- Often hiccups / feel bloated / reflux
- Nausea may be completely resolved by vomiting
- May be large volume vomit
Cause
- Gastric stasis / reduced motility
- Obstruction / partial obstruction / ileus
- Due to mechanical obstruction (extrinsic or intrinsic); altered bowel motility from drugs or neuropathy; metabolic disturbance
- If suspect complete obstruction seek advice from specialist - do not use prokinetic. If stent in situ, prokinetic may increase pain.
Treatment
- Prokinetic (metoclopramide / domperidone), usually via parenteral route. Palliative Medicine specialists can use higher doses of metoclopramide than 10mg tds.
- Steroids may be helpful in patients with malignancy and compression of bowel.
- Relief of constipation with rectal measures if not complete obstruction may help.
- PPI may be useful for reflux, either IV or PO as appropriate.
- Persistent feeling of nausea acompanied by vomiting
- Little if any relief from vomiting
Cause
- Trigger of chemoreceptor trigger zone by "toxins"
- Drugs such as antibiotics, opiates, anti-cancer drugs, digoxin.
- Metabolic disturbances: hypercalcaemia, uraemia, DKA, Addisons
- Cancer driven / cytokine mediated.
Treatment
- Underlying cause if possible
- Dopamine antagonist (eg) haloperidol 0.5-1mg bd or metoclopramide 10mg tds.
- If not improving / od SC dosing required, try levomepromazine 2.5-5mg nocte.
- 5HT3 antagonist if chemotherapy related e.g. Ondansetron
- Unclear cause / not responding to usual treatments
- May be underlying anxiety / anticipation of nausea / nausea triggered by pain
Cause
- Consider higher centre involvement - part of anxiety / mood disorder
- If no evidence of this, and not responding to usual antiemetics, then refractory nausea. Seek specialist input.
Treatment
- If evidence anxiety, consider psychology referral / anxiolytics as appropriate (starting dose 0.5mg lorazepam bd and titrate up / down as necessary)
- For refractory nausea, consider adding steroids or broad spectrum antiemetic such as levomepromazine.