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Effective Management of Nausea and Vomiting in Palliative Care: Insights from EPEC-O Seminar

This seminar, held in Salzburg, Austria, focuses on the challenges of managing nausea and vomiting in palliative care, particularly in oncology settings. Led by Dr. Jamie H. Von Roenn from Northwestern University, the session explores the pathophysiology, assessment techniques, and evidence-based management strategies to improve patient experiences. Attendees will gain insights into neurotransmitters involved, pharmacological options, and the importance of comprehensive assessment in effectively addressing nausea and vomiting in cancer patients.

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Effective Management of Nausea and Vomiting in Palliative Care: Insights from EPEC-O Seminar

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  1. Seminar in Palliative Care September 26 – October 02, 2010Salzburg, Austria in Collaboration with

  2. The EPEC-O TM Education in Palliative and End-of-life Care - Oncology Project The EPEC-O Curriculum is produced by the EPECTM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

  3. Nausea / Vomiting Jamie H. Von Roenn, MD Northwestern University,Feinberg School of Medicine, Chicago, Illinois, USA

  4. Nausea / vomiting . . . • Definition • Nausea is an unpleasant subjective sensation of being about to vomit • Vomiting is the reflex expulsion of gastric contents through the mouth

  5. . . . Nausea / vomiting • Impact very distressing: • Awareness of nausea • Inability to keep food or fluids down • Acid and bitter tastes • Unpleasant smells of vomitus

  6. Key points • Pathophysiology • Assessment • Management

  7. Pathophysiology • Nausea • Subjective sensation (easily learned) • Stimulation • Gastrointestinal lining, CTZ, vestibular apparatus, cerebral cortex • Vomiting • Neuromuscular reflex

  8. Pathophysiology ChemoreceptorTrigger Zone (CTZ) Cortex Vestibular apparatus Vomiting center • Neurotransmitters • Acetylcholine • Dopamine • Histamine • Neurokinin • Serotonin GI tract

  9. Metastases Meningeal irritation Movement Mental anxiety Medications Mucosal irritation Mechanical obstruction Motility Metabolic Microbes Myocardial Causes

  10. Assessment • When • Acute versus chronic • Intermittent or constant • Associated with sights or smells • Eating patterns • Bowel patterns • Medications

  11. Dopamine antagonists Antihistamines Anticholinergics Serotonin antagonists Neurokinin antagonists Prokinetic agents Antacids Cytoprotective agents Other medications Management Gralla R, et al. J Clin Oncol, 1999.

  12. Chemotherapy nausea • Acute • < 24 hr • Chemoreceptor trigger zone • Serotonin release in the gut • Delayed • 24 hr (may be days) • Unclear mechanism

  13. Chemotherapy emetogenicity

  14. Haloperidol Prochlorperazine Droperidol Thiethylperazine Promethazine Trimethobenzamide Metoclopramide Olanzapine Perphenazine Dopamine antagonists

  15. Histamine antagonists (antihistamines) • Diphenhydramine • Meclizine • Hydroxyzine

  16. Acetylcholine antagonists(anticholinergics) • Scopolamine

  17. Serotonin antagonists • Ondansetron • Granisetron • Dolasetron • Palonosetron

  18. Neurokinin-1 antagonists • Aprepitant

  19. Prokinetic agents • Metoclopramide • Domperidone • Macrolide antibiotics, eg, erythromycin

  20. Antacids • Antacids • H2 receptor antagonists • Cimetidine • Famotidine • Ranitidine • Proton pump inhibitors • Omeprazole • Lansoprazole

  21. Other medications • Dexamethasone 6 – 20 mg PO daily • Tetrahydrocannabinol 2.5 – 5 mg PO tid • Lorazepam 0.5 – 2 mg PO q 4 – 6 h • Octreotide 10 mg / hr IV / SC infusion • or 100 mg SC q 8 h for bowel obstruction

  22. Summary Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience

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