• Home
• GJF
  • Joint Wound Care Formulary
  • . . . Introduction
  • 1. Gastro-Intestinal System
  • 2. Cardiovascular System
  • 3. Respiratory System
  • 4. Central Nervous System
    • 4.1 Hypnotics and anxiolytics
    • 4.2 Drugs used in psychoses and related disorders
    • 4.3 Antidepressants
    • 4.4 CNS stimulants and other drugs used for ADHD
    • 4.5 Drugs used in the treatment of obesity
    • 4.6 Drugs used in nausea and vertigo
    • 4.7 Analgesics
    • 4.8 Antiepileptics
    • 4.9 Drugs used in parkinsonism and related disorders
    • 4.10 Drugs used in substance dependence
    • 4.11 Drugs for dementia
  • 5. Infections
  • 6. Endocrine System
  • 7. Obstetrics, Gynaecology and Urinary Tract Disorders
  • 8. Malignant Disease and Immunosuppresion
  • 9. Nutrition and Blood
  • 10. Musculoskeletal and Joint Disease
  • 11. Eye
  • 12. Ear, Nose and Oropharynx
  • 13. Skin
  • 14. Immunological products and vaccines
  • 15. Anaesthesia
  • Appendix 1. Drugs for emergency use in General Practice
  • Appendix 2. Palliative Care
  • Appendix 3. Oral Nutritional Supplements (ONS)
  • Appendix 4. Gluten-free and cow's milk protein-free products
  • Medicines No Longer included in the GJF
  • Medicines not recommended for use in NHS Grampian
• eGJF
• Medicines Management
• Policies
• News Letters
• Shared Care Protocols
• Patient Group Directions

4.6 Drugs used in nausea and vertigo

Specialist guidance should be referred to for prescribing of anti-emetics in

• cytotoxic chemotherapy
• migraine
• palliative care
• post-operative nausea and vomiting

Prochlorperazine (5mg tablets, 3mg buccal tablets, 5mg/5mL syrup, 12.5mg/mL injection, 30mg suppositories) is used in the prophylaxis and treatment of drug-induced nausea and vomiting. It may cause extrapyramidal reactions and is mildly sedating. It should not be prescribed to patients with Parkinson's disease and should be used with caution in the elderly.

Metoclopramide (10mg tablets, 5mg/5mL oral solution, 5mg/mL injection) is the preferred agent when sedation is not required. In addition to its effects at the chemoreceptor trigger zone it has a peripheral action on the gut and is therefore contra-indicated for three to four days after gastro-intestinal surgery. Dystonic reactions are most common in the young and very old. Use in patients under 20 years should be restricted to severe intractable vomiting of known cause, vomiting associated with radiotherapy and intolerance to cytotoxic drugs, as an aid to gastrointestinal intubation, and as part of the premedication before surgical procedures. It should not be prescribed for patients with Parkinson's disease.

Severe dystonic reactions to metoclopramide or prochlorperazine should be treated with procyclidine injection.

SPECIAL INDICATIONS

Aprepitant (capsules, Emend®) is a substrate, a moderate inhibitor, and an inducer of CYP3A4. It is restricted to use in hospital for the prevention of acute and delayed nausea and vomiting associated with highly emetogenic cisplatin-based chemotherapy. Only appropriate hospital-based specialists should initiate it, and use is restricted to very high risk patients and those not controlled with standard emetogenic drugs.

Betahistine (8mg, 16mg tablets) is indicated for vertigo, tinnitus and hearing loss associated with Ménière's disease only.

Cinnarizine (15mg tablets) is indicated for vestibular disorders.

Cyclizine (tablets, suspension, injection) is the drug of choice in palliative care for vestibular-induced vomiting or if gastro-intestinal obstruction is present. In the general population it has the potential for abuse

Dexamethasone (tablets, injection) is as effective for delayed vomiting as the more expensive ondansetron in patients undergoing moderately emetogenic chemotherapy. The combination of dexamethasone and ondansetron may offer advantages in refractory cases.

Domperidone (10mg tablets, 5mg/5mL suspension, 30mg suppositories) resembles metoclopramide but as it does not readily cross the blood-brain barrier it is less likely to cause dystonic reactions. It is used for patients who cannot tolerate metoclopramide, and is the favoured anti-emetic in patients with Parkinson's disease. See Direct Healthcare Professional Communication on domperidone and cardiac safety December 2011, MHRA Drug Safety Update May 2012.

Haloperidol (tablets, capsules, oral liquid, injection) is the drug of choice for opioid-induced vomiting in palliative care.

Hyoscine hydrobromide (tablets, injection, patches) is very effective in the prevention of motion sickness. It has other specialised uses in surgery and palliative care.

Levomepromazine (tablets, injection) is used in palliative care.

Ondansetron (tablets, injection) is a 5HT₃ antagonist. It is extremely expensive compared to other antiemetics. Its use in hospital is restricted to chemotherapy with highly emetogenic regimens and wide field abdominal irradiation. It is also second-line in post-operative nausea and vomiting where prochlorperazine/cyclizine is not effective, and in ECT where vomiting is a problem.

PRESCRIBING POINTS FOR DRUGS USED IN NAUSEA AND VERTIGO

• The underlying cause of nausea should be identified and treated before starting treatment with an anti-emetic whenever possible, otherwise their use may delay diagnosis.
• Dopamine antagonists such as prochlorperazine and metoclopramide can induce acute dystonic reactions with facial and skeletal muscle spasms and oculogyric crisis. This usually occurs shortly after starting treatment and is more common in the young (especially girls and young women) and the very old. This reaction is rapidly abolished by intravenous administration of procyclidine.
• Long-term use of metoclopramide may cause tardive dyskinesia in the elderly.
• Ondansetron should be used according to local guidelines only.
• Nausea in the first trimester of pregnancy does not normally require drug therapy. Cyclizine or promethazine may be tried for up to 48 hours if vomiting is severe. If symptoms do not settle specialist advice should be sought, see NICE CG62 http://publications.nice.org.uk/antenatal-care-cg62.
• Surgical patients receiving opioids should be prescribed prophylactic anti-emetics such as cyclizine or prochlorperazine.
• Patients suffering an acute myocardial infarction should be given intravenous morphine and metoclopramide concomitantly. Cyclimorph® (containing morphine and cyclizine) is an alternative but repeated doses are not recommended.

PAEDIATRIC NOTES - NAUSEA AND VERTIGO

Antiemetics should only be used in children once the cause of vomiting is known.
For Post-Operative nausea and vomiting see Association of Paediatric Anaesthetists of Great Britain and Ireland (APA) Guidelines on prevention of Post-Operative Vomiting in Children.
For chemotherapy induced vomiting: first-line - ondansetron.
Dexamethasone is used for cisplatin induced vomiting. Metoclopramide and leomepromazine are also used for cytotoxic induced vomiting.
Metoclopramide must be used with caution in children as it can cause severe dystonic reactions in children.

 GERIATRIC NOTES - NAUSEA AND VERTIGO

Dopamine antagonists such as prochlorperazine and metoclopramide can induce acute dystonic reactions with facial and skeletal muscle spasms and oculogyric crisis. This occurs shortly after starting treatment and is more common in the very old. Drug-induced parkinsonian side-effects, postural hypotension and mental confusion can occur with these drugs and they may also precipitate falls. Domperidone may be the preferred drug of choice in the elderly - see prescribing restrictions MHRA Drug Safety Update May 2012.

Previous: Centrally Acting Appetite Suppressants | Top | Next: Analgesics