The evidence base to support prescribing of antiemetics in advanced cancer and other palliative conditions is not well developed, and much of the existing knowledge relates to chemotherapy induced nausea and vomiting, which involves a well defined “emetic pathway”. The physical causes in palliative care patients are likely to be more complex.
Choosing antiemetics based on the presumed mechanism of the symptoms, and the inferred neurotransmitter pathways thought to be involved in each mechanism, is a standard approach in palliative care. The effectiveness of this approach has been investigated in several small studies. [1, 2] However the lack of strong evidence regarding the underlying assumptions means that antiemetic choices are still, in practice, derived mainly from expert opinion. [3]
The main classes of antiemetics are:
- Dopamine antagonists (eg, metoclopramide, haloperidol, domperidone, other antipsychotics)
- Antihistamines (cyclizine, promethazine)
- Serotonin antagonists (eg, ondansetron, tropisetron, granisetron)
- Other agents (anticholinergics, steroids, neurokinin-1 antagonists, benzodiazepines for anticipatory nausea).
What is known
- There is good evidence that metoclopramide is effective in advanced cancer, and it is the best studied antiemetic in this setting. [3] It had a 75% response rate when used for chronic nausea thought to be due to gastroparesis. [4]
- There is evidence to support the effectiveness of serotonin antagonists in palliative care, however there are also concerns over cost and toxicity, and further comparative studies would help to clarify these issues. [3]
- Many antiemetics which are in common use in palliative care such as:
- Cyclizine (an antihistamine available via the Special Access Scheme)
- Haloperidol [5]
- Steroids
- Methotrimeprazine / levomepromazine (a broad spectrum antipsychotic available via the Special Access Scheme).
are likely to be effective, although the research supporting their use is not extensive. [3]
Implications for practice
- Antiemetics which can be given by the subcutaneous route are preferred. Prochlorperazine is rarely used in palliative care because it is unsuitable for the subcutaneous route.
- Inferences about the main mechanism of nausea can be reasonably used to guide choice of antiemetic according to receptor profile in most instances.
Related CareSearch pages
Bowel obstruction
Constipation
Finding out more
Guidelines
Clinical Knowledge Summaries: Palliative cancer care – nausea and vomiting
Link to prescribing information
NB Prescribing information may not yet have been updated to include the most recent evidence
Overview article
References
- Lichter I. Results of antiemetic management in terminal illness. Journal of Palliative Care. 1993 Summer;9(2):19-21.
- Bentley A, Boyd K. Use of clinical pictures in the management of nausea and vomiting: a prospective audit. Palliative Medicine. 2001 May;15(3):247-53.
- Glare P, Pereira G, Kristjanson LJ, Stockler M, Tattersall M. Systematic review of the efficacy of antiemetics in the treatment of nausea in patients with far-advanced cancer. Supportive Care in Cancer. 2004 Jun;12(6):432-40.
- Bruera E, Belzile M, Neumann C, Harsanyi Z, Babul N, Darke A. A double-blind, crossover study of controlled-release metoclopramide and placebo for the chronic nausea and dyspepsia of advanced cancer. Journal of Pain & Symptom Management. 2000 June;19(6):427-35.
- Critchley P, Plach N, Grantham M, Marshall D, Taniguchi A, Latimer E, et al. Efficacy of haloperidol in the treatment of nausea and vomiting in the palliative patient: a systematic review. Journal of Pain and Symptom Management. 2001 Aug;22(2):631-4. No abstract available.
- Flake Z, Scalley R, Bailey A. Practical selection of antiemetics. American Family Physician. 2004 Mar 1;69(5):1169-74.
This page was created on 24 May 2008 and is due for release in May 2010
Last updated 26 May 2008