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4.6 Drugs used in nausea and vertigo

1st      METOCLOPRAMIDE   

MHRA/CHM advice - Metoclopramide: risk of neurological adverse effects—restricted dose and duration of use (August 2013)

The benefits and risks of metoclopramide have been reviewed by the European Medicines Agency's Committee on Medicinal Products for Human Use, which concluded that the risk of neurological effects such as extrapyramidal disorders and tardive dyskinesia outweigh the benefits in long-term or high-dose treatment. To help minimise the risk of potentially serious neurological adverse effects, the following restrictions to indications, dose, and duration of use have been made:

In adults over 18 years, metoclopramide should only be used for prevention of postoperative nausea and vomiting, radiotherapy-induced nausea and vomiting, delayed (but not acute) chemotherapy-induced nausea and vomiting, and symptomatic treatment of nausea and vomiting, including that associated with acute migraine (where it may also be used to improve absorption of oral analgesics);

Metoclopramide should only be prescribed for short-term use (up to 5 days);

Usual dose is 10 mg, repeated up to 3 times daily; max. daily dose is 500 micrograms/kg;

Intravenous doses should be administered as a slow bolus over at least 3 minutes;

Oral liquid formulations should be given via an appropriately designed, graduated oral syringe to ensure dose accuracy.

Note - This advice does not apply to unlicensed uses of metoclopramide (e.g. palliative care)

1st      CYCLIZINE   
1st     DOMPERIDONE  
2nd     PROCHLORPERAZINE  
2nd     APREPITANT  

Metoclopramide and occasionally domperidone, may induce an acute dystonic reaction. Do not use metoclopramide in patients under 20 years of age.

Avoid the use of metoclopramide in Parkinson's disease patients due to the central dopamine antagonism of this drug

Long term metoclopramide or prochlorperazine may cause tardive dyskinesia in the elderly

Cyclizine has the potential for abuse. It may however be useful in opioid induced nausea, and in pregnancy after the first trimester

Aprepitant for prevention of late onset nausea and vomiting after cisplatin at doses greater than 70mg/m2. Onset is 2-3 days post treatment and very severe. Approved by the Cancer Network evaluation committee. Approved RED for NSCLC.

Vestibular disorders

      BETAHISTINE   
      CINNARIZINE (vertigo)  

Postoperative nausea and vomiting

1st      CYCLIZINE     
1st     ONDANSETRON    
1st     DROPERIDOL (Xomolix)    
2nd     METOCLOPRAMIDE    
2nd     DOMPERIDONE   (for Parkinson's disease patients)

Metoclopramide and domperidone aid post-operative gut motility

More than one anti-nausea agent may be required

Ondansetron peri and post operative use should be short term only

Droperidol for use by Anaesthetists in Theatre, Recovery and ITU only

Motion Sickness

      HYOSCINE HYDROBROMIDE   

Chemotherapy induced nausea and vomiting

The following drugs may be prescribed at the chemotherapy appointment by the Specialist only:

      GRANISETRON   
      DEXAMETHASONE  
        DOMPERIDONE or METOCLOPRAMIDE  
        Immediate treatment of chemotherapy induced nausea and vomiting is covered by individual chemotherapy regime protocols.

Delayed chemotherapy nausea and vomiting

1st        METOCLOPRAMIDE +/- CYCLIZINE   
1st       DOMPERIDONE +/- CYCLIZINE  
2nd       LEVOMEPROMAZINE or HALOPERIDOL  

 

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