Nausea and Vomiting (Palliative Care) Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • Patients over 18 years of age
  • Nausea and vomiting in advanced disease

This guidance does not cover:

  • Patients under 18 years of age
  • Nausea and vomiting related to chemotherapy or radiotherapy

Assessment

A logical approach to the use of anti­emetics depends on knowledge of the cause of the symptoms.

By assessing the patient with regard to the cause, treatment of the underlying problem may be more effective that anti-emetics alone.

Causes of nausea may often be multifactorial.

Consider
  • Drugs
    • Where possible, stop / change drugs which may be causing nausea (e.g. NSAID, opioids, antidepressants, iron supplements)
    • In patients with gastric stasis avoid drugs with anticholinergic effects (e.g. hyoscine, antidepressants, cyclizine)
    • Antiemetics may be necessary for a few days when opioid treatment is initiated. The nausea is usually transient.
  • Abnormal biochemistry:
    • Hypercalcaemia, renal failure, hyponatraemia
  • Constipation:
    • Prevent and treat
  • Gastritis/gastro­oesophageal reflux:
    • Treat with a PPI
  • Raised intracranial pressure:
    • Treat with corticosteroids
  • Psychosomatic factors e.g. anxiety, fear:
    • Treat with psychological approaches and pharmacological treatments
  • Malignant gastro-intestinal obstruction
    • Treat as per malignant gastro-intestinal obstruction
  • Pain
    • Treat as per treatment of pain in palliative care

Management

Choice of antiemetic

General principles

  • Ensure underlying causes have been considered and treated, as appropriate.
  • Ensure the anti­emetic is used regularly and to maximum dose before changing.
  • If the first drug is ineffective, change to a drug from another pharmacological group.
  • If the first drug is partially effective, add a drug from another pharmacological group.
  • Cyclizine, and other antimuscarinic drugs, block the final common pathway through which metoclopramide acts, therefore concurrent administration should be avoided.
  • If there is vomiting or significant nausea to oral route may not be effective. The subcutaneous route is usually preferred and drugs may be best delivered via a syringe pump.
  • The prescriber must consider the need to provide information to patients about use of "off­licence" drugs.
  • Please note there have been recent warnings relating to prolongation of the QT interval with antiemetics and therefore caution is advised in patients with known cardiac rhythm disturbance. If in doubt seek advice from the specialist palliative care team.
Biochemical causes

Including: drug induced causes, hypercalcaemia, uraemia, hyponatraemia

  • Haloperidol
    • 500 micrograms to 1.5mg PO or SC
    • Up to 5mg PO or SC in a 24 hour period
    • Syringe pump: 1 to 5mg over 24 hours
    • Avoid in Parkinson's disease as may worsen symptoms (see below)
Gastric causes (stasis and irritation)

Consider starting a PPI to cover for gastric irritation.

Metoclopramide

  • 10mg PO or SC
  • Usual dose over a 24 hour period is 30 to 60mg
  • Syringe pump: 30-60mg over 24 hours
  • Avoid in Parkinson's disease as may worsen symptoms (see below)
  • The MHRA issued a drug safety alert about metoclopramide in August 2013
    • The benefits of use only outweigh the risks when used in the short term for nausea or vomiting.
    • This would limit treatment to 30mg a day, for a maximum of 5 days
    • This relates to the risk of extrapyramidal side effects
    • In palliative care the use of medication "off label" is recognized as standard practice and, therefore, we do not necessarily need to change our practice.
    • Please seek specialist advice is planning to use Metoclopramide over these suggested limits. Continuing at the lowest effective dose, for the shortest possible time, is likely to be the safest option.

Domperidone

  • 10mg PO
  • Usual dose over a 24 hour period is 30 to 60mg
  • Not able to be given subcutaneously or via a syringe driver
  • Does not cross the blood brain barrier so fewer side effects

For antiemetic choice in malignant gastro-intestinal obstruction, see relevant section.

Raised intracranial pressure

May be completely treated by steroids. Use Dexamethasone 4- 8 mg orally once daily unless symptoms are severe or there is there is risk of herniation, in which case use Dexamethasone 16 mg orally once daily (with PPI cover).

Cyclizine

  • 50mg PO or SC, 8 hourly.
  • Maximum dose in 24 hours is 150mg.
  • Syringe pump: 100-150mg over 24 hours.
  • Due to its side effect profile it should be avoided in heart failure.
  • May crystalize when mixed with hyoscine butylbromide in a syringe pump.
Motion related causes
  • 50mg PO or SC, 8 hourly.
  • Maximum dose in 24 hours is 150mg.
  • Syringe pump: 100-150mg over 24 hours.
  • Due to its side effect profile it should be avoided in heart failure.
  • May crystalize when mixed with hyoscine butylbromide in a syringe pump.
Second line or multi-factorial causes
  • If the first drug is ineffective, change to a drug from another pharmacological group.
  • If the first drug is partially effective, add a drug from another pharmacological group.
  • Cyclizine, and other antimuscarinic drugs, block the final common pathway through which metoclopramide acts, therefore concurrent administration should be avoided.
  • Cyclizine and Haloperidol can be combined to provide broad spectrum antiemetic.
  • Levomepromazine will also provide broad spectrum cover.

Levomepromazine

  • 6.25mg PO or SC, at night.
  • Maximum antiemetic dose over a 24 hour period is 25mg.
  • Syringe pump: 6.25 to 12.5mg over 24 hours.
  • Can cause drowsiness, which may limit use.
  • Avoid in Parkinson's disease as may worsen symptoms (see below).

5HT3 antagonists

  • Ondansetron of Granisetron.
  • Role in non­chemotherapy induced nausea and vomiting is not yet clear.
  • Use only after specialist advice as they can cause significant constipation.

Steroids

  • Outside of the context of raised intracranial pressure or severely emetogenic chemotherapy, steroids are not a first line treatment for nausea and vomiting.
  • Discussion with the Specialist Palliative Care team is advised if steroids are being considered for other causes of nausea and vomiting.
Antiemetic in Parkinson's disease
  • Centrally acting anti-dopaminergic drugs such as metoclopramide, haloperidol and levomepromazine may worsen Parkinson's symptoms.
    • Consider using Domperidone or a 5HT3 antagonist.

Referral

Referral Criteria

Wakefield CCG
  • Eligibility for referral to specialist palliative care services (including inpatient, community, day hospice or outpatient service provision) is based on patient need not diagnosis:
    • The patient has active, progressive and usually advanced disease for which the prognosis is limited (although this may be several years) and the focus of care is quality of life.
    • The patient has unresolved complex needs that cannot be met by the caring team. These needs may be physical, psychological, social and /or spiritual. Examples may include complicated symptoms, difficult family situations, or ethical issues regarding treatment decisions.
  • Patients who meet the above criteria may be admitted to any part of the specialist palliative care service as required
  • An eConsultation request can also be sent via SystmOne
  • See palliative care contact details and resources for further information
North Kirklees
  • Common eligibility criteria were agreed in 2000 by all providers of SPC (specialist palliative care) working in Calderdale and Kirklees in order to ensure equity of access. The criteria reflects those adopted by other SPC services across the country and was incorporated into the new service agreement with Kirkwood on April 2015.
  • There are three elements to the common eligibility criteria:
    • Patients should have active, progressive and potentially life-threatening illness
    • Patients should have unresolved, complex needs that cannot be met by the current caring team, or it is anticipated that the patient will develop such needs in the near future. These needs may be psychological, social, spiritual or physical
    • Patients must have been recently assessed by a member of a SPC team
  • See palliative care contact details for further information

Referral Forms

Wakefield CCG
North Kirklees CCG

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation.

Patient Information/Public Health/Self Care

Evidence/Supporting Informtation

Useful Links

Hospice information
Other

Assurance & Governance

  • This guidance was developed on: 07.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 08.2017
  • Publication Date: 08.2017
  • Review Date: 07.2019
  • Ref No: PL11 - 07.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
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