Stepwise approach

Diagnostics

1. Patient history and physical examination
2. Laboratory analysis to assess dehydration and/or potassium loss: serum urea, serum creatinine, serum potassium
3. If a specific cause is suspected: laboratory analysis (Na, Ca²⁺, glucose), X-BOZ, abdominal ultrasound/CT scan, image of the small intestine with gastrografphn, gastroscopy, brain CT/MRI

Management plan

1. If possible: treat the cause:
   • targeted antitumour therapy
   • modification of the dose or discontinuation of medication
   • stent or gastrojejunostomy in the case of obstruction of the pylorus or duodenum
   • treatment of pain, constipation, cough, reflux, peptic ulcer, gastritis, gastroenteritis, pancreatitis, cholelithiasis, nephrolithiasis or cystitis
   • treatment of hypercalcaemia or hyponatraemia
   • with ascites: ascites puncture or possibly diuretics
   • surgery, stent or chemotherapy in the case of ileus
   • radiotherapy or resection of brain metastases
2. Symptomatic management:
   • non-pharmacological symptomatic treatment:
     • if required: parenteral administration of fluid and potassium
     • nutritional and lifestyle advice
     • for severe vomiting caused by pyloric obstruction or obstruction of the duodenum, ileus or gastroparesis: temporary or permanent gastric draining using a nasogastric or PEG tube
     • consider acupuncture and/or acupressure, complementary forms of care and/or psychological techniques
   • pharmacological symptomatic treatment
     • with gastroparesis:
       • metoclopramide 10-20 mg orally 3-4 times daily or 3-4 dd 20-40 mg rectally 3-4 times daily or 40-100 mg/24 hrs s.c. or i.v., or
       • domperidone 10-20 mg orally or 60-120 mg rectally 3-4 times daily
     • in the case of ileus:
       • somatostatin analogues: octreotide 100-300 microgram s.c. three times daily or 300 - 900 microgram/24 hours continuous s.c. or i.v. infusion (particularly for severe vomiting); or (during the stable phase after the efficacy of octreotide has been confirmed) ocreotide LAR 30 mg i.m. every 4 weeks or lanreotide PR 30 mg i.m. once every 2 weeks
       • hyoscine butylbromide 40-120 mg/24 hours s.c. or i.v.
     • in the case of patients treated with chemotherapy or radiotherapy:
       • prophylactically with radiotherapy or <24 hours after administration of moderately to highly emetogenic chemotherapy: ondansetron 8 mg orally or i.v. twice daily or 16 mg rectally once daily, granisetron 1 mg orally twice daily or 3 mg i.v. or 3.1 mg/24 hrs transdermal (only if treatment is for multiple days) or tropisetron 5 mg orally once daily or i.v., palonosetron single dose of 250 µg i.v., sometimes in combination with dexamethasone and aprepitant or fosaprepitant
       • if there is nausea and/or vomiting >24 hours after administration of chemotherapy, the following may be chosen: metoclopramide 10-20 mg orally or 20-40 mg rectally 3-4 times daily, domperidone 10-20 mg or 60-120 mg rectally 3-4 times daily, or a dexamethasone in a tapering dose schedule
       • f there is anticipatory nausea or vomiting: 1-2 mg lorazepam orally, s.l. or i.v., prior to chemotherapy
     • if there is nausea or vomiting with terminal renal failure:
       • ondansetron 8 mg orally or i.v. twice daily or 16 mg supp. once daily, granisetron 3 mg i.v. or 1 mg orally twice dailyor tropisetron 5 mg orally or i.v. once daily
     • for vestibular causes:
       • scopolamine TTS 1-2 1.5 mg patches every 72 hour

• in all other cases:
  • Step 1
    • metoclopramide 10-20 mg orally or 20-40 mg p.r. 3-4 times daily or 40-120 mg/24 hrs s.c. or i.v., or
    • domperidone 10-20 mg orally or 3-4 dd 60-120 mg rectally 3-4 times daily
  • Arguments for metoclopramide: more experience, based on research in patients in the palliative phase.
  • Arguments for domperidone: presumably just as effective, but less chance of central side effects (extrapyramidal side effects, akathisia = motoric unrest, dystonia, drowsiness)
  • Alternative for metoclopramide or domperidone:
    • haloperidol 1-2 mg orally or 2 dd 0.5 mg s.c. or i.v. twice daily or 1-2 mg/24 hours s.c. or i.v.
  • Step 2
    • dexamethasone (monotherapy) 4-8 mg orally, s.c. or i.v. once daily
  • Step 3
    • levomepromazine (monotherapy): 6.25-12.5 mg orally a.n. or 3.12-6.25 mg s.c. (as monotherapy; non-reimbursable but inexpensive); can also be administered buccally (1 ml=25 mg added to 9 ml tap water; dose of 1 ml of this dilution = 2.5 mg)
  • Alternatives:
    • olanzapine (monotherapy) 5 mg (as monotherapy) once or twice daily
    • serotonin (5HT3) antagonists: ondansetron 8 mg orally twice dailyor 1 dd 16 mg p.r., granisetron 1 mg orally twice dailyor tropisetron 5 mg orally once daily, in principle in combination with dexamethasone 4 - 8 mg orally once daily. Disadvantages: high costs, constipation as side effect
• If psychological factors also play a role, all the above mentioned agents can be combined with oxazepam 10 mg orally or lorazepam 1-2 mg orally or i.v. three times daily