Stepwise approach


  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
Guideline Nausea and vomiting 3.0
Treatment Level of incidence Reference(s)
Opioid rotation or changing the route of
administration of opioids
2 Bruera 1995, Drexel 1989, Heiskanen 1997, Kalso 1990, Mercadante 1998 
Placement of pyloroduodenal stent 2 Del Piano 2005, Dormann 2004, Hosono 2007, Jeurnink 2007, Johnsson 2004, Mehta 2006, Mittal 2004, Siddiqui 2007 
Abdominal paracentesis 3 McNamara 2000
Surgery for bowel obstruction in selected patients 3 Ripamonti 2008
Nasogastric/PEG tube for gastroparesis/obstructed
gastric outlet or bowel obstruction
3 Brooksbank 2002, Gemlo 1986, Pothuri 2005
Octreotide for bowel obstruction 2 Mercadante 2000, Mystakidou 2000, Ripamontin 2000
  3 Khoo 1994, Laval 2006, Mangili 1996, Mangili 2005, Shimai 2008
Lanreotide 3 Massacesi 2006, Matoulonis 2005
Butylscopolamine for bowel obstruction 3 Baines 1985, Mercadente 2000, Ripamonti 2000
Nutritional advice 4 LEVV 2007

Acupuncture and acupressure





postoperatively 2 Ezzo 2006
chemotherapy 2 Ezzo 2006, Naeim 2008
other causes 2 Brown 1992, Nystrom 2008, Perkins 2008, Wright 2005

Complementary therapies and psychological





massage 2 Ahles 1999A, Cassileth 2004, Graelish 2000A
aromatherapy 3 Gilligan 2005
distraction 3 Vasterling 1993A
progressive muscle relaxation, with(out) guided fantasy excercises 1-2 Luebbert 2001A, Devine 1995A
listening to music 3 Ezzone 1998A, Standley 1992A
Metoclopramide 2 Bruera 1994, Bruera 1996, Bruera 2000, Shivshankar 1983, Wilson 2002
Domperidone 4  
Erythromycin for gastroparesis 3 Maganti 2003B
Haloperidol 4 Critchley 2001, Perkins 2009
Serotonin (5HT3) antagonists for radiotherapy- or chemotherapy-induced nausea and vomiting 1 Herrstedt 2008, Kris 2006, Roila 2006
Serotonin (5HT3) antagonists for nausea and vomiting due to other causes 2 Buchanan 2007, Cole 1998, Currow 1997, Ljutic 2002, Mystakidou 1998, Nicholson 1992, Porcel 1998, Sussman 1999

Dexamethasone for chemotherapy-induced nausea and vomiting

(combined with serotonin (5HT3) antagonists)

1 Kris 2006, Naeim 2008
Dexamethasone for nausea and vomiting due to other causes (combined with other antiemetics) 3 Bruera 1996, Hardy 2001, Mystakidou 1998, Bruera 2004
Aprepitant for chemotherapy-induced nausea and vomiting 1 Herrstedt 2008, Kris 2006, Roila 2006
Cyclizine 4  
Scopolamine 4  
Levomepromazine 3 Eisenchlas 2005, Kennett 2005, Skinner 1999, Twycross 1997
Olanzapine 3 Jackson 2003, Passik 2002, Srivastava 2003

Study on nausea and vomiting following chemotherapy

Study in patients with idiopathic or diabetic gastroparesis; no data available on use in patients with cancer in the palliative phase

Level 1 = based on a systematic review or at least two randomised trials of sufficient quality

Level 2 = based on at least two comparative clinical trials of moderate quality or insufficient size, or other comparative studies

Level 3 = based on one comparative trial or a non-comparative trial

Level 4 = based on expert opinion


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