Prescribe a single agent based on underlying cause (see below). Use regularly and to maximum dose before changing. N.B. Avoid using Metoclopramide and Haloperidol in those with Parkinson’s spectrum disorders.
Eg. opioids, hypercalcaemia, uraemia
Haloperidol (most potent dopamine D2 receptor antagonist)
Oral: 1.5mg–3mg/24hrs – Reduce starting dose in renal impairment and elderly e.g. 500 micrograms–1mg
SC: 2.5mg–5mg/24hrs
Preparations:
Tablets: 500 micrograms, 1.5mg, 5mg, 10mg
Oral solution: 1mg/ml, 2mg/ml
Injection: 5mg/1 ml, 20mg/2ml
CAUTIONED USE IN EPILEPSY
AVOID IN PATIENTS WITH PARKINSON’S DISEASE & LEWY BODY DEMENTIA as has Extrapyramidal side effects (EPSEs)
Metoclopramide (dopamine D2 receptor antagonist)
Use with caution in young adults aged 15-19 (see BNF)
Oral: 10mg TDS to QDS before meals
SC: 30mg–100mg/24hrs
Preparations:
Tablets: 10mg
Oral solution: 5mg/5ml
Injection: 10mg/2ml
AVOID IN PATIENTS WITH PARKINSON’S DISEASE as can cause EPSEs
AVOID IN PATIENTS WITH COMPLETE (MECHANICAL) BOWEL OBSTRUCTION
OR Domperidone (dopamine D2 receptor antagonist; does not cross blood brain barrier so fewer side effects)
Oral: 10mg TDS
Preparations:
Tablets: 10mg
Suspension: 5mg/5ml (Maximum dose is 30mg/24 hours)
Domperidone is now contraindicated in people:
- with conditions where cardiac conduction is, or could be, impaired with underlying cardiac diseases such as congestive heart failure receiving other medications known to prolong QT interval or potent CYP3A4 inhibitors.
- with severe hepatic impairment.
Cyclizine
(anticholinergic antihistamine)
Oral: 50mg TDS
SC: 75mg- 100mg / 24hours
Preparations:
Tablets: 50mg
Injection: 50mg / 1ml
CAUTIONED USE IN EPILEPSY
CONTRAINDICATED IN SEVERE HEART FAILURE
Useful if multiple possible causes or if the above have not worked
Combine first line agents e.g. haloperidol and cyclizine
or use single broad spectrum agent
Levomepromazine
Acts at Multiple receptor sites: dopamine D2, anticholinergic antihistamine (drug can accumulate in renal impairment and may require a dose reduction to be considered)
Oral: 6.25mg PRN (Up to 25mg/24hr)
SC: 2.5mg – 6.25mg PRN (Up to 25mg/24hr)
Preparations:
Tablets: 25mg, 6mg (6mg unlicensed available on named patient basis).
Injection: 25mg/1ml
Cautioned use in renal and hepatic impairment, epilepsy, narrow-angle glaucoma, urinary tract obstruction. Elderly are more susceptible to antimuscarinic effects.
3 day course of 5HT3 – Receptor Antagonist
For example ondansetron and granisetron
Ondansetron Oral: 8mg OD – BD
SC: up to 24mg over 24 hours
Granisetron Oral SC: 1mg–2mg per 24 hours
Preparations:
Ondansetron
Tablets and dispersible tablets: 4mg, 8mg
Syrup: 4mg/5ml
Suppositories: 16mg
Injection: 4mg/2ml, 8mg/4ml
Granisetron
Tablets: 1mg, 2mg
Solution: 1mg/5ml
Injection: 1mg/1 ml,3mg/3ml
Patch: 3.1mg/24 hours
Change patch every 7 days (formulary restrictions may apply)
Contraindicated in congenital prolonged QT interval.
Serious drug interaction: a combination of IV metoclopramide and IV ondansetron occasionally causes cardia arrhythmias.
Constipation is a side effect.
Neurokinin receptor antagonists for example Aprepitant
Aprepitant: 80mg–125mg OD PO
Capsules: 80mg, 125mg
Disclaimer
This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.
Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.
While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.