Clearance of all anti-emetics may be reduced in renal failure and as such, the general principles of starting with lower doses and increased intervals between doses should be followed.
Choice of anti-emetic should predominantly be decided by identifying the underlying mechanism of nausea and awareness of contra-indications for each drug.
Generally safe.
Metabolism: Metabolised by liver, inactive metabolites excreted by kidneys.
Dose adjustments: Start with reduced dose in severe renal impairment with increased dose interval (i.e. 25mg PO/12.5mg SC BD).
Comments: Can accumulate with repeated use due to long half-life, may induce hypotension and tachyarrythmia due to antimuscarinic effects so is avoided by some centres. Can reduce seizure threshold.
Use with caution.
Metabolism: Metabolised by liver, active metabolites may accumulate.
Dose adjustments: Reduced maximum doses may be required for regular use (i.e. 1.5mg SC / 24hr via syringe pump).
Comments: Increased risk of QT prolongation in renal failure.
Use with caution.
Metabolism: Metabolised by liver, active metabolites may accumulate. Excreted by kidneys and GI tract.
Dose adjustments: Start with reduced dose
(i.e. 6.25mg ON PO or 2.5mg – 5mg SC).
Comments: Increased risk of QT prolongation in renal failure.
Use with caution.
Metabolism: Metabolised by liver, excreted by kidneys
(20-30% unchanged).
Dose adjustments: Start with reduced dose (i.e. 5mg PO/SC TDS).
Comments: Clearance reduced in renal impairment. Increased risk of extrapyramidal side effects.
Generally safe.
Metabolism: Metabolised by liver, no active metabolites.
Dose adjustments: Dose generally unchanged (i.e., 4mg-8mg BD/TDS)
Comments: Increased risk of QT prolongation in renal failure. Effect on 5HT3 receptors in GI tract can cause constipation.
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.