Term
| Centrally acting agents - CTZ |
|
Definition
prochlorperazine maleate (Compazine)
promethazine (Phenergan)
metoclopramide (Reglan) |
|
|
Term
|
Definition
centrally acting agent - CTZ
Phenergan
IV, IM, rectal suppository, tablets, liquid
12.5-25 mg PO q4h-q6h |
|
|
Term
|
Definition
centrally acting agent - CTZ
Reglan
IV*, IM, PO
5-10 mg PO/IM/IV q6h-q8h |
|
|
Term
|
Definition
vertigo and motion sickness - anticholinergic agent
Transderm Scop
1.5 mg over 3 days in a patch applied behind the ear |
|
|
Term
| vertigo and motion sickness antihistamines |
|
Definition
Block H1 receptors, OTC agents
dimenhydrinate (Dramamine)
diphenhydramine (Benadryl)
meclizine (Antivert) |
|
|
Term
|
Definition
Antihistamine for vertigo or motion sickness
Antivert
Rx: 25-50 mg PO qd
> 12 years |
|
|
Term
| What % of patients with inferior MI present with nausea and vomiting? |
|
Definition
|
|
Term
| What % of patients with diabetic ketoacidosis present with nausea and vomiting? |
|
Definition
|
|
Term
| What % of patients with Addisonian chrisis, acute pancreatitis, or acute appendicitis present with nausea and vomiting? |
|
Definition
|
|
Term
| How is nausea and vomiting stimulated? |
|
Definition
| many different ways - but they all stimulate the medullary vomiting center (directly or indirectly) |
|
|
Term
|
Definition
chemoreceptor trigger zone
area postrema - circumventricular organ
located in the brain stem
highly vascularized area of brain
lacks a true blood/brain barrier
activated by noxious stimuli - uremia, acidosis, toxins (ex. chemo)
secondarily activated by serotonin, dopamine, and neurokinin (has receptors) |
|
|
Term
| What neurotransmitters have receptors in the CTZ? |
|
Definition
serotonin (5-HT3)
dopamine (D2)
neurokinin (NK1) |
|
|
Term
| How does reduced GI motility cause nausea and vomiting? |
|
Definition
| enterochromaffin cells of the GI tract can trigger the afferent Vagus nerve which leads to serotonin and dopamine stimulation of the vomiting center and/or CTZ |
|
|
Term
| How does vestibular input cause nausea and vomiting? |
|
Definition
release of histamine and acetylcholine which stimulates the medullary vomiting center and/or CTZ
can be caused by conditions that affect the labyrinths (infection, Meniere's Disease, tumors), increase in intracranial pressure (migraine, tumor), or emotional or physical stressors (anorexia or bulimia) |
|
|
Term
T/F
CNS etiologies for nausea and vomiting are unlikely without other neurologic symptoms. |
|
Definition
|
|
Term
| What 3 things does the vomiting center control? (associated with vomiting) |
|
Definition
1. salivation
2. respiratory change
3. muscle contractions - pharyngeal, GI, and abdominal muscles |
|
|
Term
| What are the key receptors involved in the mechanism of vomiting? |
|
Definition
serotonin (5-HT3)
dopamine
neurokinin (NK-1)
also: histamine, endorphins, acetylcholine, cannaboids, and GABA |
|
|
Term
|
Definition
| antacid - base, osmotic diarrhea |
|
|
Term
|
Definition
|
|
Term
| Why are Mg hydroxide and Al hydroxide often used together as antacid? |
|
Definition
Mg causes osmotic diarrhea and Al causes constipation but both are basic and neutralize acid
Milk of magnesia contains both |
|
|
Term
|
Definition
antacid - base, constipation
also practical source of calcium for treating osteoporosis |
|
|
Term
| What is the M of A of antacids? |
|
Definition
| reduce stomach acid, reduce intestinal irritation, and reduce visceral stimulation |
|
|
Term
| What are the side effects of prochlorperazine maleate (Compazine)? |
|
Definition
sedation
BBW: dementia-related psychosis
QT prolongation (sudden death)
blood dyscrasias |
|
|
Term
| What is the Black Box Warning for prochlorperazine maleate (Compazine)? |
|
Definition
dementia-related psychosis
risk in elderly patients on conventional or atypical antipsychotics due to infection or cardiovascular events |
|
|
Term
| In what modalities are prochlorperazine maleate (Compazine) and promethazine (Phenergen) available? |
|
Definition
| IV, IM, rectal suppositories, tablets, and liquid |
|
|
Term
| What is the M of A of prochlorperazine maleate (Compazine)? |
|
Definition
| selectively antagonizes dopamine (D2) receptors in the CTZ |
|
|
Term
| What is the M of A of promethazine (Phenergan)? |
|
Definition
non-selective antihistamine
blocks central and peripheral H1 receptors
some effect on dopamine receptors in the CTZ |
|
|
Term
| What is the main side effect of promethazine (Phenergan)? |
|
Definition
|
|
Term
| What are the Black Box Warnings for promethazine (Phenergan)? |
|
Definition
respiratory depression in those under 2 years
injection may cause tissue necrosis and gangrene |
|
|
Term
| What modalities is metoclopramide (Reglan) available? |
|
Definition
|
|
Term
| What is the M of A of metoclopramide (Reglan)? |
|
Definition
blocks dopamine receptors in the CTZ
enhances release of acetylcholine to stimulate upper GI motility |
|
|
Term
| What are the side effects of metoclopramide (Reglan)? |
|
Definition
bradycardia
BBW - extrapyramidal symptoms, dystonia |
|
|
Term
| What are the black box warnings for metoclopramide (Reglan)? |
|
Definition
| extrapyramidal symptoms and dystonia |
|
|
Term
| What is used to treat vertigo and motion sickness? |
|
Definition
| anticholinergic agents and antihistamines |
|
|
Term
| What is the M of A of scopolamine (Transderm Scop)? |
|
Definition
| antagonizes acetylcholine at muscarine receptors |
|
|
Term
| What are the side effects of scopolamine (Transderm Scop)? |
|
Definition
| sedation, urinary retention, dry mouth, withdrawal symptoms if used for more than 3 days |
|
|
Term
| What is a counter-indication for scopolamine (Transderm Scop)? |
|
Definition
|
|
Term
| What drugs can have drug-drug interactions with scopolamine (Transderm Scop)? |
|
Definition
| cannabinoids and alpha blockers |
|
|
Term
| What is the M of A of antihistamines? |
|
Definition
|
|
Term
| How long before activity should you take dimenhydrinate (dramamine)? |
|
Definition
|
|
Term
| What is the M of A of meclizine (Antivert)? |
|
Definition
| antagonizes acetylcholine receptors and blocks H-1 (histamine) receptors |
|
|
Term
| What are the side effects of meclizine (Antivert)? |
|
Definition
| sedation, dry mouth, and urinary retention |
|
|
Term
| What antiemetic is used during pregnancy? |
|
Definition
preferably none - don't use until patients present with dehydration, weight loss, or electrolyte abnormalities
pyridoxine (B6) - category A
ginger is also used
antihistamines - doxylamine and promethazine (category C) |
|
|
Term
| what is hyperemesis gravidarum? What is the treatment? |
|
Definition
extreme, persistent nausea and vomiting
during pregnancy that may lead to dehydration
rule out hyperthyroidism, H. pylori
tx: replace fluids and electorlytes
antiemetic therapy |
|
|
Term
| What pregnancy category is pyridoxine? |
|
Definition
|
|
Term
| What drugs are used to combat nausea and vomiting associated with chemotherapy? |
|
Definition
5-HT3 receptor antagonists
(serotonin receptor antagonists) |
|
|
Term
| 5-HT3 receptor antagonists for chemotherapy nausea and vomiting |
|
Definition
dolasetron (Anzemet)
granisetron (Kytril)
ondansetron (Zofran)
palonosetron (Aloxi) |
|
|
Term
| When are 5-HT3 receptor antagonists given to fight nausea and vomiting from chemo? |
|
Definition
| 30 min - 1 hour before treatment |
|
|
Term
| List the 5-HT3 receptor antagonist medications from shortest half life to longest half life. |
|
Definition
dolasetron = 10 min
ondansetron = 5.7 hours
granisetron = 6.2 hours
palonosetron = 40 hours |
|
|
Term
T/F
Palonosetron (Aloxi) was found to be as effective as ondansetron (Zofran). |
|
Definition
|
|
Term
T/F
A single dose of palonosetron (Aloxi) is as effective as 3 dose regimen of granisetron (Kytril) when used with dexamethasone for cisplatin therapy. |
|
Definition
|
|
Term
| How do serotonin agents help with nausea and vomiting? |
|
Definition
| block serotonin receptors in small bowel, vagus nerve, and CTZ |
|
|
Term
| What drugs did serotonin agents replace in treating chemo nausea and vomiting and why? |
|
Definition
replaced antipsychotics to reduce danger of extrapyramidal symptoms in chemo pts
often used with single dose of corticosteroid before first dose of chemo |
|
|
Term
| What is the gold standard for antiemetic therapy during chemo? |
|
Definition
| 5-HT3 receptor antagonists |
|
|
Term
T/F
The 5-HT3 receptor antagonists are equally efficacious. |
|
Definition
|
|
Term
T/F
Palonosetron (Aloxi) has 100x the binding of 5-HT3 as the other 5-HT3 receptor antagonists. |
|
Definition
|
|
Term
| What are the side effects of 5-HT3 receptor antagonists? |
|
Definition
HA - 10-15%
Constipation - 10-15%
rarely: anxiety, dizziness, diarrhea, fatigue |
|
|
Term
T/F
Poor metabolizers of CYP2D6 have a low incidence of CINV. Ultrafast metabolizers have a high incidence. |
|
Definition
|
|
Term
| Which drugs does ondanestron (Zofran) interact with? |
|
Definition
| paroxetine (Paxil) and tramadol (Ultram) |
|
|
Term
T/F
Granisetron (Kytril) with aprepitant (Emend) does not exhibit any drug-drug interactions. |
|
Definition
|
|
Term
|
Definition
substance P antagonist
antiemetic |
|
|
Term
| Which of the 5-HT3 receptor antagonists causes QT prolongation? |
|
Definition
| dolasetron (Anzemet) and ondansetron (Zofran) - higher doses |
|
|
Term
| What is the DOC for the National Comprehensive Cancer Network for triple therapy in high risk patients? |
|
Definition
| palonosetron (Aloxi) - more effective than dolesetron or odansetron |
|
|
Term
| Why is granisetron (Kytril) a good choice for use against CINV? |
|
Definition
can be given IV or PO
length of effect
side effect profile |
|
|
Term
|
Definition
neurokinin-1 receptor antagonist
enhances the effect of 5-HT3 receptor antagonists
selectively antagonizes substance P at NK-1 receptors
given on days 1, 2, and 3
fosaprepitant is the IV/injectable form |
|
|
Term
T/F
5-HT3 receptor antagonists are more effective when administered with a corticosteroid. |
|
Definition
True
methylprednisone (Medrol)
dexamethasone (most often used) |
|
|
Term
| What is the triple therapy used for severe nausea caused by chemotherapy? |
|
Definition
1. Any 5-HT3 receptor antagonist
(usually palonosetron (Aloxi))
2. dexamethasone
3. aprepitant (Emend) |
|
|
Term
| What is delayed emesis from chemo? |
|
Definition
| emesis at least 24 hours after therapy that may last up to 5 days |
|
|
Term
T/F
The subcommittee on acute gastroenteritis recommends not to use antiemetics in pediatrics. |
|
Definition
False - no recommendation
they recommend not using antidiarrheal agents |
|
|
Term
| What are some potential side effects of anti-emetics in pediatrics? |
|
Definition
extrapyramidal symptoms - akinesia, akathisia
seizure |
|
|
Term
| What is the most important part of treating emesis in pediatrics? |
|
Definition
|
|
Term
| Which drug is used to treat emesis in dehydrated children and is considered safe? |
|
Definition
|
|
Term
| What is the DC for nausea and vomiting in pediatrics? |
|
Definition
promethazine (Phenergan)
PR/IM/IV
usually given per rectum |
|
|
Term
| What is the black box warning for promethazine (Phenergan) for pediatrics? |
|
Definition
respiratory depression < 2 years
injection site reactions (if IM) |
|
|
Term
| Name 2 drugs used to treat nausea and vomiting in pediatric patients. |
|
Definition
promethazine (Phenergan) - DOC
trimethobenzamide (Tigan) |
|
|
Term
| If untreated, what proportion of patients who undergo surgery will have PONV within 24 hours? |
|
Definition
|
|
Term
T/F
PONV is the leading cause of hospital admission after a planned ambulatory surgery. |
|
Definition
|
|
Term
| What are the possible risks of PONV? |
|
Definition
| aspiration, suture dehiscence, esophageal rupture, and bilateral pneumothoraxes |
|
|
Term
| Risk for PONV depend on what 3 things? |
|
Definition
patient
anesthetic
surgical procedure |
|
|
Term
| What are the patient risk factors for PONV? |
|
Definition
female
nonsmoker
Hx of motion sickness, emesis during pregnancy, or PONV |
|
|
Term
| What are the anesthetic risk factors for PONV? |
|
Definition
Use of volatile anesthetics
use of nitrous oxide
use of opiods - perioperatively |
|
|
Term
| What are the surgical procedure risk factors for PONV? |
|
Definition
duration of surgery
type of procedure - abdominal, gynecologic, ENT |
|
|
Term
| What are the most important risk factors for PONV? |
|
Definition
female
nonsmoker
hx of motion sickness, emesis during pregnancy or PONV
use of opiods perioperatively |
|
|
Term
|
Definition
a score to predict the probabitlity of POBV
assigns 1 point each to risk factors:
female
nonsmoker
history of PONV or motion sickness
postoperative opiod tx is planned
Score
0 - 10%
1 - 21%
2 - 39%
3 - 61%
4 - 78% |
|
|
Term
| What are the rescue agents used for PONV? |
|
Definition
ondansetron (Zofran) - DOC in PACU
promethazine (Phenergan) - 2nd or 3rd line
dexamethasone |
|
|
Term
T/F
Inhaled isopropyl alcohol is used to treat PONV and is equally as efficacious as ondansetron. |
|
Definition
|
|
Term
| In the low risk patient, how is PONV treated? |
|
Definition
No prophylaxis
5-HT3 receptor antagonists used as rescue meds |
|
|
Term
| In the moderate risk patient, how is PONV treated? |
|
Definition
droperidol (Inapsine) prophylaxis
5-HT3 receptor antagonists for breakthrough nausea |
|
|
Term
| In the high risk patient, how is PONV treated? |
|
Definition
droperidol (Inapsine) prophylaxis
dexamethasone prophylaxis
5-HT3 receptor antagonists for breakthrough nausea |
|
|
Term
|
Definition
anesthetic
may block dopamine receptors in the caudate nucleus and nucleus accumbens
lasts 2-4 hours, but alteration of alertness may last 12 hours
Binding of GABA receptors in CTZ - antiemetic effect |
|
|
Term
|
Definition
dolasetron (Anzemet)
granisetron (Kytril)
ondansetron (Zofran)
palonosetron (Aloxi) |
|
|
