Nausea and vomiting
Nausea and vomiting (acute attack), 10mg, 8 hourly.
Nausea and vomiting (acute attack), 10mg, 8 hourly.
30mg every 12 hours.
Prescribing Notes:
- Anti-emetics may only be necessary for short-term management of nausea & vomiting. Patients should be reviewed regularly and treatment discontinued when appropriate.
- Domperidone does not cross the blood brain barrier; it is less likely than metoclopramide and prochlorperazine to cause sedation or dystonic reactions.
- The MHRA have advised that domperidone should only be prescribed at the lowest effective dose for the shortest period of time. This is due to small increased risk of serious cardiac side effects. Product literature should be consulted for further information including those at risk.
History Notes
27/10/2022
East Region Formulary content agreed.
Orally, 50mg up to 3 times daily.
By intramuscular or intravenous injection, 50mg up to 3 times daily.
Acute attack, 20mg then 10mg after 2 hours; prevention, 5-10mg 2-3 times daily.
1-2 tablets twice daily.
By deep intramuscular injection, 12.5mg when required followed if necessary after 6 hours by oral dose, as above.
By rectum, 25mg followed if necessary after 6 hours by oral dose, as above.
By rectum, 25mg followed if necessary after 6 hours by oral dose, as above.
Prescribing Notes:
- Note that cyclizine has potential for abuse.
- Surgical patients receiving morphine should be prescribed prophylactic anti-emetics such as cyclizine or prochlorperazine.
- Patients suffering an acute myocardial infarction should be given intravenous morphine and metoclopramide concomitantly. Cyclimorph (containing morphine and cyclizine) is an alternative but repeated doses are not recommended.
- Prochlorperazine should not be prescribed to patients with Parkinson’s disease or Dementia with Lewy bodies.
History Notes
11/05/2023
Prochlorperazine 5mg/5ml oral solution removed as discontinued.
27/10/2022
East Region Formulary content agreed.
Prescribing Notes:
- Refer to the Scottish Palliative Care Guidelines.
History Notes
27/10/2022
East Region Formulary content agreed.
Metoclopramide can cause acute dystonic reactions, prescribers should discuss with patients prior to prescribing.
10mg for 1 dose, to be administered as soon as migraine symptoms develop.
10mg for 1 dose, to be administered as soon as migraine symptoms develop.
10mg for 1 dose, to be administered as soon as migraine symptoms develop, given by intravenous injection over at least 3 minutes.
10mg for 1 dose, to be taken as soon as migraine symptoms develop, maximum 30mg a day.
1-2 tablets for 1 dose, to be taken as soon as migraine symptoms develop.
By deep intramuscular injection, 12.5mg when required followed if necessary after 6 hours by oral dose, as above.
By rectum, 25mg followed if necessary after 6 hours by oral dose, as above.
By rectum, 25mg followed if necessary after 6 hours by oral dose, as above.
Prescribing Notes:
- See also Migraine recommendations.
- Anti-emetics may be given in combination with an analgesic for migraine symptoms in an acute attack.
- Metoclopramide or prochlorperazine may be necessary to relieve nausea and have the advantage of promoting gastric emptying and normal peristalsis.
- Anti-emetics are recommended to be given as soon as possible after migraine symptoms develop, the dose is given as a one-off in an acute attack.
- Metoclopramide can cause acute dystonic reactions, usually in the young (especially girls and young women) and the very old. Benzatropine (benztropine) may be given by intramuscular or intravenous injection if acute dystonic reactions occur (dose, 1-2mg repeated if symptoms reappear). If benzatropine is not readily available, then intravenous diazepam may be prescribed.
- Long-term metoclopramide and prochlorperazine may cause tardive dyskinesia in the elderly.
- Metoclopramide should not be used regularly due to the risk of extrapyramidal side-effects. Due to risk of neurological side-effects, metoclopramide is now only licensed for limited indications and the maximum duration of treatment is 5 days in all patients. For further advice, see MHRA Drug Safety Update, August 2013.
- Metoclopramide is preferred when patient sedation should be avoided. Prochlorperazine may be preferred when sedation is required.
- Prochlorperazine buccal tablets may be a suitable alternative formulation for patients who are vomiting.
- Prochlorperazine and metoclopramide should not be prescribed to patients with Parkinson’s disease or Dementia with Lewy bodies.
History Notes
11/05/2023
Prochlorperazine 5mg/5ml oral solution removed as discontinued.
27/10/2022
East Region Formulary content agreed.
Orally, 50mg up to 3 times daily.
By intramuscular or intravenous injection, 50mg 3 times daily.
10mg 3 times daily and reduce to 5mg 3 times daily after improvement in symptoms.
1-2 tablets twice daily.
By deep intramuscular injection, 12.5mg when required followed if necessary after 6 hours by oral dose, as above.
Prescribing Notes:
- Nausea in the first trimester of pregnancy does not usually require drug treatment. If vomiting is severe, an anti-emetic may be prescribed and specialist advice sought after 24-48 hours if symptoms do not settle.
- Management of hyperemesis gravidarum includes hospitalisation, intravenous fluid and electrolyte replacement, oral thiamine supplements (sometimes oral pyridoxine), and anti-emetics until normal diet can be resumed.
- Stress management, acupuncture and massage can be helpful.
- High dose prochlorperazine (25mg 2-3 times daily by the rectal route) is used in hospital for 3-4 days only, reverting to the oral route as soon as possible.
- When symptoms improve, slowly reduce the antiemetic dose over a week. Do not stop suddenly.
- Women should be advised to ensure adequate fluid intake and to eat small meals frequently.
- Recent epidemiological studies suggest exposure to ondansetron during the first trimester of pregnancy is associated with a small increased risk of the baby having a cleft lip and/or cleft palate. See MHRA January 2020.
- Prochlorperazine should not be prescribed to patients with Parkinson’s disease or Dementia with Lewy bodies.
History Notes
11/05/2023
Prochlorperazine 5mg/5ml oral solution removed as discontinued.
27/10/2022
East Region Formulary content agreed.
Initially 8mg, dose to be taken 1-2 hours before treatment, then 8mg every 12 hours for up to 5 days.
Initially 8mg, dose to be taken 1-2 hours before treatment, then 8mg every 12 hours for up to 5 days.
Initially 8mg, dose to be taken 1-2 hours before treatment, then 8mg every 12 hours for up to 5 days.
Initially 8mg, dose to administered immediately before treatment, then (by mouth) 8mg every 12 hours for up to 5 days.
Initially 8mg, dose to administered immediately before treatment, then (by mouth) 8mg every 12 hours for up to 5 days.
Initially 8mg, dose to be taken 1-2 hours before treatment, then 8mg every 12 hours for up to 5 days.
Initially 8mg, dose to be taken 1-2 hours before treatment, then 8mg every 12 hours for up to 5 days.
Orally, 50mg up to 3 times daily.
By intramuscular or intravenous injection, 50mg up to 3 times daily.
Orally, 4mg as a one-off dose.
By intramuscular or intravenous injection, 3.3mg as a one-off dose.
For use in anticipated problematic post operative nausea and vomiting.
0.625-1.25mg dose to be given 30 minutes before end of surgery, then every 6 hours as required.
Prescribing Notes:
- Consider cause of nausea and the mechanism of action of appropriate anti-emetic.
- Review the response to anti-emetics already prescribed and use anti-emetics with different actions (i.e. cyclizine and prochlorperazine) when more than one anti-emetic is necessary.
- Avoid using combinations of anti-emetics with antagonistic actions (i.e. cyclizine and metoclopramide).
- Nausea and vomiting which has not responded to treatment with first line antiemetics may resolve with a short course of ondansetron (use outwith the perioperative period / chemotherapy or radiotherapy is unlicensed).
- A trial of withdrawal of prokinetic therapy should be tried in all patients. A full discussion should be had with the patient ensuring they are aware of the risks and benefits of prolonged treatment. The discussion should be documented in the patient’s notes.
- The ‘Melt’ formulation of ondansetron is relatively expensive compared to standard tablets and should only be considered when patients are continuously vomiting and are unable to take the standard tablets.
History Notes
27/10/2022
East Region Formulary content agreed.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
Prescribing Notes:
- Anti-emetics are generally only prescribed when the cause of vomiting is known because otherwise, they may delay diagnosis, particularly in children. If anti-emetic drug treatment is indicated, the drug is chosen according to the aetiology of vomiting. Domperidone acts at the chemoreceptor trigger zone.
- Domperidone does not cross the blood brain barrier; it is less likely than metoclopramide and prochlorperazine to cause sedation or dystonic reactions.
- For treatment of gastric stasis or delayed gastric emptying in children see the formulary recommendations for Treatment of gastric stasis.
- The MHRA have highlighted that domperidone may prolong the QT interval in adults, although no current evidence exists in children. Caution should be exercised in the co-prescribing of medicines which are known to prolong the QT interval. Key elements of the MHRA advice is domperidone should be used at the lowest effective dose for the shortest possible time. MHRA advice also notes that due to no evidence of benefit over placebo, domperidone is no longer licensed in under 12 years of age. For more information refer to MHRA Advice Domperidone 16 December 2019.
- Domperidone treatment is contraindicated in patients with underlying cardiac conditions and other risk factors. Consult prescribing literature for further information.
History Notes
09/11/2023
East Region Formulary content agreed.
The orodispersible ondansetron formulation is relatively expensive compared to standard tablets and should only be considered when patients are continuously vomiting and are unable to take the standard tablets.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
Prescribing Notes:
- Note that cyclizine has potential for abuse.
- Ondansetron is more effective than metoclopramide in treating opiate-induced nausea and vomiting in children and has a more favourable side-effect profile.
- Surgical patients receiving morphine should be prescribed prophylactic anti-emetics such as ondansetron or cyclizine.
History Notes
09/11/2023
East Region Formulary content agreed.
Prescribing Notes:
- Refer to the BNFc and for more detailed recommendations on the management of nausea and vomiting in paediatric palliative care refer to The Association of Paediatric Palliative Medicine resources.
- The treatment of children with opioid induced nausea and vomiting (palliative care) is under specialist management. Specialists in paediatric palliative care will provide a supporting anticipatory care plan for individual patients with details of treatment. Supplies will be provided initially by secondary or tertiary care providers. In some instances, following specialist initiation, it may be appropriate for ongoing supplies to be provided in a primary care setting.
History Notes
09/11/2023
East Region Formulary content agreed.
Dose as per BNFc.
Dose as per BNFc.
Dose as per BNFc.
Prescribing Notes:
- Anti-emetics may only be necessary for short-term management of nausea & vomiting. Patients should be reviewed regularly and treatment discontinued when appropriate.
- See also Migraine recommendations.
- Anti-emetics may be given in combination with an analgesic for migraine symptoms in an acute attack.
- Anti-emetics are recommended to be given as soon as possible after migraine symptoms develop, the dose is given as a one-off in an acute attack.
History Notes
09/11/2023
East Region Formulary content agreed.
The orodispersible ondansetron formulation is relatively expensive compared to standard tablets and should only be considered when patients are continuously vomiting and are unable to take the standard tablets.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For use in anticipated problematic post operative nausea and vomiting.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
Prescribing Notes:
- For guidance on post operative nausea and vomiting refer to the Association of Paediatric Anaesthetists of Great Britain and Ireland Guidelines on the Prevention of Post-operative Vomiting in Children.
- Consider cause of nausea and the mechanism of action of appropriate anti-emetic.
- Review the response to anti-emetics already prescribed and use anti-emetics with different actions (i.e. cyclizine) when more than one anti-emetic is necessary.
- Avoid using combinations of anti-emetics with antagonistic actions (i.e. cyclizine and metoclopramide).
- Nausea and vomiting which has not responded to treatment with first line anti-emetics may resolve with a short course of ondansetron (use outwith the perioperative period / chemotherapy or radiotherapy is unlicensed).
- Note that cyclizine has potential for abuse.
- Ondansetron is more effective than metoclopramide in treating opiate-induced nausea and vomiting in children and has a more favourable side-effect profile.
- Surgical patients receiving morphine should be prescribed prophylactic anti-emetics such as ondansetron or cyclizine.
History Notes
09/11/2023
East Region Formulary content agreed.
The first line setting for access to treatments for motion sickness (i.e. travel sickness) is via Pharmacy First.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
Prescribing Notes:
- Refer to pharmacy first travel sickness recommendations for access to treatments for motion sickness (i.e. travel sickness) via the Pharmacy First Service.
- Anti-emetics should be given to prevent motion sickness rather than after nausea or vomiting develop. Hyoscine hydrobromide is licensed to prevent motion sickness symptoms such as nausea, vomiting, and vertigo. Antihistamine drugs e.g. cinnarizine may also be effective.
History Notes
09/11/2023
East Region Formulary content agreed.
Dose according to age and product licence.
Dose according to age and product licence.
Dose according to age and product licence.
History Notes
27/10/2020
Content migrated from ‘East Region Formulary: Pharmacy First - supporting minor ailments’ document.