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4.4 Nausea and labyrinth disorders

First line drugs Second line drugs Specialist drugs Secondary care drugs

Traffic light status (TLS) explained:

  • Green: Routine prescribing within licensed indication
  • Amber 1: specialist recommendation followed by GP initiation and continuation
  • Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
  • Amber 3: specialist initiation and stabilisation followed by GP continuation
  • Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
  • Red: Hospital or specialist prescribing only

 

Important Notes:

  • Anti-emetics should be prescribed only when the cause of vomiting is known because otherwise they may delay diagnosis, particularly in children.
  • The underlying cause of the nausea should be treated before starting treatment with an anti-emetic wherever possible.
  • Haloperidol and levomepromazine are also used for the relief of nausea.
  • Palliative Care. Anti-nausea drugs (including haloperidol) should be prescribed prophylactically when giving opioid analgesics in terminal care.
  • Chlorpromazine and trifluoperazine may also be used.  

 

Antihistamines

Cinnarizine

  • Tablets 15mg  

 

Cyclizine

  • Tablets 50mg
  • Injection 50mg in 1mL  

 

 

Antimuscarinics 

Hyoscine hydrobromide 

  • Chewable Tablets 150 micrograms, 300 micrograms
  • Patch 1mg per 72hrs
  • Injection 400 micrograms in 1mL 

 

 

Antipsychotics (first-generation)

Levomepromazine (Amber 2)

  • Tablets 25mg
  • Injection 25mg/mL  

Notes:

  • For palliative care use

 

 

Dopamine receptor antagonists

Domperidone

  • Tablets 10mg
  • Oral suspension 5mg in 5mL

Notes

  • For short term use for nausea and vomiting only as per MHRA advice.
  • MHRA advice: Domperidone - risks of cardiac side effects (Dec 2014)
  • The maximum treatment duration should not exceed one week
  • 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

 

 

 

Metoclopramide hydrochloride

  • Tablets 10mg
  • Syrup 5mg in 5mL
  • Injection 10mg in 2mL

Notes:

  • Traffic light status: Green for Palliative Care and Amber 2 for all other indications

 

 

  • Not recommended for patients under 20 years of age due to risk of dystonic reactions.

 

 

5HT3 Receptor Antagonists

Ondansetron (Amber 1)

  • Tablet 4mg  
  • Tablet 8mg
  • Syrup sugar free 4mg in 5mL
  • Injection 4mg in 2mL, 8mg in 4mL

Notes:

 

 

 

 

 

Meniere's disease 

Histamine Analogues 

Betahistine dihydrochloride

  • Tablet 8mg, 16mg

Notes:

  • Vertigo and nausea associated with Ménière’s syndrome and middle ear surgery may be difficult to treat. Hyoscine, antihistamines, and phenothiazines (such as prochlorperazine) are effective in the prophylaxis and treatment of such conditions.
  • Betahistine is licensed solely in treatment of Ménière’s syndrome and prescribers should ensure that betahistine is not being prescribed to treat side effects of other medication.  

 

 

 

 

Traffic light status (TLS) explained:

  • Green: Routine prescribing within licensed indication
  • Amber 1: specialist recommendation followed by GP initiation and continuation
  • Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
  • Amber 3: specialist initiation and stabilisation followed by GP continuation
  • Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
  • Red: Hospital or specialist prescribing only

Return to Chapter: 4. Nervous System

Last updated by: Dupe Fagbenro on 02-01-2019 14:41