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 Formulary Chapter 4: Central nervous system - Full Chapter
04.06  Expand sub section  Drugs used in nausea and vertigo
 note 

Antiemetics should only be prescribed when the cause is known, otherwise they may delay diagnosis especially in children.

Some antiemetics can cause unpleasant side effects which may cause more problems than the original nausea and vomiting.

Please see under each option for indications and first/ second/ third line choices.

Order below alphabetical and indicative of the preferred order of use.

Some can carry an anticholinergic burden that can be problematic when combined with other drugs.

Special Groups:

Vomiting in pregnancy

Nausea in pregnancy is generally mild and does not require treatment.

Occasionally where vomiting is severe an antihistamine such as promethazine may be used

If severe vomiting persists longer than 48 hours specialist input is recommended. Hyperemesis gravidarum may require IV fluids and electrolyte support.

Post operative nausea and vomiting

Risks should be assessed prior to operation. Various factors may affect post-operative nausea and vomiting

Treatment depends on risk, type of surgery and anaesthetic used.

This should be managed prior to discharge. Continuation of antiemetics post discharge is rarely required.

Cytotoxic Chemotherapy Antiemetics required as a result of chemotherapy should be managed through the individuals regimen.
Palliative Care For guidance in this area please see Isle of Wight Palliative Care Symptom Control Guidelines 2018

 

Cyclizine
(Oral and IM/IV)
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First Choice
Green

First line for Opioid induce nausea and vomiting (excluding Palliative care) & Postoperative nausea and vomiting

Second line for motion sickness

Antihistamine antiemetic

Some potential for abuse

 

 
Cinnarizine
(Oral)
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First Choice
Green

First line

  • Labyrinthine vertigo
  • Meniere's disease (short term acute treatment)

Sedating antihistamine

 
DomperidoneBlack Triangle
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First Choice
Green

First line for gastric stasis

Second line for Migraine

MHRA: Risk of cardiac side effects. Lowest possible dose for shortest period.

Adults and adolescents over 12.

Does not cross the blood brain barrier therefore less likely to cause sedation and dystonic reactions

 
Hyoscine Hydrobromide
(tablets/ patches/ SC)
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First Choice
Green

First line - Tablets OTC option for motion sickness

Other indications include:

Patches are option when oral route not available - 1 patch every 72 hours

 
Metoclopramide
(Oral and IM/IV)
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First Choice
Green

First line - migraine

Second line - postoperative nausea and vomiting

MHRA - Risk of neurological adverse effects.

Over 18's only for max 5 days.

Can induce acute dystonic reactions

 

 
Prochlorperazine
(Oral/ IM/ SC)
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Second Choice
Green

Second line for:

  • Opioid induced nausea and vomiting (not palliative care)
  • Labyrinthine vertigo
  • Meniere's Disease (acute short term treatment)

Prochlorperazine has risk of acute dystonic reactions.

Long term use may cause TD in elderly

 
   
Betahistine Dihydrochloride
(Oral)
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Third Choice
Green

Third Line:

  • Meniere's disease - prophylaxis in confirmed diagnosis

 

 
   
Levomepromazine
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Formulary

See palliative care guidelines for dosing and indications

 
   
Aprepitant (Emend®)
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Restricted Drug Restricted
Red

Prevention of late onset nausea and vomiting following cisplatin at doses greater then 70mg/m2

Onset is 2-3 days post treatment and very severe.

Approved by Cancer Network evaluation committee

Approved for NSCLC

 
   
Droperidol (Xomolix®)
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Restricted Drug Restricted
Red

For use by anaesthetists in theatre, recovery and ITU only

 
   
Granisetron
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Formulary
Red

Short term use

To be supplied by CHemotherapy service at specialist request

 
   
Ondansetron
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Formulary
Green

Peri and post operative nausea and vomiting

Short term use only

 
   
04.06  Expand sub section  Phenothiazines and related drugs
04.06  Expand sub section  5HT3 antagonists
 ....
Key
note Notes
Section Title Section Title (top level)
Section Title Section Title (sub level)
First Choice Item First Choice item
Non Formulary Item Non Formulary section
Restricted Drug
Restricted Drug
Unlicensed Drug
Unlicensed
Track Changes
Display tracking information
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Link to adult BNF
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Link to children's BNF
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Link to SPCs
SMC
Scottish Medicines Consortium
Cytotoxic Drug
Cytotoxic Drug
CD
Controlled Drug
High Cost Medicine
High Cost Medicine
Cancer Drugs Fund
Cancer Drugs Fund
NHSE
NHS England
Homecare
Homecare
CCG
CCG

Traffic Light Status Information

Status Description

Green

Drugs that may be initiated, stabilised and maintained by primary, secondary or tertiary care Secondary and tertiary care prescribing may be continued by primary care. [this does not indicate first/second line choice]  

Green Hospital

Items used by the Hospital but would not normally be continued into primary care. Primary care prescribers can change to GREEN first or second.   

Green plus

Initiation of drugs by primary care following written advice from secondary/ tertiary care advice. These can then be continued by primary care with little or no monitoring requirements.  

Yellow

Drugs that may be continued in primary care following initiation and stabilisation in secondary/tertiary care  

Advice

Drugs which require initiation by secondary or tertiary care. These should be continued until patient stabilised. Once stable an agreement with the GP should be met to take over prescribing and any monitoring between specialist reviews. The specialist will provide prescribing guidelines for the management of these patients.  

Amber

Items requiring a shared care agreement. These items should be initiated and stabilised by secondary or tertiary care. The GP should only be asked to take over prescribing through a formal shared care agreement. Secondary care will be expected to continue prescribing until the agreement is made.  

Red

Hospital/ Trust ONLY. These are items the secondary and tertiary care are responsible for prescribing and will need to continue to prescribe for long term maintenance. These items will NOT be prescribed in primary care. But primary care should be informed the patient is receiving these items. This will include NHSE funded items requiring repatriation.  

GP - Black

Items covered by NHSE ‘Should not prescribe in primary care list’ – See CCG policy on Drugs of limited clinical value  

GP - Grey

Grey List: Items covered by NHSE ‘Should not prescribe in primary care list’ that are not to be routinely prescribed but may be suitable in a defined population – See CCG policy on Drugs of limited clinical value  

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