Key notes on symptom control issues in Palliative Care

Chemical or drug induced

Chemical induced nausea & vomiting
Step one	Diagnose the cause and treat if possible	Start regular haloperidol
Step two	Add in regular cyclizine to haloperidol
Step three	Stop haloperidol & cyclizine and try levomepromazine	Ask for help

This can be iatrogenic due to drugs such as morphine sulphate, NSAIDs or anti-depressants, or due to biochemical abnormalities such as uraemia, jaundice, or hypercalcaemia. All these affect the chemoreceptor trigger zone in the brain to produce nausea and or vomiting.

Treat reversible causes where possible

Drug of choice: Haloperidol 2.5-5mg sc. initially then 3-5mg orally as single dose. This may be combined with cyclizine 75-150mg over 24 hours in a syringe driver to maximise response.

Second line: Levomepromazine 12.5–25mg nocte or 12.5-25mg over 24hours subcutaneously in a syringe driver.