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Video etiologi mual muntah....

1) Chemoreceptor Trigger Zone2) Vestibular3) Cortex4) GI/peripheral pathways

Etiology of Nausea

Yang perlu dikaji....

Onset Frequency Relationship to eating Relationship to meds Current anti-emetics Chronic vs. Progressing Alleviating factors Severity (scale: 1-10) Goal

Penyebab Umum.....

* Drugs (chemo, opioids, NSAIDS, SSRIs)* Constipation* Gastroparesis* GERD* Uremia* Infection

* Pain* Dehydration* Electrolyte imbalance (high Ca)* Endocrine dysfunction* Increased ICP (intra Cranial Pressure)* Anxiety

Penyebab lain...

* Pregnancy* Cyclic Vomiting Syndrome* Hepatic disease* Migraine headaches* Following surgery* Myocardial infarction* Violent coughing* Hangover

Non PharmacologicTreatment

•Reassurance/relaxation•Correct dehydration, correct electrolyte distrubances•correct constipation•Oral hygeine•Reduce portions and use cold food•Reduce or eliminate tube feedings•Avoid odors

Matching Etiology with Mechanism

1) Chemoreceptor Trigger Zone2) Vestibular3) Cortex4) GI/peripheral pathways

1) D2 and 5HT3 antagonists2) Antihistamines and Anti-muscarinics 3) Antihistamines and Anxiolytics4) D2 and 5HT3 antagonists

CHEMOTHERAPY-INDUCED NAUSEA AND VOMITING (CINV) Depending on Chemotherapy agents

SSRI (Selective Serotonin Receptor Inhibitors )

SSRIs act by blocking presynaptic serotonin receptors on sensory vagal fibers in the gut wall.

SSRIs dolasetron, granisetron, ondansetron, and palonosetron

The most common side effects associated with these agents are constipation, headache

Substance P/Neurokinin 1 Receptor Antagonists

Substance P is a peptide neurotransmitter in the NK family whose preferred receptor is the NK1 receptor. Substance P is believed to be the primary mediator of the delayed phase of CINV and one of two mediators of the acute phase of CINV.

Aprepitant is the first approved member of this class of drugs and is indicated as part of a multiple drug regimen for prophylaxis of nausea and vomiting associated with high-dose cisplatin-based chemotherapy

Corticosteroids

Dexamethasone has been used successfully in the management of chemotherapy-induced nausea and vomiting (CINV) and postoperative nausea and vomiting (PONV), either as a single agent or in combination with selective serotonin reuptake inhibitors (SSRIs).

For CINV, dexamethasone is effective in the prevention of both cisplatin-induced acute emesis and when used alone or in combination for the prevention of delayed nausea and vomiting associated with CINV

POSTOPERATIVE NAUSEA AND VOMITING (PONV)

DISORDERS OF BALANCE

Beneficial therapy for patients with nausea and vomiting associated with disorders of balance can reliably be found among the antihistaminic anticholinergic agents.

Neither the antihistaminic nor the anticholinergic potency appears to correlate well with the ability of these agents to prevent or treat the nausea and vomiting associated with motion sickness.

ANTIEMETIC USE DURING PREGNANCY

Initial management of nausea and vomiting of pregnancy often involves dietary changes and/or lifestyle modifications.

Pyridoxine (10 to 25 mg one to four times daily) is recommended as firstline therapy.

If symptoms persist, addition of a histamine-1 receptor antagonist, such as dimenhydrinate, diphenhydramine, or meclizine, is recommended

ANTIEMETIC USE IN CHILDREN

For children receiving chemotherapy of high or moderate risk, a corticosteroid plus SSRI should be administered. The best doses or dosing strategyhas not been determined.

For nausea and vomiting associated with pediatric gastroenteritis, thereis greater emphasis on rehydration measures than on pharmacologic intervention.

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