4.6.1 Drugs for the treatment of nausea and vomiting

For migraine see section 4.7.4

ChoiceDrugDosage
1st choicesProchlorperazine tablets 5mgDose:
Nausea and vomiting, acute attack, 20mg initially then 10mg after 2 hours; prevention 5-10mg 2-3 times daily
3mg tablets (buccal)

Reserve buccal tablets for active vomiting

1-2 tablets twice daily; tablets are placed high between upper lip and gum and left to dissolve

Short-term use only

Or
Domperidone tablets 10mg; suspension 5mg/5ml

Dose: 10mg up to 3 times daily; max 30mg daily

Max length of treatment 1 week - see restrictions below

Or
Metoclopramide tablets 10mg; oral solution 5mg/5ml; injection 5mg/ml

Dose: Orally, or by intramuscular or intravenous injection, 10mg (5mg in 15-19 year olds under 60kg) three times daily

Max length of treatment 5 days - see restrictions below

Prescribing Notes

  • Metoclopramide is associated with neurological effects such as short-term extrapyramidal disorders and tardive dyskinesia. These side-effects usually occur in the young (especially girls and young women) and the very old; it is best avoided, if possible, in patients under 20 years old.
  • Metoclopramide should only be prescribed for short-term use (up to 5 days) for prevention of postoperative nausea and vomiting; radiotherapy-induced nausea and vomiting; delayed (but not acute) chemotherapy-induced nausea and vomiting; and symptomatic treatment of nausea and vomiting, including that associated with acute migraine (where it may also be used to improve absorption of oral analgesics). For further information click https://www.gov.uk/drug-safety-update/metoclopramide-risk-of-neurological-adverse-effects.
  • Long-term metoclopramide and prochlorperazine may cause tardive dyskinesia in the elderly.
  • Domperidone does not cross the blood brain barrier; it is less likely than metoclopramide and prochlorperazine to cause sedation or dystonic reactions.
  • Domperidone is associated with a small risk of serious cardiac side effects. Its use is now restricted to the relief of symptoms of nausea and vomiting and the dosage and duration of use have been reduced. Treatment should generally only be given for up to one week. Domperidone is contraindicated in those with underlying cardiac conditions and other risk factors. Risks are higher in people older than 60 years. For further information click https://www.gov.uk/drug-safety-update/domperidone-risks-of-cardiac-side-effects.
  • Note that cyclizine has potential for abuse.
  • Ondansetron should be avoided in patients with congenital long QT syndrome and used with caution in patients with risk factors for QT interval prolongation or cardiac arrhythmias. These include:
    • electrolyte abnormalities
    • congestive heart failure
    • bradyarrhythmias
    • use of other medicines that prolong the QT interval (including cytotoxic drugs), or may lead to electrolyte abnormalities
    • use of medicines which lower the heart rate
  • Hypokalemia and hypomagnesemia should be corrected prior to ondansetron administration.