Title: Trouble treating your gastroparetic? Consider an antipsychotic! (Submitted by Dr. Bradford Schwartz)<br/>Author: Tu Carol Nguyen<br/><a href='http://umem.org/profiles/faculty/1234/'>[Click to email author]</a><hr/><div class="gmail_quote" style="font-family: arial, sans-serif; font-size: 12.8px;">
<font face="tahoma, sans-serif">Haloperidol has a higher D2 receptor antagonist effect than standard antiemetic treatment agents such as metoclopramide. In addition, newer antipsychotic agents such as Olanzapine have a high affinity at multiple antiemetic sites such as the dopamine and serotinergic receptors.</font></div>
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<font face="tahoma, sans-serif">While formal RCT's are still in the works, multiple sources including palliative care, emergency medicine, and pain journals support their use in refractory emesis.</font><br />
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<span class="im"><strong><span style="font-family: tahoma, sans-serif;">Consider Haloperidol 3-5 mg IV. </span></strong><br />
<span style="font-family: tahoma, sans-serif;">Check an EKG for long QTc prior to use. Consider dose reduction of haloperidol in those with hepatic impairment. Also consider dose reduction in patients taking c</span></span><span class="im" style="color: rgb(80, 0, 80);"><font color="#000000" style="font-family: tahoma, sans-serif;">arbamazepine, phenytoin, phenobarbital, rifampicin, or quinidine due to that pesky CYP3A4 inhibition.</font><span style="font-family: tahoma, sans-serif; color: rgb(0, 0, 0);"> </span></span><br />
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<strong><font face="tahoma, sans-serif"><font color="#000000">Consider Olanzapine 2-5 mg IV.</font></font></strong></div>
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<font face="tahoma, sans-serif"><font color="#000000">Several case reports have shown a higher rate of success with olanzapine for refractory emesis. Olanzapine has similar precautions as those to haloperidol (EKG, hepatic impairment), although it's CYP drug interactions are less common. </font>Additionally, use olanzapine cautiously in hyperglycemic patients as there are several case reports of olanzapine prompting episodes of DKA. Consider frequent blood sugar checks or small doses of insulin in hyperglycemic patients. </font></div>
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<strong><font face="tahoma, sans-serif">Take home points:</font></strong></div>
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<font face="tahoma, sans-serif">Consider the antipsychotic agents Haloperidol or Olanzapine for patients with refractory emesis, they may be more effective than traditional antiemetics. </font></div>
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<span style="font-family: tahoma, sans-serif; font-size: 12.8px;">Get an EKG prior to administration to check for QTc prolongation. As the classical and atypical antipsychotic agents are sedating, use caution in conjunction with other sedating medications (such as benzodiazepines). </span><span style="font-family: tahoma, sans-serif; font-size: 12.8px;"> </span></div>
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<fieldset><legend>References</legend>
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<span class="im" style="color: rgb(80, 0, 80);"><span style="font-family: tahoma, sans-serif;">Glare P, Miller J, Nikolova T, Tickoo R. Treating nausea and vomiting in palliative care: a review. Clin Interv Aging. 2011;6:243-59.</span><br />
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<span style="font-family: tahoma, sans-serif;">Prommer E. Olanzapine: palliative medicine update. Am J Hosp Palliat Care. 2013 Feb;30(1):75-82</span><br />
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<span style="font-family: tahoma, sans-serif;">Pommer E. Role of Haloperidol in Palliative Medicine: An Update. Am J Hosp Palliat Care. 2012 Jun;29(4):295-301</span></span><br />
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<span class="im" style="color: rgb(80, 0, 80);"><span class="m_2559552384157457937gmail-"><font face="tahoma, sans-serif">Navari RM, Nagy CK, Gray SE. The use of olanzapine versus metoclopramide for the treatment of breakthrough nausea and vomiting in patients receiving highly emetogenic chemotherapy. Support Care Cancer. 2013 Jun;21(6):1655-63.</font></span></span></div>
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<span class="im" style="color: rgb(80, 0, 80);"><font face="tahoma, sans-serif"><span style="background-color: rgb(252, 252, 252); color: rgb(51, 51, 51); letter-spacing: 0.102px;">Jackson WC, Tavernier L (2003) Olanzapine for intractable nausea in palliative care patients. J Palliat Med 6:251–255</span> <br />
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<font face="tahoma, sans-serif">Bradford MV, Glode A. Olanzapine: An antiemetic option for chemotherapy-induced nausea and vomiting. J Adv Pract Onc. <span style="color: rgb(0, 0, 0);">2014 Jan;5(1):24-9.</span></font></div>
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<font color="#000000" face="tahoma, sans-serif">Chan EW, Knott, JC, Taylor DM, Phillips GA, Kong DC. Intravenous olanzapine- another option for the acutely agitated patient. Emery Med Australas. 2009 Jun; 21 (3) 241-2</font></div>
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<span class="m_2559552384157457937gmail-cit-auth" style="margin: 0px; padding: 0px; border: 0px; outline: 0px; vertical-align: baseline; font-size: 12.96px; line-height: inherit; color: rgb(0, 0, 0);">Cole JB et al.</span><span style="color: rgb(0, 0, 0); font-size: 12.96px;"> </span><span class="m_2559552384157457937gmail-cit-article-title" style="margin: 0px; padding: 0px; border: 0px; outline: 0px; vertical-align: baseline; font-size: 12.96px; line-height: inherit; color: rgb(0, 0, 0);">A prospective observational study of patients receiving intravenous and intramuscular olanzapine in the emergency department.</span><span style="color: rgb(0, 0, 0); font-size: 12.96px;"> </span><span class="m_2559552384157457937gmail-cit-source" style="margin: 0px 0.1em 0px 0px; padding: 0px; border: 0px; outline: 0px; vertical-align: baseline; font-size: 12.96px; font-style: italic; line-height: inherit; color: rgb(0, 0, 0);">Ann Emerg Med</span><span style="color: rgb(0, 0, 0); font-size: 12.96px;"> </span><span class="m_2559552384157457937gmail-cit-pub-date" style="margin: 0px; padding: 0px; border: 0px; outline: 0px; vertical-align: baseline; font-size: 12.96px; line-height: inherit; color: rgb(0, 0, 0);">2016</span><span style="color: rgb(0, 0, 0); font-size: 12.96px;"> </span><span class="m_2559552384157457937gmail-cit-month" style="margin: 0px; padding: 0px; border: 0px; outline: 0px; vertical-align: baseline; font-size: 12.96px; line-height: inherit; color: rgb(0, 0, 0);">Nov</span><span style="color: rgb(0, 0, 0); font-size: 12.96px;"> </span><span class="m_2559552384157457937gmail-cit-day" style="margin: 0px; padding: 0px; border: 0px; outline: 0px; vertical-align: baseline; font-size: 12.96px; line-height: inherit; color: rgb(0, 0, 0);">4</span><span style="color: rgb(0, 0, 0); font-size: 12.96px;">; [e-pub]. </span></div>
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<span class="im" style="color: rgb(80, 0, 80);"><font face="tahoma, sans-serif">C. Roldan, Y. Chathampally. Haloperidol vs. placebo in addition to conventional therapy to treat pain secondary to gastroparesis in the emergency department. Journal Of Pain. April 2015 Volume 16, Issue 4, Supplement, Page S34<br />
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<span style="color: rgb(36, 36, 36); font-family: tahoma, sans-serif;">Ramirez R et al. Haloperidol Undermining Gastroparesis Symptoms (HUGS) in the Emergency Department. AJEM 2017</span></span><br />
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