UMEM Educational Pearls

Takeaways

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.

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.


Consider Haloperidol 3-5 mg IV. 
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 carbamazepine, phenytoin, phenobarbital, rifampicin, or quinidine due to that pesky CYP3A4 inhibition. 

Consider Olanzapine 2-5 mg IV.

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. 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. 

 

Take Home Points:

Consider the antipsychotic agents Haloperidol or Olanzapine for patients with refractory emesis, they may be more effective than traditional antiemetics. 

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).  

 

In-Depth

References

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Prommer E. Olanzapine: palliative medicine update. Am J Hosp Palliat Care. 2013 Feb;30(1):75-82

Pommer E. Role of Haloperidol in Palliative Medicine: An Update. Am J Hosp Palliat Care. 2012 Jun;29(4):295-301


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.

Jackson WC, Tavernier L (2003) Olanzapine for intractable nausea in palliative care patients. J Palliat Med 6:251–255 
Hasse Abrahamsson. Treatment options for patients with severe gastroparesis. Gut. 2007 Jun; 56(6): 877–883.
 
Bradford MV, Glode A. Olanzapine: An antiemetic option for chemotherapy-induced nausea and vomiting. J Adv Pract Onc. 2014 Jan;5(1):24-9.
 
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
 
Cole JB et al. A prospective observational study of patients receiving intravenous and intramuscular olanzapine in the emergency department. Ann Emerg Med 2016 Nov 4; [e-pub]. 
 
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

P. Stalcup, B. Croft, R. Ramirez, M. Darracq. Research Forum Abstract: 204 Haloperidol Undermining Gastroparesis Symptoms in the Emergency Department. Annals Of Emergency Medicine. October 2016. Volume 68, Issue 4, Supplement, Page S80


Ramirez R et al. Haloperidol Undermining Gastroparesis Symptoms (HUGS) in the Emergency Department. AJEM 2017


Lindenmayer JP, Patel R. Olazapine-induced ketoacidosis with diabetes mellitus (letter) Am J Psychiatry. 1999;156:1471

Roefaro J, Mukherjee SM. Olanzapine-lnduced hyperglycemic nonketonic coma. Ann Pharmacother. 2001;35:300–2.

 Lee JS, Kim JY, Ahn JH, Kim CY. Diabetic ketoacidosis in a schizophrenic patient treated with olanzapine: a case report. J Korean Neuropsychiatr Assoc. 2005;44:116–119.

Ragucci KR, Wells BJ. Olanzapine-induced diabetic ketoacidosis. Ann Pharmocother. 2001; 35: (12) 1556-8