Recommendation: Require medical referral

Recommendation: Require medical referral

• These are complex medical conditions that often cause nausea and vomiting as a secondary symptom.
• Treatment should be directed at the underlying cause and managed by a healthcare professional.

Recommendation: Non-pharmacological therapy

• Dietary adjustments, eating habits, and environmental factors

  • For the bedroom:
    • Make sure the room is well-ventilated.
    • Keep dry crackers by the bed to eat in the morning.
    • Eat several crackers before getting out of bed and rest for 10-15 minutes.
    • Get out of bed slowly and avoid sudden movements.
  • For meal times:
    • Nibble on dry toast or crackers before breakfast.
    • Ensure the area where meals are prepared and eaten has plenty of fresh air.
    • Eat four to five small meals per day instead of three large ones.
    • Avoid overeating.
    • Do not drink fluids or eat soups at mealtimes. Instead, drink small sips of liquids between meals.
    • Try small sips of carbonated beverages or fruit juices when nauseated.
  • For food choices:
    • Avoid greasy foods (e.g., fried foods, gravies, mayonnaise, salad dressings) and spicy or acidic foods (e.g., citrus fruits and beverages, tomatoes).
    • Eat food chilled rather than warm or hot, as it tends to be less nauseating.

(***Please use these medicines under Doctor’s guidance)

• Pyridoxine (Vitamin B6): Direction:
  • Often recommended as a first-line treatment. Can be taken alone or in combination with doxylamine.
  • Precautions: Generally considered safe in recommended doses.
  • Adverse Effects: Minimal at normal doses. High doses can potentially cause neuropathy, but this is rare.
• Pyridoxine + Doxylamine:
  • Direction: Doxylamine is an antihistamine. The combination is more effective than Vitamin B6 alone. Take as directed by your doctor, typically at bedtime, but it can be taken up to three times a day.
  • Precautions: Doxylamine can cause drowsiness.
  • Adverse Effects: Drowsiness is the most common. Other possible side effects include dry mouth, constipation, and dizziness.
• Ginger:
  • Direction: Can be consumed in various forms, including ginger ale, ginger candy, ginger tea, or ginger capsules.
  • Precautions: Generally safe.
  • Adverse Effects: May cause mild heartburn or gastrointestinal discomfort in some individuals.
• Antihistamines: Dimenhydrinate and Diphenhydramine:
  • Use under a doctor's supervision.
  • Precautions: Can cause drowsiness.
  • Adverse Effects: Drowsiness, dry mouth, dizziness, and constipation.

Recommendation: Require medical referral

• Physiological Changes: Pregnancy causes significant hormonal and physiological changes that can affect the gastrointestinal system, often leading to nausea and vomiting, commonly known as "morning sickness." While mild cases are common, moderate to severe symptoms pose risks.
• Nutritional Concerns: Severe vomiting can lead to dehydration, electrolyte imbalances, and nutritional deficiencies in the mother, which can harm both the mother and the developing fetus. The fetus relies on the mother for all its nutritional needs, and persistent vomiting can disrupt this supply.
• Medication Safety: The developing fetus is highly vulnerable to the effects of medications. Many drugs, even some available over-the-counter, can cross the placenta and potentially cause birth defects or other complications. Therefore, self-treating with antiemetics without medical supervision is risky.
• Underlying Conditions: In some cases, severe nausea and vomiting during pregnancy may indicate a more serious condition called hyperemesis gravidarum. This condition requires medical management, which may include intravenous fluids, nutritional support, and prescription medications that are considered safe for pregnancy but need careful monitoring.

Recommendation: Require medical referral

• Medication Transfer: Medications taken by a breastfeeding mother can pass into breast milk and potentially affect the nursing infant. The infant's liver and kidneys are not fully developed and may not be able to efficiently process and eliminate drugs.
• Potential Adverse Effects: Even medications considered relatively safe for adults may have adverse effects on an infant. For example, some antiemetics can cause drowsiness or other unwanted effects in the baby.
• Milk Supply: Some medications can potentially reduce breast milk production, which can be detrimental to the nursing infant.
• Lack of Research: There is often limited research on the safety of medications during breastfeeding. Therefore, caution is advised, and medical supervision is essential.

Recommendation: Pharmacological and non pharmacological

Behavioral and environmental modifications

• Avoid reading during travel.
• Keep your line of vision straight ahead.
• Avoid excess food or alcohol before and during extended travel.
• Position yourself where motion is least experienced (e.g., front of the car, near the wings of an airplane, or midship on a boat).
• Avoid strong odors, especially from food or tobacco smoke.

Pharmacological

• • Antihistamines:
    • Dosing :
      • Meclizine
        • • Adults: 25-50 mg 1 hour before travel (50 mg maximum daily dosage)
          • Children 6 to <12 years: Not recommended
          • Children 2 to <6 years: Not recommended
      • Cyclizine
        • • Adults: 50 mg 30 minutes before travel, then 60 mg every 4-6 hours (200 mg maximum daily dosage)
          • Children 6 to <12 years: 25 mg every 6-8 hours (75 mg maximum daily dosage)
          • Children 2 to <6 years: Not recommended
      • Diphenhydramine
        • • Adults: 25-50 mg every 4-6 hours (300 mg maximum daily dosage)
          • Children 6 to <12 years: 12.5-25 mg every 4-6 hours (150 mg maximum daily dosage)
          • Children 2 to <6 years: 6.25 mg every 4-6 hours (37.5 mg maximum daily dosage)
      • Dimenhydrinate
        • • Adults: 50-100 mg every 4-6 hours (400 mg maximum daily dosage)
          • Children 6 to <12 years: 25-50 mg every 6-8 hours (150 mg maximum daily dosage)
          • Children 2 to <6 years: 12.5-25 mg every 6-8 hours (75 mg maximum daily dosage)
    • Take 30 to 60 minutes before departure to allow ample time for the onset of effect and continued during travel.
    • Adverse Effects:
      • Drowsiness
        • Caution: Do not combine with alcohol-containing products, drive a vehicle, operate hazardous machinery, or engage in tasks requiring a high degree of physical dexterity or mental alertness.
      • Anticholinergic adverse effects: Blurred vision, dry mouth, urinary retention, and constipation.
      • Paradoxical stimulatory reactions: Insomnia, nervousness, and irritability.
      • Interacts with other CNS depressants.
    • CI
      • Respiratory conditions (chronic bronchitis or emphysema), Glaucoma, Prostate gland enlargement, Lactating women (Antihistamines may reduce milk supply in lactating women), Children and elderly patients (use with caution)

    • DI

      • CNS Depressants: Antihistamines may result in additive sedation when combined with other CNS depressants (e.g., alcohol, tranquilizers, hypnotics, sedatives).
      • CYP 2D6 Inhibitors:
        • Diphenhydramine has been shown to interfere with the metabolism of metoprolol by inhibiting the CYP 2D6 enzyme. This interaction can lead to decreased metoprolol clearance and more pronounced effects on heart rate and blood pressure.
        • Similarly, diphenhydramine increased venlafaxine plasma concentration in a study.
        • Caution is advised when using diphenhydramine with medications metabolized by CYP 2D6 isoenzymes (e.g., opiates, certain psychiatric medications, β-blockers, and certain antiarrhythmics).
      • Tricyclic Antidepressants: Additive sedation or anticholinergic effects may occur when antihistamines are combined with tricyclic antidepressants.

Recommendation: Pharmacological and non pharmacological

• Avoiding known disagreeable foods: coffee, tea & alcohol smoking; & NSAID exposure.
• Reduce stress & lose weight, if applicable.

At patient's request, OTC H2RAs, antacids, bismuth-containing products, or phosphorated carbohydrate solution.

• Antacids:
  • A/E: Belching and flatulence, diarrhea (Mg containing), constipation (Al/Ca containing)
    • Sodium bicarbonate antacids: may cause fluid overload, Caution in Cardiovascular disease, renal failure, cirrhosis, pregnancy, sodium-restricted diets
  • Onset: take at the onset of symptoms and relief is expected within 5 minutes. Duration of action is 20-30 min but increased when taken with food
  • Frequency: Do not use for more than 4 times and for more than 2 weeks
  • CI: 2 years
• H2RAs:
  • A/E: headache, diarrhea, constipation, dizziness and drowsiness
  • Onset: Take 30-60 min before food prior to anticipated symptoms; relief is expected within 30-45 min. DoA is 4-10 hrs
  • Frequency:
    • Use as needed rather than scheduled basis to avoid tolerance
    • Do not use more than 2 times a day for more than 2 weeks
  • Combined with antacids: Provide quicker and sustained relief
  • CI: 12 years
• PPIs:
  • A/E:
    • Common: Diarrhea, constipation, flatulence and headache
    • Chronic excessive use: Increased risk of infection, reduced bone mineral density, CV events, CAP, CKD, dementia, Vit. B12 deficiency, hypomagnesemia, and iron malabsorption. Many of these effects occur when use exceeds one year
  • Administration: Do not chew or crush; 30-60 min before breakfast, NICE guideline says they can be used on demand.
  • Onset and duration: Pain relief in 1-3 hours and works for 12-24 hrs. Complete relief can take 1-4 days
  • They heal ulcers but have no role in relieving symptoms of GERD
  • Avoid:
    • Self-use is limited to 14 days, no more than once every 4 months
    • If endoscopy is planned, do not take within 2 weeks (may mask pathology)
    • Use cautiously in poor renal function
  • CI: 18 years
• Drug interactions
  • Antacids
    • itraconazole, ketoconazole, iron
      • Potential interactions: Decreased absorption due to increased pH causing impaired dissolution, disintegration or ionization
      • Management/ Preventive measures: Separate doses by at least 2 hours
    • Amphetamines
      • Potential interactions: increased absorption and decreased excretion
      • Management/ Preventive measures: Avoid concurrent use or monitor therapy
    • Rosuvastatin
      • Potential interactions: decreased absorption
      • Management/ Preventive measures: Separate doses by at least 2 hours
    • Enteric coated tablets
      • Potential interactions: increased gastric pH may cause premature breakdown of enteric coating
      • Management/ Preventive measures: Separate doses by at least 2 hours
  • CaCo3, Mg(OH)2, Al(OH)3
    • levothyroxine
      • Potential interactions: Absorption is delayed or impaired
      • Management/ Preventive measures: Separate doses by at least 6 hours
    • Tetracyclines
      • Potential interactions: decreased absorption
      • Management/ Preventive measures: Separate doses by at least 2 hours
    • Fluoroquinolones
      • Potential interactions: decreased absorption
      • Management/ Preventive measures: Take antibiotics 2 hour before or 6 hours after taking antacids
  • Na2CO3, Mg(OH)2, Al(OH)3
    • Azithromycin
      • Potential interactions: decreased absorption
      • Management/ Preventive measures: Separate doses by at least 2 hours
    • Quinidine
      • Potential interactions: increased urinary pH may decrease excretion
      • Management/ Preventive measures: Avoid concurrent use or monitor therapy
    • Salicylates
      • Potential interactions: increased urinary pH may decrease excretion
      • Management/ Preventive measures: Avoid concurrent use or monitor therapy
  • Antacids, H2RA, PPI
    • erlotinib, dosatinib, gefitinib, , other TKIs, rilpivirine, ledipasvir/sofosbuvir
      • Potential interactions: decreased absorption
      • Management/ Preventive measures: Avoid concurrent use
  • H2RAs, PPI
    • itraconazole, ketconazole, iron, CaCO3
      • Potential interactions: Decreased absorption due to increased pH causing impaired dissolution, disintegration or ionization
      • Management/ Preventive measures: Avoid concurrent use or monitor therapy
    • Citalopram
      • Potential interactions: Inhibit CYP450 2C19 leading to increased concentration and dose dependent QT prolongation
      • Management/ Preventive measures: Citalopram dose should not exceed 20 mg per day if used concurrently
  • PPIs
    • Warfarin, theophylline, tacrolimus, mycophenolate mofetil
      • Potential interactions: Inhibit CYP450 2C19 leading to increased concentration
      • Management/ Preventive measures: Avoid concurrent use
    • Digoxin
      • Potential interactions: increased absorption
      • Management/ Preventive measures: Check with prescriber
    • Methotrexate
      • Potential interactions: increased toxicity
      • Management/ Preventive measures: Avoid use of high dose methotrexate. clinically significant toxicity unlikely at lower weekly doses
  • Omeprazole, esomeprazole
    • Clopidogrel
      • Potential interactions: Inhibits conversion to its active form
      • Management/ Preventive measures: Avoid concurrent use or check with prescriber. clinically significant interaction is unlikely
    • Cilostazol, diazepam
      • Potential interactions: increased concentration of target drug
      • Management/ Preventive measures: Avoid concurrent use. lansoprazole may be a safer alternative

Recommendation: Pharmacological and non pharmacological

• Hydration is Key:
  • Replace fluids: Vomiting and diarrhea lead to fluid loss. Oral rehydration solutions (ORS) are ideal (these contain the right balance of water, sugar, and electrolytes). Sip small amounts frequently. Clear broths, diluted juices, and non-caffeinated beverages can also help.
  • Avoid dehydration triggers: Avoid caffeine and alcohol, as they can worsen dehydration.
• Rest the Stomach:
  • Stop solid foods: Initially, it's best to avoid solid foods to give your digestive system a chance to recover.
  • Bland diet: As you start to feel better, introduce bland, easily digestible foods gradually. The "BRAT" diet (bananas, rice, applesauce, toast) is often recommended. Avoid fatty, fried, spicy, or overly sweet foods.
• Symptom Relief (with caution):
  • Antiemetics: Antiemetics usually not necessary, but give at patient's request.
  • Ondansetron: This is a commonly used antiemetic, particularly in emergency room settings, to control severe nausea and vomiting. It works by blocking serotonin receptors.
  • Promethazine or Prochlorperazine: These are older antiemetics that also have anti-dopaminergic effects. They can be effective but have more potential side effects, such as drowsiness.
  • Avoid anti-diarrheal (loperamide) initially: In some cases, diarrhea helps your body get rid of the toxins. Unless the diarrhea is very severe, it's often best to let it run its course for a while.
• Warning signs: Watch for signs that indicate you need medical attention.
  • Persistent vomiting: Inability to keep down fluids.
    • Severe dehydration: Decreased urination
    • Dizziness or lightheadedness
    • Extreme thirst
    • Dry mouth and skin
  • Bloody vomit or stool:
  • Severe abdominal pain:
    • Neurological symptoms: Blurred vision
    • Muscle weakness
    • Numbness or tingling
  • High fever:
  • Symptoms not improving after 12 hours:

Recommendation: Require medical referral

Recommendation: Require medical referral