Antiemetics... Can someone give me the lowdown?

[WonderRN]

so I am a new grad in the ED, and I was wondering if someone could give me the lowdown on the antiemetics...Zofran, Reglan, and Compazine.... I've read my drug book, but I find it is less helpful than info from other nurses.

I am scared of Reglan and Compazine cause of the whole EPS thing and dystonic reactions, but it seems some of the ED docs love Compazine, and I am just not sure why. Why not Zofran instead?

Also, if someone could tell me some of most common side effects, what to warn patient's of, teaching points, why you prefer one over the other...

Thanks so much!! I want SO BADLY to be the best ED nurse, I love this forum!

[alisant]

As a nursing student, I don't know much but I do know that Zofran is ridiculously expensive and that is why it's not used more often (from what I've been told).

[helper T cell]

Hi,

I know somethimes they don't use zofran at least at my hospital because it is the most expensive compared to lets say phenergan. I believe that Reglan is used more for helping with GI motility then as an antiemetic. In my 2 years as an RN I've given alot of zoran and phenergen, some reglan not much compazine. Have not had anyone display the extapyramidle effects, but then again I am only using the drugs short term in the MedSurg setting..

You have to be careful with phenergen IV as it is very hard on the veins and is also a sedative. We are finding that zofran SL works really well. Anyway hope this helps.

[AmaurosisFugax]

Ondansetron (Zofran) is no longer ridiculously expensive now that generics are out, & it apparently works much better than phenothiazines or other dopamine inhibitors with less side effects. However, the EPS, NMS, & other really bad AEs associated with dopamine inhibitors usually happen with prolonged use...the neurokinin/substance P inhibitors (aprepitant [Emend], now that's expensive!) are a new area of antiemetics (I seem to have read somewhere that substance P is the ultimate neurotransmitter for vomiting response but can't verify it)...& of course there are the good old cannabinoids (like nabilone [Cesamet]) & some antihistamines...

BTW, in many countries ginger is approved as an antiemetic especially for N/V of pregnancy.

[Sonjailana]

Zofran- works extremely well, clean drug, doesn't interact much, I've never seen anyone react to it. Also expensive so often only approved for 24 hrs post op or for cancer pts. 32mg/max/day

Phenergan- works well, makes old people loopy, causes respiratory depression, sedating, will fry your veins and if it goes sub-q..yowch!

Compazine- works ok, moderately sedating, and reacts with TONS of things in IV tubing to for precipitate

Reglan- used for GI motility, not nausea so much. Those pesky extrapyramidal side effects..but never actually seen any.

[F.E.R.N., BSN, RN]

A couple other things to add...not sure if it's patient teaching....

Because Zofran is not sedating and has fewer SE than the other 3, it is frequently given in my ER for people who are not expected to stay and need to be able to drive themselves home.

Phenergan should be diluted in NS and given slowly to avoid harming the veins (our facility requires 10 ml NS for every 25 mg phenergan). Phenergan is often used as not only a nausea med, but a adjuvant for pain meds.

Sometimes Compazine is only stocked in very large dose vials and can be expensive for that reason alone. Although the average ER doc is not likely to be aware of this unless you tell him.

[Larry77, RN]

Ondansetron (generic) in IV form is not very expensive but the ODT version is still quite expensive...for us $120.00 for a starter pack of 4 tabs (management is always reminding us...lol). I've heard that if you administer Ondansetron too fast you can give the pt ringing in their ears--never seen it though. Phenergan is terrible on veins and like stated before very sedating--be careful with elderly but is awesome for drug seekers :-) Compazine/Reglan are famous for making your patient jump out of the bed or feel like they want to (nerves go crazy, especially if given too fast).

You should look up some pics of Phenergan given in infiltrated IV's...the tissue necrosis is horrible...some facilities have banned the IV form because of this.

[Virgo_RN, BSN, RN]

We do not give IV Phenergan at my facility. We have a N/V protocol. Start with Zofran and then Compazine if the N/V continues. Zofran works most of the time, but for some people, the Compazine works better.

[caroladybelle, BSN, RN]

The issues:

Phenergan and Compazine are older drugs and substantial cheaper. They are relatively common, have been around for years. Used on a limited basis, they are relatively safe and reliable for common, nonchemo related nausea. Have some people can have bad reactions to them, they can cause sedation, and some people will experience jitteriness. They are also very irritating to tissues and cause a lot of pain and/ or damage given IV if not diluted/small IV/poor IV/given fast. Compazine generally is less problematic than phenergan as far as tissue damage/irritation.

Compazine, however, is also subject to frequent national shortages.

Reglan relieves nausea and emesis in part by increasing GI motility. It is usually easier to IV then phenergan/compazine, though you do have to take care to give it slowly. It is generally given to postop pts, as those pts often have impaired/slowed bowel function, though may be used with general medical pts.

It is generally NOT used in chemo/rad pts, especially if they have treatment related diarrhea. The pts are often at high risk for GI side effects of rad/chemo, as the rapid growing cells of the GI tract are generally heavily affected by many systemic chemos. The Gi tract becomes inflamed and pt develops diarrhea. Reglan may increase motility and further aggravate the situation. Though there are occasionally exceptions this rule.

Haldol may be used for a nausea, but rarely. It has to be given slowly if IV (sometimes as a IVPB) and the pt getting IV needs to get regular EKGs as it can alter cardiac rhythm. It is not very effective and obviously not all that practical.

Droperidol gets used in the PACU and I really haven't dealt with it much.

Ativan is given on hardcore hemo/onco floors (my speciality). It is inexpensive, effective, easy to give IV, but can cause a great deal of sedation. And it has an issue with staying "on board" for a really long time, for an IV drug. With some pts, especially in the elderly, it stays and stays and the patient is sedated for an excessive period of time. Mix that with some pain med, and your pt is a major fall risk, if not worse. It is also a controlled med in many settings.

Zofran the "oldest" 5HT-3 drug (younger ones include kytril, anzemet, aloxi) has been around for about 20 years, and were developed for treatment of chemo related nausea. Chemo related nausea, specifically that associated with the infusion and the 24-48 hr period after it - phenergan, compazine, reglan were either inadequate or completely ineffective for. One common drug, Cisplatin (known in onco circles as the most pukecidal drug known, though there are others less common) had a rate of about 99% of people vomitting from it, with little relief offered by previous agents. The 5HT3s revolutionized chemo administration and made it much more tolerable. Most of the stories about massive vomiting from chemo, were from chemo given before widespread use of 5HT3s. The 5HT3s are relatively safe, rarely cause sedation, longer acting and very effective. Some of them may cause EKG changes in prolonged dosing, but less so than haldol. They can be given easily IV, and rarely cause tissue injury. However, while some are available as generics, they are generally more expensive than many of the older drugs, and some forms are still not generic. These drugs are primarily recommended more for chemo related nausea, and mainly used as premeds for chemo and for the first 48 hours, though can be used for other things and for longer. Originally they were used in combination with decadron as premeds. However, since decadron can alter the effectiveness of chemo, this varies with regimen/disease, and is less common now.

The latest in the nausea orificenal is a new drug class, and the drug is emend. Given generally as a PO premed, it has a loading dose and two more lower daily doses. It is effective for 4-5 days after the last dose, so you are talking a week worth of effect from 3 doses, something that is advantageous. It is supposed to ALWAYS be used in conjunction with zofran (and occasionally with decadron). It is specifically approved for use with highly emetagenic chemo (cisplatin would apply), or in people with known high risk /history of emesis. It is quite expensive (several hundred dollars for 3 day dosing), should be used with the 5HT3 zofran, often not covered by insurance, and only for chemo administration, not for extended periods after/between cycles. Though that may change after more research.

Often for chemo, after the initial several days of treatment, we may change from zofran and/or decadron and/or emend, we can scale back to the less expensive meds, when not actively getting chemo. And sometimes the pt cannot tolerate the step down and may have to stay on zofran.

Marinol and other cannabis related drugs have not demonstrated that much effectiveness, in my experience, but can sometimes increase appetite.

[caroladybelle, BSN, RN]

Forgot Vistiril in the above.

Vistiril (I haven't given it for nausea in about 15 years) , was given IM, often in conjunction with narcotics, for pain and nausea control. It is very irritating to tissue and had to be given deep IM. Not used for IV use. Really not a good antiemetic drug. Currently used PO for reducing itching. Can be sedating.