Practice Therapeutics

Drug treatment of adults with nausea and vomiting in primary care

BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g4714 (Published 07 August 2014) Cite this as: BMJ 2014;349:g4714
  1. Jeremy S Furyk, senior staff specialist1, adjunct associate professor2,
  2. Robert Meek, staff specialist in emergency medicine3, adjunct lecturer2,
  3. Suzanne McKenzie, associate professor, general practice and rural medicine3, conjoint associate professor4
  1. 1Townsville Hospital, Angus Smith Drive, Douglas, Townsville, Qld, Australia 4810
  2. 2 James Cook University, Townsville, Qld, Australia
  3. 3Monash Health, Melbourne, Vic, Australia
  4. 4School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, Australia
  1. Correspondence to: J S Furyk Jeremy.Furyk{at}health.qld.gov.au

A usually healthy 25 year old man presents to you as his general practitioner at 9 am. He has had fluctuating nausea with four vomits and one loose stool overnight, associated with colicky central abdominal pain. No blood was present in the vomit or stool, and he reports that his girlfriend was recently diagnosed as having “viral gastro.” He is afebrile, intermittently uncomfortable, but otherwise well, with mild epigastric tenderness but no guarding or rebound. Clinically, you believe viral gastroenteritis is the most likely cause of his symptoms, and you consider his request for treatment that will help to stop his vomiting so that he can get to his evening shift at a factory.

What drugs are available and how do they work?

Nausea and vomiting are a common reason for patients to seek treatment in primary care, which we take here to include general practice and the emergency department. Identification and management of underlying problems are important, if these are apparent on clinical grounds. This article will focus on common causes in primary care such as gastroenteritis (usually viral), adverse drug reactions, pregnancy, vestibular disorders, and motion sickness. Other causes of nausea and vomiting such as postoperative, chemotherapy and radiotherapy associated, and specific conditions such as migraines are briefly discussed but are beyond the scope of this article.

Although still incompletely understood, nausea and vomiting are thought to follow activation of a medullary “vomiting centre,” by either afferent input from the gastrointestinal tract due to presence of local irritants or stimulation of the central chemoreceptor trigger zone by circulating emetogenic substances; however, other pathways exist. Dopamine and serotonin seem to be key transmitters both centrally and in the gastrointestinal tract.

Surveys of emergency physicians in Australia and the United States identified the most commonly prescribed agents as metoclopramide, prochlorperazine, promethazine, droperidol, and ondansetron.1 2 Anecdotally, cyclizine and …

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