Wednesday, July 2, 2008

Chemo-induced nausea/vomiting review

NEJM recently had a review article on chemotherapy-induced nausea and vomiting, which relatively succinctly reviews its pathophysiology and gives an evidence-based overview for its therapy. Good one for the teaching file. I'll comment on a minor point in the article, which is the dosing of metoclopramide for CINV - it's 1-2 mg/kg IV (pre-chemo) with 0.5 mg/kg q6 hours afterwards. That is - the doses are in the 30+ mg range (easily) per-dose - much higher than the 'standard' anti-emetic dosing of metoclopramide of 5-10 mg/dose. I started medicine well into the age of 5HT-3 inhibitors which are clearly superior than dopamine blockers for CINV - I've never seen them used in fact for this indication, although I've heard stories from my 'elders' about high-dose metoclopramide back in the day.

My question is this: for those of you who use metoclopramide as a general anti-emetic (not for CINV) - what doses do you use? Do you ever push it above 10mg a pop? My own practice has been to occasionally try 20mg at a time but if that's not working, and other agents like 5HT-3 antagonists, steroids, etc. aren't working, I often move on to chlorpromazine, which works really darn well, albeit with some sedation.

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