NAUSEA & VOMITTING

Devyani diah wulansari

Outline
1. Ethiology
2. Pathophysiology
3. Clinical presentation
4. Pharmacology
5. Pharmacotherapy
 ETHIOLOGY

EFEK SAMPING OBAT

KONDISI PATOLOGIS
KEMOTERAPI
KEHAMILAN
PATHOPHYSIOLOGY
motion-sickness
PATHOPHYSIOLOGY

NK1R 5-HT3R M1R H1R

VOMITING CENTRE
PATHOPHYSIOLOGY

SUSUNAN SARAF PUSAT • GANGGUAN PSIKIATRIK

• STRESS
• MUNTAH ANTISIPATORIK

VOMITING CENTRE SEBELUM KEMOTERAPI

PATHOPHYSIOLOGY

• DRUGS (OPIOID, CHEMOTHERAPY)

VOMITING CENTRE CTZ

• POST OPERATIVE
• PREGNANCY

D2R 5-HT3R NK1R CB1R

PATHOPHYSIOLOGY

• KEMOTERAPI
• RADIASI

VOMITING CENTRE • INFEKSI

CTZ

5-HT3R
PATHOPHYSIOLOGY

• VERTIGO
• MOTION SICKNESS
VOMITING CENTRE

M1R H1R
 PATHOPHYSIOLOGY

VOMITING CENTRE

EMESIS
VC langsung : higher cortical
CLINICAL PRESENTATION
CHEMOTHERAPY-INDUCED NAUSEA AND VOMITING [CINV]

Five categories of CINV: acute, delayed, anticipatory, breakthrough, and

refractory.

Nausea or vomiting that occurs prior to receiving chemotherapy is

termed anticipatory nausea and vomiting (ANV).

Within 24 hours of  acute CINV

Starts >24 hours  delayed CINV
Within 5 days  breakthrough CINV
Principles of Antiemetic Use for CINV

1. The primary goal of emesis prevention is no nausea and/or vomiting throughout the period of
emetic risk.
2. The duration of emetic risk is 2 days for patients receiving moderately emetogenic chemotherapy
and 3 days for highly emetogenic chemotherapy. Emetic prophylaxis should be provided through the
entire period of risk.
3. The selection of the antiemetic regimen should be based on the chemotherapy drug with highest
emetogenicity. Prior emetic experience and patient-specific factors should also be considered.
4. When given in equipotent doses, oral and IV 5-HT3-RAs are equivalent in efficacy.
5. The toxicities of antiemetics should be considered and managed appropriately.
RADIATION-INDUCED NAUSEA AND VOMITING

Four radiotherapy-induced emesis risk groups have been defined by the

ASCO and MASCC/ESMO antiemetic practice guidelines:
1. Highest risk: Total-body irradiation (TBI)  5-HT3-RA + Dexamethasone
2. Moderate risk: Upper body or abdomen and craniospinal RT  5-HT3-RA
3. Low risk: Brain, head and neck, thorax, and pelvic RT  5-HT3-RA,
dexamethasone, or dopamine receptor antagonist
4. Minimal risk: Extremity or breast RT  5-HT3-RA, dexamethasone, or
dopamine receptor antagonist
POSTOPERATIVE NAUSEA AND VOMITING (PONV)
DISORDERS OF BALANCE

Ethiology : infectious,
postinfectious, demyelinative,
Vertigo, dizziness, and motion vascular, neoplastic,
sickness degenerative, traumatic,
toxic, psychogenic, or
idiopathic

Antihistaminic–anticholinergic Scopolamine 
agents First line for motion sickness
Nausea and vomiting of pregnancy (NVP)

A prenatal vitamin should be started 1 month prior to becoming pregnant, which may help reduce
the incidence and severity of NVP.

Pyridoxine (vitamin B6), with or without doxylamine, is recommended as first-line therapy.

Dimenhydrinate, diphenhydramine, prochlorperazine, or promethazine

Ondansetron, promethazine, and metoclopramide have similar effectiveness for hyperemesis

gravidarum, although ondansetron may be better tolerated due to less adverse effects

Ondansetron, promethazine, and metoclopramide have similar effectiveness for hyperemesis

gravidarum

Glucocorticoids, like methylprednisolone, may be used in patients with severe NVP or hyperemesis
gravidarum, but should be used only after 10 weeks of gestation due to the increased risk of cleft lip.
ANTAGONIS SEROTONIN 5-HT3

5-HT3R

VOMITING
CENTRE CTZ
 ANTAGONIS SEROTONIN 5-HT3

EFEKTIF PADA MUNTAH MELIPUTI EFIKASI ↑ JIKA

KARENA STIMULASI ONDANSETRON, DIKOMBINASI DENGAN
VAGUS (PASKA GRANISETRON, KORTIKOSTEROID DAN
OP/KEMOTERPI) DOLASETRON ANTAGONIS NK1-R

<<<<< EFEKTIF UNTUK

T1/2 4-9 JAM  1DD1
MABUK PERJALANAN
 ANTAGONIS SEROTONIN 5-HT3

REGIMENTASI 1 REGIMENTASI 2
(RUTE IV 30 MENIT SEBELUM KEMOTERAPI) (RUTE PO 1 JAM SEBELUM KEMOTERAPI)
ONDANSETRON 8 MG ONDANSETRON 8 MG 2DD1/ 24 MG 1DD1

GRANISETRON 1 MG GRANISETRON 2 MG

DOLASETRON 100 MG DOLASETRON 100 MG

PALONOSETRON 0,25 MG
ANTAGONIS NEUROKININ 1

NK1R

VOMITING CENTRE CTZ

ANTAGONIS NEUROKININ 1
DAPAT DIGUNAKAN UNTUK EMESIS DINI DAN LANJUT PADA
KEMOTERAPI

DIGUNAKAN DALAM KOMBINASI DENGAN ANTAGONIS

5HT3-R DAN KORTIKOSTEROID

PENGHAMBAT METABOLISME DOKSETAKSEL,PAKLITAKSEL,

VINBLASTIN, VINKRISTIN (≠ METABOLISMENYA)

KADAR PLASMA ↑ JIKA DIGUNAKAN DENGAN

KETOKONAZOL, CIPROFLOKSASIN, VERAPAMIL, RITONAVIR,
KUINIDIN)
ANTAGONIS DOPAMIN D2

VOMITING CENTRE CTZ

D2R
 ANTAGONIS DOPAMIN D2

DAPAT MENYEBABKAN
EFEK ANTIMUAL
DIGUNAKAN GALAKTOREA,
DAN ANTIMUNTAH
SEBAGAI AGEN GINEKOMASTIA,
POTEN
PROKINETIK IMPOTEN

ESO DOMPERIDON  ≠
METOKLOPRAMID : MENEMBUS
SINDROMA SAWAR DARAH
EKSTRAPIRAMIDAL OTAK
ANTAGONIS HISTAMIN H1

VESTIBULAR

H1R

VOMITING CENTRE
ANTAGONIS HISTAMIN H1

BERGUNA UNTUK MABUK PERJALANAN DAN

MENGOBATI VERTIGO

ESO : MENGANTUK, MULUT KERING

MEMILIKI SIFAT ANTIKOLINERGIK SIGNIFIKAN

ANTAGONIS MUSKARINIK

M1R

VOMITING CENTRE
ANTAGONIS MUSKARINIK

INSIDEN ANTIKOLINERGIK
(ANTISPASMODIK) >>> JIKA
DIBERIKAN PO/PARENTERAL

LEBIH DITOLERANSI SEBAGAI

PATCH TRANSDERMAL

FENOTIAZIN
(CHLORPROMAZINE) 
ANTIPSIKOTIK YANG MEMILIKI
EFEK SEDATIF DAN ANTIEMETIK
ANTAGONIS CANABINOID CB1

VOMITING CENTRE CTZ

CB1R
ANTAGONIS CANABINOID CB1

THC  PSIKOAKTIF UTAMA DALAM

MARIYUANA

ESO : HALUSINASI, EUFORIA, MENGANTUK

MEMILIKI EFEK OTONOMIK  TAKIKARDIA,

HIPOTENSI ORTOSTATIK
PATIENT CARE PROCESS
Collect

• Patient characteristics (eg, age, sex, pregnancy status, triggers)

• Patient medical history (personal and family), history of NV

• Social history (eg, tobacco/ethanol/cannabis use) and dietary habits

• Current medications including prescription and nonprescription medications, herbal products,

dietary supplements

• Objective data (eg, QTc prolongation, BP/pulse, complete metabolic panel, CBC, liver function,

weight, skin turgor, urine output)

Assess

1. Duration, frequency, severity of nausea and vomiting

2. Ability/willingness to pay for treatment options
3. Emotional status (eg, presence of anxiety, depression)
4. Assess ability of the patient to use oral, rectal, injectable, or transdermal
medications
5. Success of previous antiemetic regimens
6. For CINV: Assess emetic risk
7. For PONV: Assess risk factors for developing PONV
Plan
1. Drug therapy regimen including specific antiemetic(s), dose, route, frequency, and duration
2. Monitoring parameters including efficacy (eg, reduction in symptoms, resolution of lab abnormalities,
resumption of normal oral intake) and safety (eg, QTc prolongation, drug–drug interactions); frequency
and timing of follow-up
3. Patient education (eg, purpose of treatment, dietary and lifestyle modification, invasive procedures,
drug-specific information, medication administration technique)
4. Self-monitoring for resolution of symptoms, when to seek emergency medical attention
5. Referrals to other providers when appropriate (eg, gastroenterologist, dietitian, OBGYN, oncologist,
anesthesiologist)
Implement
• Provide patient education regarding all elements of treatment plan
• Use motivational interviewing and coaching strategies to maximize adherence
• Schedule follow-up, adherence assessment

Follow-up: Monitor and Evaluate

• Resolution of nausea and vomiting symptoms
• Need for rescue antiemetics
• Presence of adverse effects
• Patient adherence to treatment plan
Postclass Engaged Learning Activity
1. Mengapa Ondansetron Lebih Direkomendasikan Untuk Mengatasi Emesis Paska Operasi/Premedikasi
Kemoterapi?
2. Apakah Obat Ranitidin (Antagonis Histamin) Dapat Digunakan Sebagai Antiemetik? Jelaskan Alasannya.
3. Mengapa Preparat Hiosin Sebagai Antiemetik Direkomendasikan Dalam Bentuk Transdermal?
4. Sebutkan tabel yang berisi mekanisme kerja, bentuk sediaan, rute pemberian, dosis, frekuensi pemberian, ESO
dan sebutkan minimal 2 Merk Dagang Dari Obat Berikut Ini :
a. Antasida g. Deksametason n. Klorpromazine
b. Dimenhidrinat h. Cimetidin o. Promethazin
c. Diphenhidramin i. Famotidin p. Aprepitan
d. Scopolamin j. Nizatidin
e. Lorazepam k. Ranitidin
f. Haloperidol l. Metoclopramid
g. Nabilon m. Olanzapin