• Correct the correctable (for example renal function, hypercalcaemia, hyponatraemia, hyperglycaemia, constipation, symptomatic ascites, cerebral oedema/raised intracranial pressure, review medicines).
• Consider non-pharmacological measures (refer to non-pharmacological management below).
• Choose an anti-emetic appropriate to a likely identified cause.
• A combination of anti-emetics may be appropriate.
• A broad spectrum anti-emetic may be indicated if multiple concurrent factors are present.
• Adjuvant corticosteroid and/or benzodiazepine may be combined with the prescribed anti-emetic drug(s).
• Try to avoid the concurrent prescribing of prokinetics (for example QTmetoclopramide) and anticholinergics (for example cyclizine) medication. The anticholinergics will diminish the prokinetic effect.
• Consider the route of administration of medication as:
  • the oral route may not provide adequate absorption or be available as a result of nausea (which inhibits gastric emptying) or vomiting
  • buccal or sublingual medication administration may be helpful but may trigger symptoms of nausea or vomiting in susceptible individuals
  • the parenteral route may reduce tablet burden which may be a contributing factor to nausea.

• Anti-dopaminergics should be avoided in patients with Parkinson’s disease.

Non-pharmacological measures are important and should be considered alongside the prescribing of appropriate anti-emetics. Measures include:

• Regular mouth care (refer to Mouth care guideline)
• Regularising bowel habit - constipation may be a relatively common cause of nausea
• Regular small palatable portions rather than large meals
• Avoid food preparation and cooking smells
• A calm and reassuring environment
• Acupressure bands (for example Seaband^®)
• Acupuncture
• Psychological approaches.

Almost all causes of nausea and vomiting can be placed in the following categories, and managed using a specific drug or class of drugs.

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