Vomiting (emesis)

Steps in vomiting (emesis)

Nausea : Unpleasant sensation that often comes before vomiting

(wanting to vomit)

Retching : Strong involuntary effort to vomit, usually after

nausea

Vomiting : Forceful expulsion of the stomach contents through

the mouth

American Journal of Therapeutics 2010;17:476-486

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What happens in vomiting
?
 Cause
s
Vestibular (e.g. motion sickness, otitis media)

Obstruction (e.g. pyloric stenosis, intussusception)

Metabolic (e.g. Diabetic ketoacidosis)

Infections (Gastrointestinal or other systems)

Toxins and drugs (e.g. chemotherapeutic agents, radiotherapy)

Increased intracranial pressure

Nephrologic disease (e.g. acute/chronic renal failure )

Gastrointestinal (e.g. GERD, peptic ulcer disease)

Indian Journal of Pediatric 2013;80(4):318-325
 Parts
Central : involved
CTZ/Area Postrema and Vomiting Centre, vestibular apparatus, cerebral cortex

Peripheral:
Vagal and Sympathetic nerves (affarent nerves)
 Parts of brain involved with
nausea and vomiting

4th ventricle

Dopamine, serotonin,
histamine, acetylcholine
Cerebellum
receptors

Area postrema/CTZ
Vomiting Centre
Nucleus of the
solitary tract
 Sight, smell,
memory
Chemoreceptor
Motion trigger zone

Drugs,
toxins

Vomiting
centre
Serotonin receptor
 Consequences of vomiting

Acute/short-term Chronic/long-term

Dehydration Starvation, malnutrition and

(loss of water and vitamin deficiency
electrolytes)

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Management
 Antiemetic
Target Class Drug s Good for use in: Side effects
receptor
Dopamine Dopamine Domperidone GI induced emesis, Extra-pyramidal, Dystonia
antagonists nausea caused by (rarely)
dopamine agonists
Metoclopramide GI induced emesis, Restlessness, involuntary
gastric stasis (e.g. shaking of the limbs, spasms of
migrane), CINV neck, inability to sit still
Histamine Antihistamines Promethazine Motion sickness Respiratory depression, apnoea,
cardiac arrest, seizures, dystonic
reactions and
hallucinations,urinary retention,
dry mouth
Serotonin Serotonin Ondansetron Minimal side effects
(5-HT3) antagonists CINV, PONV, Mild headache, constipation,
radiotherapy dizziness
Granisteron

Roger Walker, Clive Edward, 2003; Churchill Livingstone; 3 rd edition:509-514

5-HT3 receptor
antagonist
Ondansetron

 Prevents binding of serotonin both

peripherally (at vagal nerve terminals)
and centrally (in CTZ)
 Highly selective for 5-HT3 (with
little affinity for other serotonin,
alpha or beta adrenergic, or
dopamine receptors)

Pediatric Pharmacotherapy 1997;3(9)

 Ondansetron better than domperidone

Ondansteron Domperidone
Potent , highly selective 5-HT3
Dopamine antagonist
receptor antagonist

Convenient dosage schedule Multiple dosing (3-4 times a day)

Oral bioavailability (approx. 60%) Oral bioavailability (approx. 15%)

Higher incidence of extra pyramidal

Less side effects (headache and
side effects (neurological) and
constipation)
prolactin secretion

Domperidone packinsert
 Ondansetron better than metoclopramide
Ondansteron Metoclopramide
Potent , highly selective 5-HT3 receptor
Dopamine antagonist
antagonist
Convenient dosage schedule Multiple dosing (3-4 times a day)
Studies have shown higher efficacy Studies have shown lower efficacy

Oral formulations are not recommended

Safe and well tolerated in children
in children and adolescents*
More serious side effects
Less side effects (constipation and (restlessness, involuntary shaking of the
headache) limbs, spasms of neck, inability to sit
still)

* http://www.imt.ie/mims/2012/03/metoclopramide-%E2%80%93-new-recommendations-for-treatment-of-children.html
 Ondansetron better than promethazine

Ondansteron Promethazine
Potent , highly selective 5-HT3
Histamine antagonist
receptor antagonist
Multiple dosing (4-6 times a
Convenient dosage schedule
day)
Studies have shown higher Studies have shown lower
efficacy efficacy
More serious side effects
Less side effects (constipation (respiratory depression, apnoea,
and headache) cardiac arrest, seizures, dystonic
reactions and hallucinations)
 COMPETITORS
Pack – 30 ml Dosage – 0.15 mg/kg body weight BRANDS COMPANY
ONDEM ALKEM*
VOMIKIND MANKIND
Target doctors : Pediatricians, GP & Pediatric EMESET CIPLA
Gastroenterologist EMIGO EMCURE*
PERISET IPCA LABS

Indication

• Prevention & Treatment of nausea and vomiting

PTS PTR MRP

23.9 34.8

Manufactured at LL – Cipla, Baddi