How to prevent vomiting after taking medicine

Bonthala N, Wong MS. Gastrointestinal diseases in pregnancy. In: Landon MB, Galan HL, Jauniaux ERM, et al, eds. Gabbe's Obstetrics: Normal and Problem Pregnancies. 8th ed. Philadelphia, PA: Elsevier; 2021:chap 53.

Hainsworth JD. Nausea and vomiting. In: Niederhuber JE, Armitage JO, Kastan MB, Doroshow JH, Tepper JE, eds. Abeloff's Clinical Oncology. 6th ed. Philadelphia, PA: Elsevier; 2020:chap 39.

Rengarajan A, Gyawali CP. Nausea and vomiting. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 11th ed. Philadelphia, PA: Elsevier; 2021:chap 15.

Dr. McNatty is an assistant professor of pharmacy practice at Midwestern University College of Pharmacy, Glendale, Arizona.

Nausea is one of the most commonmedication side effects that patients report, as virtuallyall agents have the ability to cause stomach disturbances. Nausea can range from a slight annoyance to a debilitating condition causing disruption to a patient's daily life.

Medication-related nausea can have a profound impact on patient outcomes because nonadherence to prescribed therapy can lead to treatment failure. A loss of appetite may occur, which can lead to poor nutrition. Nausea also can have psychological effects on patients, and they may become apprehensive about taking medications in the future. Patient education by pharmacists and other health care professionals can reduce substantially the likelihood of nauseaas a side effect and help patients achieve optimum benefit from medicationtherapy.

Chemotherapy-induced Nausea

Chemotherapy-induced nausea is the most studied type of medication-related nausea. Nausea and vomiting due to chemotherapy is a very common and debilitating event for patients undergoing this treatment, and guidelines written specifically for this side effect have been developed.1,2

Nausea and vomiting can cause dehydration,malnourishment, increased anxiety, and stress in a patient populationalready at high risk for medication-related complications. Nausea and vomiting are categorized as acute, delayed, anticipatory, breakthrough, and refractory; in the ambulatory care setting, delayed and anticipatory nauseaare seen frequently.

Medication-induced Nausea

When a patient who is not receiving chemotherapy presentswith nausea, it is often difficultto determine the cause. In addition to medications, other causes (eg, migraine, emotional response, pregnancy, and gastrointestinaldisorders) must be considered.

Nausea caused by medicationsis typically acute rather than chronic and usually is seen shortly after starting a medication.3 Medications can cause nausea via severalmechanisms. Dopaminergic agonists, nicotine, digoxin, and opiates have been shown to act on the area postrema. Some agents (eg, nonsteroidal anti-inflammatorydrugs [NSAIDs] and erythromycin) activate peripheral afferent pathways, stimulating the brainstem nuclei.3 Nausea also can be induced through stimulation and activation of the chemoreceptor triggerzone (CTZ). Stimuli cause the CTZ to recognize a substance as foreign and activate the vomiting center.

The most common substances to cause stimulation are chemotherapy drugs, opiates, and ipecac syrup. Many other drugs (eg, antibiotics, NSAIDs, selective serotonin reuptake inhibitors [SSRIs], and digoxin) also can cause the activation of the CTZ.4 The mechanism associated with a number of medication classes known to cause nausea remains unclear. Some of these include anti-arrhythmics, antihypertensives,diuretics, oral hypoglycemics, and oral contraceptives.3

Prevention

Preventing nausea caused by medicationoften can be achieved with a few simple reminders. Unless an agent is meant to be taken on an empty stomach, patients can be advised to take their medications with food. This is an easy way to prevent nausea, especially with notorious offenders, such as antibiotics, NSAIDS, and multivitamins. The time of day a medication is taken may be an important consideration when preventingnausea caused by dizziness. Taking medications such as SSRIs at bedtime prevents the vomiting center from being activated by dizziness because the body is asleep.4

o n l i n e

A complete discussion of treatment guidelines for chemotherapy-related nausea can be accessed at www.nccn.org/patients/patient_gls.asp.

If these simple interventions are noteffective, the next step is to identify any alternative agents that can be used to provide equal efficacy with less nauseafor the patient. If the nausea is being caused by any of the excipients, a simple formulation switch may help. The patient can try either the same product from a different manufacturer or change formulations—from a tablet to a liquid, for example. If this is not possible or does not work, changing to an alternativeagent with the same mechanism of action may alleviate the nausea. Finally, if this option is not possible or proves to be ineffective, changing to a medication with an entirely different mechanism of action may be warranted. These nonpharmacologicinterventions are summarizedin the Figure.

Pharmacologic Agents

When nonpharmacologic recommendationsdo not work, patients can turn to pharmacologic agents to prevent and/or treat nausea caused by medication use. Dopamine antagonists, such as promethazineand prochlorperazine, are especiallyeffective for opioid-induced nausea, but can be beneficial for nausea caused by other medications as well. They are a good choice for short-term offenders, such as antibiotics and NSAIDS. Long-term use may be limited by extrapyrimidalside effects. The use of serotonin receptor antagonists (eg, ondansetron and granisetron) may be beneficial for long-term prevention of nausea. The use of this class of agents is often limited by cost to the patient.

Many patients consider nausea to be a sign of an allergic reaction. This can have profound effects on future therapy. If an allergy is documented in a patient's profile,it could lead to the choice of a less-than-optimal agent for future treatment.

Pharmacists can play a key role in makingsure every patient understands the difference between an allergic reactionand an adverse reaction. An ideal time to do this is during the initial contact with the patient while getting a medication history. Verifying allergies and the specific reaction caused by the offending agents is the first step in identifying misinterpretedreactions. In addition, health care professionals should be vigilant about documenting new allergies/intolerances and counseling patients appropriately about these issues.

Nausea is a common medication-related side effect with many potential causes. Nausea can have a significant impact on a patient's physical and psychologicalhealth. Proper counseling on prevention and treatment of nausea due to medication use can help patients betterunderstand how to take their medicationsfor optimum benefit with minimal side effects.

Figure

References

• Jordan K, Sippel C, Schmoll HJ. Guidelines for antiemetic treatment of chemotherapy-induced nausea and vomiting: past, present, and future recommendations. Oncologist. 2007;12:1143-1150.
• American Cancer Society and National Comprehensive Cancer Network. Nausea and Vomiting: Treatment Guidelines for Patients with Cancer (Version IV 2007). www.nccn.org/patients/patient_gls.asp.
• Quigley EM, Hasler WL, Parkman HP. AGA technical review on nausea and vomiting. Gastroenterology. 2001;120:263-286.
• Garrett K, Tsuruta K, Walker S, Jackson S, Sweat M. Managing nausea and vomiting. Current strategies. Crit Care Nurse. 2003;23(1):31-50.

Key facts

• Vomiting is a reflex that helps the body get rid of substances that may be harmful.
• Gastroenteritis — an infection of the digestive tract — is one of the most common causes of nausea and sudden vomiting.
• If vomiting is caused by an infection, such as gastroenteritis or food poisoning, it can often be managed at home if you stay hydrated.
• Vomiting due to viral gastroenteritis usually clears up without any specific treatment within 2 days
• Ongoing or recurrent episodes of vomiting should be investigated by your doctor.

Vomiting is one of the symptoms of COVID-19. Even if your symptoms are mild, get tested for COVID-19 immediately — use the COVID-19 Symptom Checker if you're not sure what to do.

Vomiting is the forceful ejection of the contents of the stomach and upper digestive system through the mouth. It is sometimes known as throwing up or being sick.

Vomiting is a reflex that helps the body get rid of substances that may be harmful. Most people will experience vomiting at some point.

This information concerns vomiting in adults and children over 12 years of age. See vomiting in children for information relating to children between 0 and 12 years.

What symptoms relate to vomiting?

Vomiting is accompanied by forceful contractions of the abdominal muscles. It is different from reflux or regurgitation which happen without any abdominal contractions.

Vomiting can sometimes be forceful — projectile vomiting can send the stomach contents more than a metre away.

Other symptoms that you may feel alongside vomiting are:

• Nausea — before vomiting, a person usually experiences nausea. Nausea is the unpleasant feeling that you are about to vomit and is known as ‘feeling sick’. Once you have vomited, the feeling of nausea may ease or go away.
• Mouthwatering — your mouth will often start to water if you are about to vomit.
• Abdominal pain — pain anywhere between the bottom of your ribs and pelvis, and stomach cramps can both happen alongside vomiting.
• Diarrhoea — diarrhoea and vomiting are a common combination of symptoms in gastroenteritis. They are both methods the body uses to get rid of harmful substances.
• Dizziness — a feeling of light-headedness, unsteadiness or faintness.
• Vertigo — a false sensation of movement or spinning, when the body is not moving.

Ongoing vomiting can lead to dehydration, where your body has lost more fluid than it has taken in, and doesn't have enough water to function properly.

Retching is similar to vomiting, because it involves forceful stomach contractions. However, with retching, you will not bring up anything from your stomach.

CHECK YOUR SYMPTOMS — Use the diarrhoea and vomiting Symptom Checker and find out if you need to seek medical help.

What causes vomiting?

Vomiting can be a sudden isolated bout of vomiting (acute) that usually lasts less than 2 days or it can be part of a pattern of ongoing or recurring attacks (chronic). The underlying causes of vomiting are usually categorised into acute or chronic vomiting causes.

Acute vomiting causes

Some causes of sudden vomiting are serious, but one of the most common causes is viral gastroenteritis, which usually clears up without any specific treatment within 2 days. The following conditions can cause acute vomiting.

• Gastroenteritis — an infection of the digestive tract — is one of the most common causes of nausea and sudden vomiting.
• Food poisoning — some bacteria can cause food poisoning due to toxins (poisons) they secrete into food that is not stored properly.
• Poisoning — this can cause nausea and vomiting, drowsiness, fits and seizures.
• Motion sickness — this is more common in children than adults, but can also be the cause of vomiting in adults.
• Alcohol — drinking excess alcohol frequently results in nausea and vomiting.
• Post-operative — at least one-third of adults get nausea and vomiting after surgery, known as post-operative nausea and vomiting.
• Gastrointestinal obstruction — an obstruction in your digestive tract will cause vomiting, often without nausea to start with.
• Appendicitis — nausea and vomiting can both be caused by appendicitis.
• Pancreatitis — inflammation of the pancreas usually causes abdominal pain, vomiting and fever.
• Raised intracranial pressure — raised pressure in the skull is a medical emergency and can cause nausea and vomiting.
• Meningitis — symptoms start suddenly and include vomiting, fever, a stiff neck, pain when looking at bright lights (photophobia) and sometimes a red or purple rash that doesn't go away when gently pressed.
• COVID-19 — nausea, diarrhoea and vomiting can all be symptoms of COVID-19.
• Diabetic ketoacidosis — vomiting can be a symptom of diabetic ketoacidosis, where there is not enough insulin for the body to break down sugar.

Chronic vomiting causes

The following conditions can cause chronic vomiting.

• Medicines — vomiting can be a side effect of some medicines, such as chemotherapy medicines used to treat cancer.
• Radiation treatments — vomiting can be a side effect of radiation treatment.
• Vitamins — high doses of vitamins can cause vomiting.
• Pregnancy — Morning sickness is common during early pregnancy. It causes nausea and vomiting at any time of the day, but often in the morning.
• Migraine — nausea and vomiting are common symptoms in the headache phase of a migraine.
• Food allergies — coeliac disease can cause ongoing digestive symptoms, including vomiting.
• Upper digestive tract disorders — vomiting after meals can be caused by GORD or gastrointestinal obstruction.
• Gastroparesis — this is a delayed emptying of the stomach due to nerve damage. It can lead to nausea and vomiting after meals.
• Kidney stones — nausea and vomiting are symptoms of kidney stones, along with gripping pain in the back.
• Functional nausea and vomiting — this is the name given to chronic nausea and vomiting for which there is no clear medical cause.

When should I see my doctor?

If vomiting because of a simple case of gastroenteritis, it can often be managed at home without needing to see a doctor. But some underlying causes of vomiting can be more serious.

You should go to a hospital's emergency department or call triple zero (000) for an ambulance if you:

• vomit blood or a substance that looks like coffee grinds
• vomit bile — this colours the vomit green
• vomit faecal material (poo)
• have severe or constant tummy (abdominal) pain
• have a stiff neck and high temperature with or without photophobia (pain when looking at bright lights)
• have a severe headache
• have bleeding from your bottom (rectum) or bloody diarrhoea
• have chest pain

Seek immediate medical attention, either from your doctor or from the emergency department, if you are vomiting and:

• have a high temperature (fever)
• have signs of dehydration
• can't take in more than a few sips of liquid or can't keep water down
• it continues for more than 48 hours

Make an appointment to see your doctor if you have been vomiting and have unexplained weight loss.

FIND A HEALTH SERVICE — The Service Finder can help you find doctors, pharmacies, hospitals and other health services.

How is vomiting diagnosed?

Ongoing or recurrent episodes of vomiting should be investigated by your doctor. They will first want to assess you for dehydration.

Then, depending on your symptoms and the results of a physical examination, your doctor may suggest tests, including:

• blood tests
• urine tests
• a pregnancy test

Sometimes, when it is difficult to find a cause for recurrent vomiting, investigations such as an endoscopy or a CT scan may help with diagnosis.

Your doctor may suggest referring you to a gastroenterologist or neurologist.

ASK YOUR DOCTOR — Preparing for an appointment? Use the Question Builder for general tips on what to ask your GP or specialist.

How is vomiting treated?

Treatment for vomiting depends on the underlying cause. Some causes of vomiting will need specific treatment, depending on how serious they are. Treatments include the following:

Surgery

Some causes of vomiting, such as appendicitis or bowel obstruction, will need emergency surgery.

Antiemetic medicines

Antiemetics are medicines that help prevent and treat nausea and vomiting. There are various types, depending on the underlying condition, and they work in different ways. Antiemetics are mostly prescription medicines.

Antiemetics can be used to treat vomiting that results from various causes, including the following:

• Post-operative vomiting — this is vomiting after an operation. Antiemetics may also be given to prevent vomiting from happening in the first place.
• Chemotherapy — vomiting is a common side effect of chemotherapy. Antiemetic medicines are often given to prevent or treat vomiting after chemotherapy.
• Radiation treatment — this treatment to some areas of the body may cause vomiting. Antiemetic medicines may be given to prevent and treat nausea and vomiting caused by radiation.
• Migraine — antiemetics can reduce nausea and vomiting caused by migraine.
• Motion sickness — specific antiemetics that act on the vomiting centre of the brain may help with motion sickness.

Ginger

Ginger may help with nausea and vomiting due to several causes, including pregnancy, chemotherapy and motion sickness.

Dietary changes

Changes to your diet mayhelp to reduce symptoms while doctors determine the cause of your vomiting. These include eating small meals, reducing fat content and avoiding spicy food or ingredients that cause you problems.

Vomiting and home care

If vomiting has an infectious cause, such as gastroenteritis or food poisoning, it can often be managed at home, as long as you stay hydrated.

• Stay home to avoid passing the infection to others.
• Drink plenty of clear fluids or oral rehydration solution to replace lost fluids — take small sips if you feel sick.
• Avoid fruit juice, cordial and sugary drinks.
• Avoid alcohol and caffeine.
• Manage your diet until you get back to normal — eat bland foods, such as rice, pasta and crackers, and avoid fatty food.

What are the complications of vomiting?

Dehydration is one of the most serious complications of vomiting. If you lose too many fluids, you will lose electrolytes — minerals that are essential for your body to work properly. For this reason, you should take oral rehydration solution. Sip these slowly to avoid triggering more vomiting.

Ongoing vomiting may lead to weight loss. This is when a person can’t hold down their food, or the accompanying nausea results in them not wanting to eat, for a sustained period.

If you vomit within 2 hours of taking your oral contraceptive pill, you may not be protected from pregnancy. Refer to the instructions since you may need to use some other form of contraception, such as condoms, for the next 7 hormone pills.

A person can inhale vomit into their lungs, especially if they have ongoing vomiting. Breathing food or liquid into the lungs is referred to as aspiration and can cause pneumonia.

Violent vomiting can, very rarely, tear the lining of the oesophagus (food pipe).

Can vomiting be prevented?

The most common cause of vomiting — viral gastroenteritis — is very infectious and is mostly spread by contact with another person who has the illness.

Things you can do to stop the spread of gastroenteritis:

• Wash your hands frequently, using a good handwashing technique.
• Practice good food safety.
• If a household member has gastroenteritis, they should not prepare food for other family members, and everyone should practice regular handwashing and good hygiene.
• Anyone with gastroenteritis should not visit hospitals, aged care facilities, or swimming pools.
• When cleaning up vomit, wear gloves, an apron and a mask. Dispose of it in a tied plastic bag and wash your hands afterwards. Clean the area with detergent and warm water.

Eating dry crackers or ginger may help alleviate vomiting caused by some conditions such as morning sickness or motion sickness.

Resources and support

If you need advice on what to do if you are vomiting, call healthdirect on 1800 022 222 to speak with a registered nurse, 24 hours, 7 days a week.

For more information and support, visit The Gut Foundation

For information in languages other than English:

• Health translations — Vomiting
• Health translations — Gastroenteritis

Therapeutic Guidelines (Nausea and vomiting), Therapeutic Guidelines (Supportive management of acute gastroenteritis), Gut Foundation (Symptoms: Vomiting), Australian Family Physician (Nausea and vomiting in adults - A diagnostic approach), NSW Health (Viral gastroenteritis fact sheet), NSW Food Authority (Food poisoning), Department of Health (Epidemiology of bacterial toxin mediated foodborne gastroenteritis outbreaks in Australia, 2001 to 2013), State Government of Victoria, Department of Health (Accidental poisoning in children), Australian Family Physician (Functional nausea and vomiting), Australian Prescriber (Preventing motion sickness in children), Queensland Government (Motion sickness), DrinkWise (Alcohol poisoning: when drinking turns toxic), Cancer Council Victoria (Chemotherapy), Cancer Council Victoria (Radiation therapy), Migraine & Headache Australia (Migraine - a common and distressing disorder), Coeliac Australia (Symptoms), GESA (Coeliac disease), Diabetes Australia (What you need to know about gastroparesis), AusMed (Increased intracranial pressure: a guide for nurses), The Royal Children's Hospital Melbourne (Meningitis), Abdominal Radiology (Abdominal imaging findings in patients with SARS-CoV-2 infection: a scoping review), Australian Department of Health (What you need to know about coronavirus (COVID-19)), Diabetes Australia (Ketoacidosis), Kidney Health Australia (Kidney stones), SA Health (Outpatient GP referral guidelines Gastroenterology. Nausea and vomiting), Queensland Government (Spewing 101: Why am I vomiting?), Healthy WA (Diarrhoea and vomiting), Australian Prescriber (Management of acute bleeding in the upper gastrointestinal tract), StatPearls (Aspiration pneumonia), Australian Family Physician (Not just another sore throat), The Royal Women's Hospital, Victoria (Contraceptive pills), Australian Prescriber (Antiemetic drugs: what to prescribe and when), Integr Med Insights (The Effectiveness of Ginger in the Prevention of Nausea and Vomiting during Pregnancy and Chemotherapy), Department of Health (8.2.4 Cleaning up vomit or faeces)

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Last reviewed: June 2021