Is a comparison guide for common medications used for side-effect management, such as constipation, nausea, anxiety, etc. that includes a cost comparison available? —Name withheld on request

Nausea and vomiting is a common side effect of cancer treatment. Chemotherapy-induced nausea and vomiting (CINV) is a challenging side effect to manage, especially when patients are treated in the outpatient setting or CINV manifests as a late or anticipatory effect. The list below presents information on medications indicated for managing nausea and vomiting. This list is not all-inclusive; it does not include medications indicated for pregnancy-related nausea and vomiting or motion sickness. Future installments of this chart will present information on other side-effect management medications. —The editors

TABLE 1. Nausea and vomiting medications.

Product or generic (brand name) Indication Contraindications Warnings/
Cautions
Interactions Adverse
reactions
Price (OTC or Rx)
aprepitant (Emend) In combination with other antiemetic agents to prevent acute and delayed nausea and vomiting associated with initial and repeat courses of moderately to highly emetogenic cancer chemotherapy, including high-dose cisplatin

Continue Reading

Prevention of post-op nausea and vomiting

Concomitant pimozide, cisapride Not for chronic continuous use

Severe hepatic insufficiency

Pregnancy (Cat.B)

Nursing mothers: not recommended

See contraindications

Monitor, and caution with, CYP3A4 substrates, including chemotherapy agents (eg, ifosfamide, vinblastine, vincristine);
CYP3A4 inhibitors (eg, azole antifungals, macrolides, nefazodone, ritonavir, nelfinavir, diltiazem); and with CYP3A4 inducers (eg, carbamazepine, phenytoid, rifampin)

Potentiates dexamethasone (reduce dose by 50%), methylprednisolone (reduce IV dose by 25% and oral dose by 50%), midazolam, alprazolam, triazolam

May antagonize warfarin (closely monitor INR for 2 weeks after starting each regimen); phenytoin, tolbutamide, other CYP2C9 substrates; paroxetine, oral contraceptives (use alternative or backup method during and for 1 month after last dose)

Asthenia

Fatigue

Hiccups

ALT/AST
increased

Headache

Constipation

Anorexia

GI upset

Eructation

Hypotenion

Pruritus

Pyrexia

Injection site pain

$$ (Rx)
dolasetron mesylate (Anzemet) Prevention of nausea and vomiting associated with moderately emetogenic cancer chemotherapy, including initial and repeat courses Injection solution 
administered by IV: This formulation is contraindicated for prevention of nausea and vomiting associated with cancer chemotherapy
Increased risk of developing QTc, PR, and QRS interval prolongation

Avoid in patients with congenital QT syndrome, hypokalemia, hypomagnesemia, complete heart block, or risk of (unless paced)

Correct electrolyte imbalances prior to therapy

Monitor ECG periodically

Congestive heart failure

Bradycardia

Pre-existing conduction abnormalities and underlying structural heart disease

Sick sinus syndrome

Atrial fibrillation with slow ventricular response

Recent MI

Renal impairment

Elderly

Pregnancy (Cat.B)

Nursing mothers

Caution with drugs 

which can prolong ECG intervals (eg, verapamil, flecainide, quinidine), diuretics, and with cumulative high-dose anthracycline therapy

Potentiated by cimetidine, atenolol (IV dolasetron)

Antagonized by rifampin

Headache

Dizziness

Pain

Fatigue

Diarrhea

Bradycardia

Tachycardia

Dsypepsia

Chills/shivers

ECG changes

2nd or
3rd-degree
AV block

$$$$ (Rx)
dronabinol (Marinol) Refractory nausea and vomiting 
associated with cancer chemotherapy

Seizure or cardiac disorders

History ofpsychiatric
disorders (eg, mania, depression, schizophrenia) or substance abuse

Write script for smallest practical amount

Keep patient under responsible adult supervision (especially when dose is adjusted)

Children

Elderly (minotor: especially with dementia)

Pregnancy (Cat.C)

Nursing mothers: not recommended

Potentiates CNS depression with benzodiazepines, barbiturates, alcohol, other CNS depressants and other psychoactive substances (avoid)

May affect, or be affected by other drugs that are highly protein bound (eg, sympathomimetics, anticholinergics, tricyclic antidepressants)

Antagonizes theophylline

Phenothiazines may potentiate effect without additional toxicities

Psychomimetic reactions

Euphoria

Depression

Behavior disorders

Drowsiness

Dizziness

Fatigue

Somnolence

Altered mental status

Seizures
(discontinue if occurs)

Ataxia

Anxiety

Paresthesia

Tachycardia Hypotension

Vasodilation

Tolerance and withdrawal syndrome 

$$$-$$$$ (Clll)
droperidol To reduce incidence of nausea and vomiting associated with surgical and diagnostic procedures QT prolongation (including congenial long QT syndrome)

Perform ECG prior to administration to determine if prolonged QT interval present;
if prolonged, do not administer unless treatment outweighs risks;
if treating, monitor for arrhythmias: perform ECG prior to treatment and 2-3 h after completion

Risk factors for QT prolongation: CHF, bradycardia, cardiac hypertrophy, hypokalemia, hypomagnesemia, >65 y, alcohol abuse

Pheochromocytoma

Hepatic or renal impairment

Elderly

Debilitated

Critically ill

Labor and delivery: not recommended

Pregnancy (Cat.C)

Nursing mothers

Risk of QT prolongation with concomitant Class I and III antiarrhythmics, MAOIs, antimalarials, calcium channel blockers, benzodiazepines, volatile anesthetics, IV opiates, other drugs that prolong QT interval

Caution with drugs that induce hypokalemia, hypomagnesemia (eg, diuretics, laxatives)

Additive effects with CNS depressants (eg, barbiturates, tranquilizers, opioids, general anesthetics)

Possible hypertension with concomitant fentanyl citrate injection

Hypoention

Tachycardia

Dysphoria

Drowsiness

Restlessness

Hyperactivity

Anxiety

QT prolongation

Torsade de pointes

Cardiac arrest

Ventricular tachycardia

Neuroleptic malignant syndrome

Post-op hallucinatory episodes

$$ (Rx)
Emetrol Nausea and vomiting

Do not dilute or permit oral fluids immediately before or for 15 minutes after dosage

Diabetes

$ (OTC)
granisetron (Granisol, Sancuso)

Prevention of nausea and vomiting associated with chemotherapy (including high-dose cisplatin)

Prevention and treatment of post-op nausea and vomiting

Abdominal surgery

May mask progressive ileus and/or gastric distention

Pre-existing arrhythmias or cardiac conduction disorders

Cardiac disease, concomitant cardio-toxic chemotherapy or electrolyte abnormalities: increased risk of QT prolongation

Pregnancy (Cat.B)

Nursing mothers

Caution with drugs that affect CYP450 or prolong the QT interval

Headache

Asthenia

Diarrhea

Constipation

QT prolongation

$$-$$$$ (Rx)
nabilone (Cesamet Treatment of nausea and vomiting associated with cancer chemotherapy in patients who have not responded adequately to other antiemetics

Hypertension

Heart disease

History of psychiatric disorders (eg, bipolar disorder, depression, schizophrenia) or substance abuse

Write script for limited quantity (ie, enough for one chemotherapy course)

Keep patient under responsible adult supervision (especially when dose is adjusted)

Renal or hepatic impairment

Elderly

Pregnancy (Cat.C)

Nursing mothers: not recommended

Potentiates CNS depression with benzodiazepines, barbiturates, alcohol, other CNS depressants and other psychoactive substances (avoid)

May affect, or be affected by, other drugs that undergo first-pass hepatic metabolism or that are highly protein bound (eg, sympathomimetics, anticholinergics, tricyclic antidepressants)

Cross-tolerance and mutual potentiation with opioids

Naltrexone: see literature

Drowsiness

Vertigo

Dry mouth

Euphoria/dysphoria

Ataxis

Headache

Tachycardia

Hypotension

Concentration difficulties

Sleep disturbance

Other psychiatric reactions (may persist for several days after dosing)

Changes in appetite

$$$$ (CII)
ondansetron (Zofran, Zuplenz)

Prevention of nausea and vomiting associated with highly emetogenic chemotherapy, including cisplatin ≥50 mg/m2

Prevention of nausea and vomiting associated with initial and repeat courses of moderately emetogenic chemotherapy

Prevention of nausea and vomiting associated with radiotherapy in patients receiving total body irradiation, single high-dose fraction to the abdomen, or daily fractions to the abdomen

Prevention of post-op nausea and vomiting

Concomitant apomorphine

Age <4 months (monitor closely)

Not a substitute for nasogastric suction in gastric or intestinal peristalsis

Congenital long QT syndrome: avoid

Electrolyte abnormalities, CHF, bradyarrhythmias, concomitant drugs that prolong QT: monitor ECG

May mask progressive ileus and/or gastric distention

Hepatic dysfunction

Pregnancy (Cat.B)

Nursing mothers

See contraindications

Profound hypotension, loss of consciousness with apormorphine

May antagonize tramadol

Diarrhea

Headache

Fever

Constipation

Fatigue

Transient blindness

Rare: angina, bronchospasm, anaphylaxis, seizures, ECG changes (including QT prolongation)

$$-$$$ (Rx)
palonosetron (Aloxi)

Prevention of acute nausea and vomiting due to initial and repeat courses of emetogenic chemotherapy in adults

Prevention of delayed nausea and vomiting due to initial and repeat courses of moderately emetogenic chemotherapy in adults

Prevention of acute nausea and vomiting due to initial and repeat courses of emetogenic chemotherapy, including highly emetogenic cancer chemotherapy in children 1 month to <17 y

Prevention of post-op nausea and vomiting for up to 24 h after surgery in adults

Pregnancy (Cat.B)

Nursing mothers: not recommended

Headache

Constipation

Bradycardia

QT prolongation

Diarrhea

Dizziness

Tachycardia

Hypotention

$$$$ (Rx)
Perphenazine

Severe nausea and vomiting

Others: Psychosis

Coma

Concomitant large doses of CNS depressants

Blood dyscrasias

Bone marrow depression

Liver damage

Subcortical brain damage

CNS depression

Epilepsy

Cardiovascular disease

Respiratory disorders

History of breast cancer

Pheochromocytoma

Avoid sun, exposure to extreme heat or phosphorus insecticides

Surgery: consider lower anesthetic dose

Monitor blood, hepatic, and renal function

Write script for smallest practical amounts

Reevaluate periodically

Debilitated

Elderly

Pregnancy, nursing mothers: not recommended

Potentiates CNS depression with alcohol, other CNS depressants

Adjust anticonvulsant doses

Additive anticholinergic effects with atropine or related drugs

Tardive dyskinesia

Drowsiness

Jaundice

Blood dyscrasias

Hypotension

ECG changes

Retinopathy May mask emetic signs of disease

Lowered seizure threshold

Rash

Skin pigmentation

Anticholinergic effects

Insomnia

Adynamic ileus

Hyperprolactinemia

Extrapyramidal reactions

Neuroleptic malignant syndrome

$$$$ (Rx)
Prochlorperazine

Severe nausea and vomiting

Others: Anxiety/OCD, Psychosis

Coma

CNS depression

Pediatric surgery

Children <2 y or <20 lb

Discontinue 48 h before to 24 h after myelography

Cardiovascular disease

Epilepsy

Bone marrow depression

Reye’s syndrome

Glaucoma

History of breast cancer

Exposure to extreme heat

Monitor blood, liver, and ocular function

Write sript using fractions rather than decimals

Children with acute illness or dehydration

Debilitated

Elderly

Pregnancy, nursing mothers: not recommended

Potentiates CNS depression with alcohol, other CNS depressants

Potentiates a-blockers

Levels of both drugs increased with propranolol

May potentiate phenytoin; monitor for toxicity

Adjust anticonvulsant doses

May antagonize oral anticoagulants

Hypotension potentiated with thiazide diuretics

Antagonized by anticholinergics

Decreases guanethidine effects

Monitor for neurologic toxicity with lithium; discontinue if occurs

May cause false (+) PKU test

Drowsiness

Dizziness

Amenorrhea

Blurred vision

Other anticoholinergic effects

Skin reactions

Hypotension

Cholestatic jaundice

Photosensitivity

Leukopenia

Agranulocytosis

Neuroleptic malignant syndrome

Agitation

Insomnia

Dystonias

Extrapyramidal reactions

Pseudoparkinsonism

Tardive dyskinesia

May mask emetic signs of disease

Lowered seizure threshold

EKG changes

Aspiration

Deep sleep

Hyperprolactinemia

Paradoxical excitement in children

$$ (Rx)
Promethazine

Motion sickness

Prevention and treatment of nausea and vomiting with anesthesia and surgery

Others: Allergies, Nonnarcotic analgesics, Sleep-wake disorders

Children <2 y

Coma

Intra-arterial or subcutaneous injection

Sulfite sensitivity

CNS depression

Impaired respiratory function (eg, COPD, sleep apnea)

Narrow-angle glaucoma

GI or GU obstruction

Cardiovascular or liver disease

Seizure disorders

Peptic ulcer

Bone marrow depression

Elderly

Pregnancy (Cat.C)

Labor and delivery

Nursing mothers: not recommended

Potentiates CNS depression with alcohol, other CNS depressants

Caution with epinephrine, anticholinergics, MAOIs

May alter hCG pregnancy test results and glucose tolerance tests

Injection site reactions

CNS depression/drawsinss

Lowered seizure threshold

Cholestatic jaundice

Anticholinergic and extrapyramidal effects

Neuroleptic malignant syndrome

Photosensitivity

Hypo- or hypertension

Rash

Blood dyscrasias

Nausea

Dry mouth

Paradoxical reactions

Children: respiratory depression (may be fatal)

$$ (Rx)
Key: $, <$50; $$, $50-$99; $$$, $100-$199; $$$$, ≥$200; OTC, over-the-counter; Rx, prescription.
Sources: OTC Prices were found via Internet search for the over-the-counter or consumer product. Prescription prices are from: Healthcare Bluebook. https://healthcarebluebook.com/page_Default.aspx. Accessed March 24, 2015.
Indications, contraindications, warnings/cautions, interactions, and adverse effects information is from MPR Drug Database, accessed via MPR app. Accessed December 8, 2014.

To access Part 1 of this series, Comparison of constipation management medications, click here.

To access Part 3 of this series, Comparison of medications for managing anxiety, click here.