Nausea and Vomiting

Background

Nausea with or without vomiting, and occasionally vomiting without nausea, can occur at any stage of HIV infection. Nausea is a common adverse effect of many antiretroviral (ARV) and other medications, and it often occurs within weeks of starting new medications. In some cases, nausea causes significant discomfort and may interfere with medication adherence. Nausea and vomiting also may be symptoms of a serious complication of ARV therapy, or signs of an opportunistic infection or neoplasm in patients with late-stage AIDS. Clinicians must identify the cause of nausea and vomiting and initiate appropriate treatment.

S: Subjective

The patient experiences nausea with or without vomiting, or vomiting without nausea.

Ascertain the following during the history:

  • Duration of symptoms
  • Characteristics, timing, and precipitating factors
  • Vomiting, including hematemesis
  • Diarrhea
  • Abdominal pain
  • Fever
  • Jaundice
  • Lightheadedness, dizziness, vertigo, or orthostatic symptoms
  • Polyuria
  • Polydipsia
  • Headache
  • Changes in vision
  • Neck stiffness
  • Pruritus
  • Medications, new and ongoing
  • Nutritional supplements and non-prescription medications
  • Possibility of pregnancy (for women) (e.g., missed menses)
  • Alcohol intake, substance use or abuse
  • History of:
    • Hepatitis
    • Kidney disease
    • Pancreatitis
    • Cytomegalovirus
    • Central nervous system (CNS) infections, including toxoplasmosis, cryptococcosis, chronic meningitis
    • CNS lymphoma

O: Objective

Check vital signs, including orthostatic blood pressure and heart rate measurements.

Conduct a thorough physical examination, including evaluation of the following:

  • Skin turgor
  • Eyes and fundi (retinal abnormalities such as papilledema)
  • Oropharynx (dryness of oral mucosa, thrush, ulcerations)
  • Neck (stiffness or other signs of meningeal irritation)
  • Abdomen (tenderness, distention, masses, organomegaly)
  • Pelvis (tenderness, masses)
  • Neurologic system (mental status, focal neurologic abnormalities)

Review recent CD4 measurements, if available, to determine the patient's risk of opportunistic illnesses.

A: Assessment

A partial differential diagnosis includes the following conditions:

  • Medication effect or reaction
  • Foodborne illness
  • Viral or other infectious gastroenteritis
  • Pancreatitis
  • Hepatitis, infectious or drug related (see chapters Hepatitis B Infection and Hepatitis C Infection)
  • Appendicitis
  • Esophagitis (see chapter Esophageal Problems)
  • Lactic acidosis attributable to nucleoside analogues
  • Pregnancy
  • Adrenal insufficiency
  • CNS lymphoma
  • Meningitis
  • Uremia
  • Diabetic ketoacidosis
  • Influenza
  • Pelvic inflammatory disease (see chapter Pelvic Inflammatory Disease)
  • Myocardial infarction

P: Plan

Diagnostic Evaluation

Perform laboratory work and other diagnostic studies as suggested by the history, physical examination, and differential diagnosis. Tests may include the following:

  • Complete blood count with differential
  • Electrolytes, creatinine, blood urea nitrogen
  • Glucose
  • Amylase and lipase if symptoms of pancreatitis are present
  • Liver function tests and hepatitis serologies for possible acute or chronic hepatitis
  • Blood cultures and other fever workup as needed (see chapter Fever)
  • Computed tomography scan of the brain if neurologic symptoms are present (see chapter Neurologic Symptoms)
  • Cortisol and cosyntropin stimulation test if indicated (e.g., fatigue, weakness, unexplained abdominal pain, weight loss, orthostasis; usually in late-stage AIDS)
  • If odynophagia or dysphagia is present, see chapter Esophageal Problems
  • Lactic acid levels if lactic acidosis is suspected
  • Pregnancy test if indicated
  • Electrocardiogram if patient has chest pain or suspicious symptoms

Consult with an HIV expert to determine whether hospitalization or other laboratory tests are needed.

Treatment

Once the diagnosis is made, appropriate treatment should be initiated. In seriously ill patients, presumptive treatment may be started while diagnostic test results are pending. See appropriate chapters in section Comorbidities, Coinfections, and Complications and relevant guidelines.

In the case of significant adverse effects from ARVs or other medications, substitute a less-emetogenic ARV for the problematic medication, if possible (without compromising the efficacy of the treatment regimen). In the case of serious or life-threatening medication toxicities (e.g., lactic acidosis or abacavir hypersensitivity reaction), discontinue the problematic medication (see chapter Adverse Reactions to HIV Medications).

After the workup and exclusion of life-threatening illness, symptomatic treatment can be considered. If nausea and vomiting are attributable to medications that are vital to the patient, and these complications are not life-threatening, antiemetic therapy may be the best treatment. Chronic therapy is not always necessary. Some patients obtain adequate relief by breaking the "nausea cycle" with effective antiemetics for 1-2 days and then establishing meals or snacks with medications. Patients with dehydration may require administration of fluids (PO or IV) to relieve nausea. For patients with chronic nausea resulting in weight loss, refer to a nutritionist for assessment and nutritional support.

Symptomatic treatment

Consider the following strategies for symptomatic treatment:

  • For nausea that occurs in relation to an event or action (e.g., after taking ARVs) antiemetics may be given preemptively (e.g., 30 minutes beforehand).
  • Ginger capsules have proven effective in clinical trials for the management of pregnancy-related and chemotherapy-related nausea. Foods and beverages containing ginger (e.g., tea, cookies, ginger ale, candies) may help provide relief.
  • Promethazine (Phenergan) may be given as a 12.5-25 mg PO tablet Q4-6H as needed. For patients unable to tolerate the PO formulation, promethazine suppositories (12.5 or 25 mg) may be used.
  • Prochlorperazine (Compazine) may be given as a 5 mg or 10 mg PO tablet, or a 25 mg rectal suppository, Q6-8H as needed. Extended-release spansule, 10 mg Q12H or 15 mg QAM, also can be considered.
  • Lorazepam (Ativan) may be given as a 0.5 mg PO tablet 30 minutes before taking medications for symptoms of anticipatory nausea. Patients with anticipatory nausea develop significant nausea or vomiting when even thinking about medications or reaching for the medications.
  • Dronabinol (Marinol) may relieve nausea, especially when nausea is accompanied by a loss of appetite. This remedy is best tolerated by patients who have tolerated inhaled marijuana. The starting dosage is 2.5 to 5 mg BID or TID.
  • 5-Hydroxytryptamine (5-HT3) receptor antagonists such as dolasetron 50 mg and 100 mg, granisetron 1 mg, and ondansetron 4 mg and 8 mg are highly effective are highly effective in relieving severe nausea and vomiting resulting from chemotherapy and other causes. However, access to these medications is limited by their cost. Their use should be considered a short-term strategy or reserved for cases of nausea/vomiting refractory to other antiemetics.
  • Metoclopramide (Reglan) may be used to enhance gastrointestinal motility in patients who experience nausea and vomiting caused by gastroparesis. The typical PO dose is 5-10 mg Q4-6H, or it can be taken TID with meals if the nausea or vomiting is associated with eating.
  • H2 antagonists or proton pump inhibitors may be helpful in treating nausea/vomiting related to gastritis or acid reflux (caution: these agents interfere with absorption of atazanavir and rilpivirine; consult dosing recommendations); see chapter Esophageal Problems and relevant tables in the U.S. Department of Health and Human Services Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents (see Appendix).

Patient Education

  • Nausea and vomiting can have many different causes. Patients should let their health care provider know if they are having these symptoms so that the most likely cause can be determined.
  • Patients should stay nourished and well hydrated even if they are experiencing nausea and vomiting. Eating small, frequent meals may be best tolerated, while avoiding dairy products, spicy or greasy foods, and high-fat meals. Taking medications with food may reduce symptoms of nausea (note that some medications must be taken on an empty stomach).
  • Patients should not stop taking any of their medications without first discussing it with their health care provider. Many medications must be continued despite nausea. Nausea and vomiting owing to ARVs may resolve or become tolerable over time.
  • Many patients wonder whether they should take their medicines again if they vomit after taking a dose. Generally, the medicines are still in the body unless the pills actually come back up. Patients should call their health care provider if they have any questions.
  • Ginger may help to relieve nausea. Ginger can be taken in a variety of ways, including ginger ale, tea, cookies, candies, and ginger capsules. Patients can choose the form of ginger that works best for them.

References

  • Chubineh S, McGowan J. Nausea and vomiting in HIV: a symptom review. Int J STD AIDS. 2008 Nov;19(11):723-8.
  • Hill A, Balkin A. Risk factors for gastrointestinal adverse events in HIV treated and untreated patients. AIDS Rev. 2009 Jan-Mar;11(1):30-8.
  • Sulkowski MS, Chaisson RE. Gastrointestinal and Hepatobiliary Manifestations of HIV Infection. In: Mandell GL, Bennett JR, Dolin R, eds. Principles and Practice of Infectious Diseases, 6th ed. Philadelphia: Churchill Livingstone, 2005;1575-80.