Antiemetic therapy (Proceedings)


Antiemetic therapy (Proceedings)

Aug 01, 2010

The vomiting reflex is a complex mechanism that can be initiated peripherally from the GI tract, pharynx, chemoreceptor trigger zone (CRTZ), and vestibular systems or centrally at the emetic center in the brain. Direct stimulation of the pharynx can result in vomiting, although this is a relatively infrequent cause in animals. Vomiting can be initiated from the GIT due to irritation, inflammation, or distention of the stomach or intestines and is typically mediated by serotonin (5HT3) receptors which than progress through the CRTZ or the solitary tract nucleus in the brain. The solitary tract nucleus contains enkephalin, histamine (H1), muscarinic (M1), substance P (neurokinin NK-1), and 5HT3 receptors. The chemoreceptor trigger zone can also initiate the vomiting reflex due to blood borne drugs or toxins (i.e. morphine induced vomiting in dogs) which is mediated by opiate, 5HT3, dopamine (D2) and M1, NK1, and norepinephrine (α-2) receptors. Motion sickness or vestibular disease can stimulate the vomiting reflex primarily through histamine (H1) and muscarinic receptors. The emetic center coordinates the vomiting reflex and contains high concentrations of 5HT1 and α-2 receptors. The complex nature and multiple pathways that can stimulate the vomiting reflex can be confusing but offer many targets for symptomatic treatment of vomiting, but no one treatment is expected to be highly efficacious for all causes of vomiting. Is is also important to reiterate that antiemetics are treating a symptom and not a disease process, therefore every effort should be made to make a primary diagnosis as some underlying disease can prove fatal if not treated.


Antihistamines are commonly used for vomiting associated with vestibular stimulation such as motion sickness or vestibular disease. Most antihistamines have weak anticholinergic effects as well, which is the reason they are typically contraindicated in glaucoma and cardiovascular disease. Diphenhydramine (Benadryl), dimenhydrinate (Dramamine), and hydroxyzine have all been used for the treatment of vestibular vomiting. The efficacy of antihistamines to treat vestibular vomiting in cats is less than that in dogs and may not be an optimal choice in cats.


Aminopentamide (Centrine) is the representative antimuscarinic agent used for vomiting in veterinary medicine. The efficacy of aminopentamide is essentially limited to vestibular induced vomiting. Aminopentamide has low efficacy for other causes of vomiting. The adverse effects of anticholinergics (decreased stomach emptying, ileus) are often contraindicated for many causes of vomiting. Other adverse effects include xerostomia, urine retention, increased intraocular pressure, constipation, and excitement in cats. The clinical usefulness of this drug class as antiemetics is minimal.