l UNLICENSED USE g Metoclopramide is used for the
treatment of acute migraine, hbut is not licensed for
MHRA/CHM ADVICE—METOCLOPRAMIDE: RISK OF NEUROLOGICAL
ADVERSE EFFECTS—RESTRICTED DOSE AND DURATION OF USE
The benefits and risks of metoclopramide have been
reviewed by the European Medicines Agency’s
Committee on Medicinal Products for Human Use, which
concluded that the risk of neurological effects such as
extrapyramidal disorders and tardive dyskinesia
outweigh the benefits in long-term or high-dose
treatment. To help minimise the risk of potentially
serious neurological adverse effects, the following
restrictions to indications, dose, and duration of use
. In adults over 18 years, metoclopramide should only
be used for prevention of postoperative nausea and
vomiting, radiotherapy-induced nausea and vomiting,
delayed (but not acute) chemotherapy-induced nausea
and vomiting, and symptomatic treatment of nausea
and vomiting, including that associated with acute
migraine (where it may also be used to improve
absorption of oral analgesics);
. Metoclopramide should only be prescribed for shortterm use (up to 5 days);
. Usual dose is 10 mg, repeated up to 3 times daily; max.
daily dose is 500 micrograms/kg;
. Intravenous doses should be administered as a slow
bolus over at least 3 minutes;
. Oral liquid formulations should be given via an
appropriately designed, graduated oral syringe to
This advice does not apply to unlicensed uses of
metoclopramide (e.g. palliative care).
l CONTRA-INDICATIONS 3–4 days after gastrointestinal
surgery . gastro-intestinal haemorrhage . gastro-intestinal
obstruction . gastro-intestinal perforation . phaeochromocytoma
l CAUTIONS Asthma . atopic allergy . bradycardia . cardiac
conduction disturbances . children . elderly . epilepsy . may
l INTERACTIONS → Appendix 1: metoclopramide
▶ Uncommon Arrhythmias . hallucination . hyperprolactinaemia . level of consciousness decreased
▶ Rare or very rare Confusion . galactorrhoea . seizure
▶ Frequency not known Atrioventricular block . blood
prolongation . shock . syncope .tremor
▶ With parenteral use Anxiety . dizziness . dyspnoea . oedema . skin reactions . visual impairment
SIDE-EFFECTS, FURTHER INFORMATION Metoclopramide
can induce acute dystonic reactions involving facial and
skeletal muscle spasms and oculogyric crises. These
dystonic effects are more common in the young (especially
girls and young women) and the very old; they usually
occur shortly after starting treatment with
metoclopramide and subside within 24 hours of stopping
it. Injection of an antiparkinsonian drug such as
procyclidine will abort dystonic attacks.
l PREGNANCY Not known to be harmful.
l BREAST FEEDING Small amount present in milk; avoid.
l HEPATIC IMPAIRMENT Manufacturer advises caution in
severe impairment (risk of accumulation).
Dose adjustments Manufacturer advises dose reduction of
Dose adjustments Avoid or use small dose in severe
impairment; increased risk of extrapyramidal reactions.
l DIRECTIONS FOR ADMINISTRATION Oral liquid preparation
to be given via a graduated oral dosing syringe.
l PRESCRIBING AND DISPENSING INFORMATION
Palliative care For further information on the use of
metoclopramide hydrochloride in palliative care, see
www.medicinescomplete.com/#/content/palliative/
l PATIENT AND CARER ADVICE Counselling on use of pipette
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral solution
▶ Metoclopramide hydrochloride (Non-proprietary)
Metoclopramide hydrochloride 5 mg per 1 ml Metoclopramide
10mg/2ml solution for injection ampoules | 5 ampoule P £1.31–
£15.00 | 10 ampoule P £25.00 DT = £2.65
Metoclopramide hydrochloride 5 mg per 1 ml Maxolon 10mg/2ml
solution for injection ampoules | 12 ampoule P £3.21
Maxolon High Dose 100mg/20ml solution for injection ampoules | 10 ampoule P £26.68
▶ Metoclopramide hydrochloride (Non-proprietary)
Metoclopramide hydrochloride 1 mg per 1 ml Metoclopramide
5mg/5ml oral solution sugar free sugar-free | 150 ml P £19.77 DT
▶ Metoclopramide hydrochloride (Non-proprietary)
Metoclopramide hydrochloride 10 mg Metoclopramide 10mg
tablets | 28 tablet P £1.40 DT = £0.61
Metoclopramide hydrochloride 10 mg Maxolon 10mg tablets | 84 tablet P £5.24
Combinations available: Paracetamol with metoclopramide,
ANTIEMETICS AND ANTINAUSEANTS ›
NEUROKININ RECEPTOR ANTAGONISTS
Adjunct treatment to prevent nausea and vomiting
associated with moderately and highly emetogenic
▶ Adult: Initially 125 mg, dose to be taken 1 hour before
chemotherapy, then 80 mg once daily for 2 days,
consult product literature for dose of concomitant
dexamethasone and 5HT3-antagonist
l CONTRA-INDICATIONS Acute porphyrias p. 1058
l INTERACTIONS → Appendix 1: aprepitant
▶ Uncommon Anaemia . anxiety . burping . dizziness . drowsiness . dry mouth .febrile neutropenia .
BNF 78 Nausea and labyrinth disorders 433
l CONCEPTION AND CONTRACEPTION Manufacturer advises
effectiveness of hormonal contraceptives may be
reduced—alternative non-hormonal methods of
contraception necessary during treatment and for
2 months after stopping aprepitant.
l PREGNANCY Manufacturer advises avoid unless clearly
necessary—no information available.
l BREAST FEEDING Manufacturer advises avoid—present in
l HEPATIC IMPAIRMENT Manufacturer advises caution in
moderate to severe impairment—limited information
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension
▶ Emend (Merck Sharp & Dohme Ltd)
Aprepitant 80 mg Emend 80mg capsules | 2 capsule P £31.61
Aprepitant 125 mg Emend 125mg capsules | 5 capsule P £79.03
l DRUG ACTION Fosaprepitant is a prodrug of aprepitant.
Adjunct to dexamethasone and a 5HT3-receptor
antagonist in preventing nausea and vomiting associated
with moderately and highly emetogenic chemotherapy
▶ Adult: 150 mg, dose to be administered over
20–30 minutes and given 30 minutes before
chemotherapy on day 1 of cycle only, consult product
literature for dose of concomitant corticosteroid and
l CONTRA-INDICATIONS Acute porphyrias p. 1058
l INTERACTIONS → Appendix 1: fosaprepitant
l CONCEPTION AND CONTRACEPTION Effectiveness of
hormonal contraceptives reduced—effective nonhormonal methods of contraception necessary during
treatment and for 2 months after stopping fosaprepitant.
l PREGNANCY Avoid unless potential benefit outweighs
risk—no information available.
l BREAST FEEDING Avoid—present in milk in animal studies.
l HEPATIC IMPAIRMENT Manufacturer advises caution in
moderate to severe impairment—limited information
l DIRECTIONS FOR ADMINISTRATION For intravenous infusion
(Ivemend ®), manufacturer advises give intermittently in
Sodium chloride 0.9%; reconstitute each 150 mg vial with
5 mL sodium chloride 0.9% gently without shaking to avoid
foaming, then dilute in 145 mL infusion fluid; give over
l NATIONAL FUNDING/ACCESS DECISIONS
Scottish Medicines Consortium (SMC) decisions
The Scottish Medicines Consortium has advised (March
2011) that fosaprepitant (Ivemend ®) is accepted for
restricted use within NHS Scotland for the prevention of
acute and delayed nausea and vomiting associated with
highly emetogenic cisplatin-based chemotherapy in
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Powder for solution for infusion
▶ Ivemend (Merck Sharp & Dohme Ltd)
Fosaprepitant (as Fosaprepitant dimeglumine) 150 mg Ivemend
150mg powder for solution for infusion vials | 1 vial P £47.42
Adjunct to dexamethasone and a 5HT3-receptor
antagonist in preventing delayed nausea and vomiting
associated with moderately and highly emetogenic
▶ Adult: 180 mg as a single dose, dose should be
administered up to 2 hours before chemotherapy.
Interval between repeated doses must be at least
2 weeks, consult product literature for dose of
concomitant corticosteroid and 5HT3-antagonist
l INTERACTIONS → Appendix 1: rolapitant
▶ Common or very common Asthenia . constipation . headache
l PREGNANCY Manufacturer advises avoid unless potential
benefit outweighs risk—limited information available.
l BREAST FEEDING Manufacturer advises avoid—present in
434 Nausea and labyrinth disorders BNF 78
l HEPATIC IMPAIRMENT Manufacturer advises caution in
severe impairment (no information available).
l RENAL IMPAIRMENT Manufacturer advises use with
caution in severe impairment—limited information
l NATIONAL FUNDING/ACCESS DECISIONS
Scottish Medicines Consortium (SMC) decisions
The Scottish Medicines Consortium has advised (September
2017) that rolapitant (Varuby ®) is accepted for restricted
use within NHS Scotland as a first-line option for the
prevention of delayed nausea and vomiting in adults
undergoing highly emetogenic chemotherapy. This advice
is contingent upon the continuing availability of the
patient access scheme in NHS Scotland or a list price that
All Wales Medicines Strategy Group (AWMSG) decisions
The All Wales Medicines Strategy Group has advised (March
2018) that rolapitant (Varuby ®) is not recommended for
use within NHS Wales for the prevention of delayed
nausea and vomiting associated with highly and
moderately emetogenic cancer chemotherapy in adults.
The case for cost-effectiveness has not been proven.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 3
EXCIPIENTS: May contain Polysorbates
Rolapitant (as Rolapitant hydrochloride monohydrate)
90 mg Varuby 90mg tablets | 2 tablet P £47.42
ANTIEMETICS AND ANTINAUSEANTS ›
SEROTONIN (5HT3) RECEPTOR ANTAGONISTS
l DRUG ACTION Granisetron is a specific 5HT3-receptor
antagonist which blocks 5HT3 receptors in the gastrointestinal tract and in the CNS.
Nausea and vomiting induced by cytotoxic chemotherapy
for planned duration of 3–5 days where oral antiemetics
▶ BY TRANSDERMAL APPLICATION USING PATCHES
▶ Adult: Apply 3.1 mg/24 hours, apply patch to clean,
dry, non-irritated, non-hairy skin on upper arm (or
abdomen if upper arm cannot be used) 24–48 hours
before treatment, patch may be worn for up to 7 days;
remove at least 24 hours after completing
Prevention of postoperative nausea and vomiting
▶ Adult: 1 mg, to be administered before induction of
anaesthesia, dose to be diluted to 5 mL and given over
Treatment of postoperative nausea and vomiting
▶ Adult: 1 mg, dose to be diluted to 5 mL and given over
30 seconds; maximum 3 mg per day
Management of nausea and vomiting induced by cytotoxic
▶ Adult: 1–2 mg, to be taken within 1 hour before start of
treatment, then 2 mg daily in 1–2 divided doses for up
to 1 week following treatment, when intravenous route
also used, maximum combined total dose 9 mg in
▶ BY INTRAVENOUS INJECTION, OR BY INTRAVENOUS INFUSION
▶ Adult: 10–40 micrograms/kg (max. per dose 3 mg), to
be given 5 minutes before start of treatment, dose may
be repeated if necessary, further maintenance doses
must not be given less than 10 minutes apart, for
intravenous injection, each 1 mg granisetron diluted to
5 mL and given over not less than 30 seconds, for
intravenous infusion, to be given over 5 minutes;
l CAUTIONS Subacute intestinal obstruction . susceptibility
to QT-interval prolongation (including electrolyte
l INTERACTIONS → Appendix 1: granisetron
▶ Common or very common Constipation . headache
▶ With intravenous use or oral use Diarrhoea . insomnia
▶ With transdermal use Appetite decreased . arthralgia . dry
mouth . flushing . generalised oedema . vertigo
▶ With transdermal use Dystonia
l PREGNANCY Manufacturer advises avoid.
l BREAST FEEDING Avoid—no information available.
l HEPATIC IMPAIRMENT Manufacturer advises caution.
l DIRECTIONS FOR ADMINISTRATION
▶ With intravenous use For intravenous infusion, give
intermittently in Glucose 5% or Sodium Chloride 0.9%;
dilute up to 3 mL in 20–50 mL infusion fluid; give over
▶ With transdermal use Patients should be advised not to
expose the site of the patch to sunlight during use and for
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Granisetron (Non-proprietary)
Granisetron (as Granisetron hydrochloride) 1 mg per
1 ml Granisetron 3mg/3ml concentrate for solution for injection
ampoules | 5 ampoule P £24.00–£30.00 | 10 ampoule P £48.00
Granisetron 1mg/1ml concentrate for solution for injection ampoules
| 5 ampoule P £8.00–£10.00 | 10 ampoule P £16.00
▶ Granisetron (Non-proprietary)
Granisetron (as Granisetron hydrochloride) 1 mg Granisetron 1mg
tablets | 10 tablet P £51.20 DT = £40.79
Granisetron (as Granisetron hydrochloride) 2 mg Granisetron 2mg
tablets | 5 tablet P s DT = £52.39
▶ Kytril (Atnahs Pharma UK Ltd)
Granisetron (as Granisetron hydrochloride) 1 mg Kytril 1mg
tablets | 10 tablet P £52.39 DT = £40.79
Granisetron (as Granisetron hydrochloride) 2 mg Kytril 2mg
tablets | 5 tablet P £52.39 DT = £52.39
Granisetron 3.1 mg per 24 hour Sancuso 3.1mg/24hours
transdermal patches | 1 patch P £56.00 DT = £56.00
BNF 78 Nausea and labyrinth disorders 435
l DRUG ACTION Ondansetron is a specific 5HT3-receptor
antagonist which blocks 5HT3 receptors in the gastrointestinal tract and in the CNS.
Moderately emetogenic chemotherapy or radiotherapy
▶ Adult: Initially 8 mg, dose to be taken 1–2 hours before
treatment, then 8 mg every 12 hours for up to 5 days
▶ Adult: Initially 16 mg, dose to be taken 1–2 hours
before treatment, then 16 mg daily for up to 5 days
▶ INITIALLY BY INTRAMUSCULAR INJECTION, OR BY SLOW
▶ Adult: Initially 8 mg, dose to be administered
immediately before treatment, then (by mouth) 8 mg
every 12 hours for up to 5 days, alternatively (by
rectum) 16 mg daily for up to 5 days
▶ INITIALLY BY INTRAMUSCULAR INJECTION, OR BY INTRAVENOUS
▶ Elderly: Initially 8 mg, dose to be administered
immediately before treatment, intravenous infusion to
be given over at least 15 minutes, then (by mouth) 8 mg
every 12 hours for up to 5 days, alternatively (by
rectum) 16 mg daily for up to 5 days
Severely emetogenic chemotherapy (consult product
literature for dose of concomitant corticosteroid)
▶ Adult: 24 mg, dose to be taken 1–2 hours before
treatment, then 8 mg every 12 hours for up to 5 days
▶ Adult: 16 mg, dose to be administered 1–2 hours before
treatment, then 16 mg daily for up to 5 days
▶ INITIALLY BY INTRAMUSCULAR INJECTION, OR BY SLOW
▶ Adult: Initially 8 mg, dose to be administered
immediately before treatment, followed by (by
intramuscular injection or by slow intravenous
injection) 8 mg every 4 hours if required for 2 doses,
alternatively, followed by (by continuous intravenous
infusion) 1 mg/hour for up to 24 hours, then (by
mouth) 8 mg every 12 hours for up to 5 days,
alternatively (by rectum) 16 mg daily for up to 5 days
▶ INITIALLY BY INTRAMUSCULAR INJECTION
▶ Adult 65–74 years: Initially 8 mg, to be given
immediately before treatment, followed by (by
intramuscular injection) 8 mg every 4 hours if required
for 2 doses, alternatively, followed by (by continuous
intravenous infusion) 1 mg/hour for up to 24 hours,
then (by mouth) 8 mg every 12 hours for up to 5 days,
alternatively (by rectum) 16 mg daily for up to 5 days
▶ INITIALLY BY INTRAVENOUS INFUSION
▶ Adult: Initially 16 mg, immediately before treatment
(over at least 15 minutes), followed by (by
intramuscular injection or by slow intravenous
injection) 8 mg every 4 hours if required for 2 doses,
then (by mouth) 8 mg every 12 hours for up to 5 days,
alternatively (by rectum) 16 mg daily for up to 5 days
▶ Adult 65–74 years: Initially 8–16 mg, immediately
before treatment (over at least 15 minutes), followed
by (by intramuscular injection or by intravenous
infusion) 8 mg every 4 hours if required for 2 doses,
then (by mouth) 8 mg every 12 hours for up to 5 days,
alternatively (by rectum) 16 mg daily for up to 5 days
▶ Adult 75 years and over: Initially 8 mg, immediately
before treatment (over at least 15 minutes), followed
by (by intravenous infusion) 8 mg every 4 hours if
required for 2 doses, then (by mouth) 8 mg every
12 hours for up to 5 days, alternatively (by rectum)
Prevention of postoperative nausea and vomiting
▶ Adult: 16 mg, dose to be taken 1 hour before
anaesthesia, alternatively (by intramuscular injection
or by slow intravenous injection) 4 mg, dose to be
administered at induction of anaesthesia
Treatment of postoperative nausea and vomiting
▶ BY INTRAMUSCULAR INJECTION, OR BY SLOW INTRAVENOUS
l CONTRA-INDICATIONS Congenital long QT syndrome
l CAUTIONS Adenotonsillar surgery . subacute intestinal
obstruction . susceptibility to QT-interval prolongation
(including electrolyte disturbances)
l INTERACTIONS → Appendix 1: ondansetron
▶ Common or very common Constipation . feeling hot. headache . sensation abnormal
▶ Rare or very rare Dizziness . QT interval prolongation . vision disorders
l PREGNANCY No information available; avoid unless
potential benefit outweighs risk.
l BREAST FEEDING Present in milk in animal studies—avoid.
l HEPATIC IMPAIRMENT Manufacturer advises caution in
moderate to severe impairment (decreased clearance).
Dose adjustments Manufacturer advises maximum 8 mg
daily in moderate to severe impairment.
l DIRECTIONS FOR ADMINISTRATION
▶ With intravenous use For intravenous infusion (Zofran ®), give
continuously or intermittently in Glucose 5% or Glucose
5% with Potassium chloride 0.3% or Sodium chloride 0.9%
or Sodium chloride 0.9% with Potassium chloride 0.3% or
Mannitol 10% or Ringers solution; for intermittent
infusion, dilute the required dose in 50–100 mL of infusion
fluid and give over at least 15 minutes.
▶ With oral use Orodispersible films and lyophylisates should
be placed on the tongue, allowed to disperse and
l PRESCRIBING AND DISPENSING INFORMATION Flavours of
oral liquid formulations may include strawberry.
l PATIENT AND CARER ADVICE Patients or carers should be
given advice on how to administer orodispersible films and
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension, oral
▶ Ondansetron (Non-proprietary)
Ondansetron (as Ondansetron hydrochloride) 4 mg Ondansetron
4mg tablets | 10 tablet P £0.81–£25.46 DT = £9.94 | 30 tablet P £3.15–£76.38
Ondansetron (as Ondansetron hydrochloride) 8 mg Ondansetron
8mg tablets | 10 tablet P £47.99 DT = £10.31
▶ Ondemet (Alliance Pharmaceuticals Ltd)
Ondansetron (as Ondansetron hydrochloride) 8 mg Ondemet 8mg
tablets | 10 tablet P £54.36 DT = £10.31 (Hospital only)
▶ Zofran (Novartis Pharmaceuticals UK Ltd)
Ondansetron (as Ondansetron hydrochloride) 4 mg Zofran 4mg
Ondansetron (as Ondansetron hydrochloride) 8 mg Zofran 8mg
tablets | 10 tablet P £71.94 DT = £10.31
▶ Zofran (Novartis Pharmaceuticals UK Ltd)
Ondansetron 16 mg Zofran 16mg suppositories | 1 suppository P £14.39
436 Nausea and labyrinth disorders BNF 78
▶ Ondansetron (Non-proprietary)
Ondansetron (as Ondansetron hydrochloride) 2 mg per
1 ml Ondansetron 8mg/4ml solution for injection ampoules | 5 ampoule P £11.80–£58.45 DT = £59.95
▶ Zofran Flexi-amp (Novartis Pharmaceuticals UK Ltd)
Ondansetron (as Ondansetron hydrochloride) 2 mg per
1 ml Zofran Flexi-amp 8mg/4ml solution for injection | 5 ampoule P £59.95 DT = £59.95
Zofran Flexi-amp 4mg/2ml solution for injection | 5 ampoule P £29.97 DT = £29.97
▶ Ondansetron (Non-proprietary)
Ondansetron (as Ondansetron hydrochloride) 800 microgram
per 1 ml Ondansetron 4mg/5ml oral solution sugar free sugar-free | 50 ml P £38.11 DT = £38.10
▶ Zofran (Novartis Pharmaceuticals UK Ltd)
Ondansetron (as Ondansetron hydrochloride) 800 microgram
per 1 ml Zofran 4mg/5ml syrup sugar-free | 50 ml P £35.97 DT =
▶ Setofilm (Norgine Pharmaceuticals Ltd)
Ondansetron 4 mg Setofilm 4mg orodispersible films sugar-free | 10 film P £28.50 DT = £28.50
Ondansetron 8 mg Setofilm 8mg orodispersible films sugar-free |
EXCIPIENTS: May contain Aspartame
▶ Zofran Melt (Novartis Pharmaceuticals UK Ltd)
Ondansetron 4 mg Zofran Melt 4mg oral lyophilisates sugar-free |
10 tablet P £35.97 DT = £35.97
Ondansetron 8 mg Zofran Melt 8mg oral lyophilisates sugar-free | 10 tablet P £71.94 DT = £71.94
▶ Ondansetron (Non-proprietary)
Ondansetron 4 mg Ondansetron 4mg orodispersible tablets |
10 tablet P £43.46 DT = £43.46
Ondansetron 8 mg Ondansetron 8mg orodispersible tablets | 10 tablet P £85.43 DT = £85.43
l DRUG ACTION Palonosetron is a specific 5HT3-receptor
antagonist which blocks 5HT3 receptors in the gastrointestinal tract and in the CNS.
Moderately emetogenic chemotherapy
▶ Adult: 500 micrograms, dose to be taken 1 hour before
treatment, alternatively (by intravenous injection)
250 micrograms for 1 dose, dose to be administered
over 30 seconds, 30 minutes before treatment
Severely emetogenic chemotherapy
▶ Adult: 250 micrograms for 1 dose, dose to be
administered over 30 seconds, 30 minutes before
l INTERACTIONS → Appendix 1: palonosetron
▶ Common or very common Constipation . headache
▶ With intravenous use Diarrhoea . dizziness . electrolyte
imbalance . metabolic disorder
▶ With intravenous use Amblyopia . anxiety . appetite
▶ With oral use Atrioventricular block . dyspnoea . eye
l PREGNANCY Avoid—no information available.
l BREAST FEEDING Avoid—no information available.
Driving and skilled tasks Dizziness or drowsiness may affect
performance of skilled tasks (e.g. driving).
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Palonosetron (Non-proprietary)
Palonosetron (as Palonosetron hydrochloride) 50 microgram per
▶ Aloxi (Chugai Pharma UK Ltd)
Palonosetron (as Palonosetron hydrochloride) 50 microgram per
1 ml Aloxi 250micrograms/5ml solution for injection vials | 1 vial P £55.89
▶ Aloxi (Chugai Pharma UK Ltd)
Palonosetron (as Palonosetron hydrochloride)
500 microgram Aloxi 500microgram capsules | 1 capsule P £55.89
Palonosetron with netupitant 20-Jun-2016
The properties listed below are those particular to the
combination only. For the properties of the components
please consider, palonosetron above.
Moderately emetogenic chemotherapy | Highly emetogenic
▶ Adult: 1 capsule, to be taken approximately 1 hour
before the start of each chemotherapy cycle
l CAUTIONS Patients over 75 years
l INTERACTIONS → Appendix 1: netupitant. palonosetron
▶ Common or very common Asthenia . constipation . headache
prolongation . sleep disorders . urticaria . vertigo
incompetence . mood altered . myocardial ischaemia . numbness . pain .tongue coated . vision blurred
l CONCEPTION AND CONTRACEPTION Manufacturer
recommends exclude pregnancy before treatment in
females of childbearing age; ensure effective
contraception during treatment and for one month after
BNF 78 Nausea and labyrinth disorders 437
l PREGNANCY Manufacturer advises avoid—toxicity in
l BREAST FEEDING Manufacturer advises avoid during
treatment and for 1 month after last dose—no information
l HEPATIC IMPAIRMENT Manufacturer advises caution in
severe impairment (risk of increased exposure, limited
l NATIONAL FUNDING/ACCESS DECISIONS
Scottish Medicines Consortium (SMC) decisions
The Scottish Medicines Consortium (December 2015) has
advised that palonosetron in combination with netupitant
(Akynzeo ®) is accepted for restricted use within NHS
Scotland for the prevention of acute and delayed nausea
and vomiting associated with highly emetogenic cisplatinbased cancer chemotherapy.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 25
▶ Akynzeo (Chugai Pharma UK Ltd) A
Palonosetron (as Palonosetron hydrochloride) 500 microgram,
Netupitant 300 mg Akynzeo 300mg/0.5mg capsules | 1 capsule P £69.00 (Hospital only)
ANTIHISTAMINES › SEDATING ANTIHISTAMINES
Relief of symptoms of vestibular disorders, such as
vertigo, tinnitus, nausea, and vomiting in Ménière’s
▶ Child 5–11 years: 15 mg 3 times a day
▶ Child 12–17 years: 30 mg 3 times a day
▶ Child 5–11 years: Initially 15 mg, dose to be taken
2 hours before travel, then 7.5 mg every 8 hours if
required, dose to be taken during journey
▶ Child 12–17 years: Initially 30 mg, dose to be taken
2 hours before travel, then 15 mg every 8 hours if
required, dose to be taken during journey
▶ Adult: Initially 30 mg, dose to be taken 2 hours before
travel, then 15 mg every 8 hours if required, dose to be
l CONTRA-INDICATIONS Avoid in Acute porphyrias p. 1058
l CAUTIONS Epilepsy . glaucoma (in children). Parkinson’s
l INTERACTIONS → Appendix 1: antihistamines, sedating
▶ Common or very common Drowsiness . gastrointestinal
discomfort. nausea . weight increased
▶ Uncommon Fatigue . hyperhidrosis . vomiting
cutaneous lupus erythematosus .tremor
l PREGNANCY Manufacturer advises avoid; however, there
is no evidence of teratogenicity. The use of sedating
antihistamines in the latter part of the third trimester may
cause adverse effects in neonates such as irritability,
paradoxical excitability, and tremor.
l BREAST FEEDING Most antihistamines are present in
breast milk in varying amounts; although not known to be
harmful, most manufacturers advise avoiding their use in
mothers who are breast-feeding.
l HEPATIC IMPAIRMENT Manufacturer advises caution in
hepatic insufficiency—no information available.
l RENAL IMPAIRMENT Use with caution—no information
Driving and skilled tasks Drowsiness may affect
performance of skilled tasks (e.g. cycling, driving);
sedating effects enhanced by alcohol.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension
CAUTIONARY AND ADVISORY LABELS 2
▶ Cinnarizine (Non-proprietary)
Cinnarizine 15 mg Cinnarizine 15mg tablets | 84 tablet p £15.40
▶ Stugeron (Johnson & Johnson Ltd, Janssen-Cilag Ltd)
Cinnarizine 15 mg Stugeron 15mg tablets | 15 tablet p £2.21 |
Cinnarizine with dimenhydrinate
The properties listed below are those particular to the
combination only. For the properties of the components
please consider, cinnarizine above.
▶ Adult: 1 tablet 3 times a day
l INTERACTIONS → Appendix 1: antihistamines, sedating . dimenhydrinate
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 2, 21
▶ Arlevert (Hennig Arzneimittel GmbH & Co. KG)
Cinnarizine 20 mg, Dimenhydrinate 40 mg Arlevert tablets | 100 tablet P £24.00 DT = £24.00
Nausea | Vomiting | Labyrinthine disorders
▶ Child 5–9 years: 12.5–37.5 mg daily
▶ Child 10–17 years: 25–75 mg daily; maximum 100 mg
▶ Adult: 25–75 mg daily; maximum 100 mg per day
Motion sickness prevention (acts longer than
▶ Child 5–9 years: 12.5 mg once daily, dose to be taken at
bedtime on night before travel or 1–2 hours before
▶ Child 10–17 years: 25 mg once daily, dose to be taken at
bedtime on night before travel or 1–2 hours before
▶ Adult: 25 mg once daily, dose to be taken at bedtime on
night before travel or 1–2 hours before travel
Motion sickness treatment (acts longer than
▶ Child 5–9 years: 12.5 mg, dose to be taken at onset of
motion sickness, then 12.5 mg daily for 2 days, dose to
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