Palliative : Anti-Emetics


Nausea & Vomiting

Persistent nausea can often be effectively controlled by using a combination of medications tailored to meet that individual's specific needs. Dosage forms include transdermal gels, suppositories, lollipops, and more.



Promethazine is commonly compounded for topical or transdermal application to treat nausea, vomiting, and vertigo, but this preparation may be used as an antiemetic for cases ranging from chemotherapy to motion sickness. The dose is typically 25mg for adults, and the dose is decreased for children. The gel is applied to an area of soft skin, such as the inside of the wrist or arm, the side of the torso, or the inside of the thigh. For children, doses are often applied to the inside of one wrist, and then the wrists are rubbed together.
US Pharmacist, August 1999; 74-5


Lorazepam, diphenhydramine, haloperidol, and metoclopramide (known in combination as "ABHR") have been prepared as a rectal suppository and in other transdermal dosage forms. The rationale is to use a variety of medications which target various pathways such as vagal nerve stimulation, the vomiting center, and the CTZ for more severe cases. Researchers at Memorial Sloan-Kettering Cancer Centre have studied the antiemetic activity and safety of the antiemetic regimen of metoclopramide, dexamethasone, and diphenhydramine in patients receiving standard outpatient chemotherapy programs. Vomiting was prevented in over 70% of patients.



Cancer 1995 Sep 1;76(5):774-8
Oral combination antiemetics in patients with small cell lung cancer receiving cisplatin or cyclophosphamide plus doxorubicin.
Click here to access the PubMed abstract of this article.


Intranasal metoclopramide may significantly reduce the frequency of acute vomiting in patients receiving highly emetogenic chemotherapy, such cisplatin-induced delayed emesis. Intranasal metoclopramide caused minor irritation of the nasal membrane and unpleasant taste in some patients, but was otherwise well tolerated, with no report of serious extrapyramidal effects.

Drugs 1999 Aug;58(2):315-22; discussion 323-4
Intranasal metoclopramide.
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ABH Transdermal Gel for Chemotherapy-Induced Nausea/Vomiting

Chemotherapy-induced nausea and vomiting (CINV) is commonly cited by patients as being among the “most unpleasant and distressing” side effects associated with chemotherapy. CINV may impair quality of life significantly and necessitate chemotherapeutic dose reductions, treatment delays, and discontinuation of therapy. Finally, it may cause a substantial number of lost work days for patients and considerable costs to the healthcare system, resulting in a substantial economic burden.

Bleicher et al. of the Haematology/Oncology Division, Creighton University Medical Centre, Omaha, NE, investigated the efficacy of "ABH," a topical gel containing lorazepam (Ativan®), diphenhydramine (Benadryl®), and haloperidol (Haldol®), in reducing breakthrough CINV. Adults receiving standard recommended prophylactic antiemetics as outpatients were instructed to apply 0.5 mL of a transdermal gel (containing lorazepam 2 mg, diphenhydramine 25 mg, and haloperidol 2 mg) when they experienced significant CINV. When the severity of CINV was quantified on a scale of 0-10, the mean CINV score decreased significantly from a 6.1 before gel application to a 1.7 as evaluated 30 minutes following gel application. Topical use of ABH gel appears to be a promising and safe rescue therapy for breakthrough CINV that occurs despite prophylactic antiemetic therapy.1

Weschules noted that of 11,181 ABHR (ABH plus metoclopramide [Reglan®]) prescriptions provided for patients, 6,529 (58.4%) were for a topical gel, and 4,312 (38.6%) were for a rectal suppository.2 Less than 0.5% of patients discontinued treatment due to adverse side effects. Another retrospective study reported use of an ABHR gel to be 98% effective in hospice patients.3 There were no adverse reactions; however, problems arose when patients with bowel obstructions were treated.

1 J Support Oncol. 2008 Jan;6(1):27-32.
Lorazepam, diphenhydramine, and haloperidol transdermal gel for rescue from chemotherapy-induced nausea/vomiting: results of two pilot trials.
Click here to access the PubMed abstract of this article.

2 J Palliat Med 2008;8:1135–1143.
Tolerability of the compound ABHR in hospice patients.
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3 Int J Pharm Compounding 2006;10:95–99.
ABHR Gel in the Treatment of Nausea and Vomiting in the Hospice Patient
Click here to access the abstract of this article.