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Broad-Spectrum Antiemesis in Decompressed MBO — SCE Palliative Medicine MCQ

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HardNausea & VomitingBroad-Spectrum Antiemesis in Decompressed MBOSCE Palliative Medicine

A 72‑year‑old woman with advanced ovarian cancer has intractable nausea and vomiting from complete large bowel obstruction. She has a venting gastrostomy draining 500 mL/day. Despite octreotide 600 µg/24 h CSCI and haloperidol, she remains nauseous. What pharmacological addition best targets residual nausea despite decompression?

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Correct answer: C — Levomepromazine 6.25–12.5 mg/24 h SC – broad‑spectrum anti‑emetic (D₂, 5‑HT₂, H₁, mAch)

This patient’s nausea persists despite decompression and blockade of key pathways (antisecretory octreotide; dopamine antagonism with haloperidol). UK palliative care guidance (Scottish guidelines and NHS England formularies) recommend levomepromazine—a broad‑spectrum anti‑emetic acting on dopamine, serotonin, histamine and muscarinic receptors—when nausea is refractory to first‑line agents. Prokinetics like metoclopramide and erythromycin are contraindicated in complete obstruction due to risk of perforation; ondansetron is too narrow in action; domperidone likewise is limited to D₂ antagonism. Levomepromazine at 6.25–12.5 mg/24 h SC aligns with standard UK practice.

Reference: Scottish Palliative Care Guidelines (Levomepromazine, 2025); SmPC Levomepromazine (2024)