# Nausea and vomiting in advanced cancer not caused by cancer treatment

Source: https://onco.cc/protocols/nausea-and-vomiting-in-advanced-cancer/  
OnCo record `nausea-and-vomiting-in-advanced-cancer` (Protocol). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

In advanced cancer, nausea and vomiting often have a cause that can be found and treated, such as constipation, a high calcium level, a medicine, or a blocked bowel. Your team will look for the cause, stop medicines that may worsen it, and choose an anti-sickness medicine that suits it, under the skin or by a small pump if tablets will not stay down. Say if it is not improving.

## Summary

MASCC/ESMO (2016, the latest statement) found the evidence minimal and of low quality, and recommend metoclopramide titrated to effect as the drug of choice, with haloperidol, levomepromazine or olanzapine as alternatives; for bowel obstruction, octreotide with an antiemetic (haloperidol), or an anticholinergic antisecretory agent where octreotide is not an option. MASCC's 2021 update keeps octreotide as the drug of choice in inoperable bowel obstruction and suggests olanzapine or metoclopramide for partial obstruction. The Scottish Palliative Care Guidelines (2025) take a cause-based approach: identify and treat reversible causes, deprescribe, choose the antiemetic for the likely mechanism (haloperidol first for chemical or drug causes, metoclopramide for gastric stasis once complete obstruction is excluded, cyclizine for raised intracranial pressure or vestibular causes, levomepromazine as a broad-spectrum agent), use non-oral routes when needed, avoid combining prokinetics with anticholinergics, consider an ECG for QTc, and start olanzapine or mirtazapine only on specialist advice. In the one randomised comparison of the two approaches (185 people), a cause-based regimen worked faster at 24 hours but was no better than haloperidol alone at 72 hours. Methotrimeprazine (levomepromazine) was no better than haloperidol in a double-blind trial, and olanzapine 5 mg markedly reduced chronic nausea against placebo in a pilot trial of 30 people.

## Fields

- Kind: Protocol
- Last checked: 2026-11-11
- Also known as: palliative nausea and vomiting; chronic nausea in advanced cancer; nausea not related to chemotherapy; antiemetic choice in palliative care; malignant bowel obstruction nausea
- Tags: protocol; nausea-and-vomiting; palliative

## Connected records

- technologies: [Antiemetics for chemotherapy-induced nausea and vomiting](https://onco.cc/technologies/antiemetic-therapy/), [Early integrated palliative care](https://onco.cc/technologies/palliative-care/), [Syringe pumps and subcutaneous syringe drivers](https://onco.cc/technologies/syringe-drivers/)
- drugs: [Dexamethasone](https://onco.cc/drugs/dexamethasone/), [Somatostatin analogues (octreotide, lanreotide)](https://onco.cc/drugs/octreotide-lanreotide/)
- protocols: [Anticipatory nausea and vomiting before chemotherapy: prevention and treatment](https://onco.cc/protocols/anticipatory-nausea-and-vomiting/), [Antiemetic prophylaxis for chemotherapy by emetic risk](https://onco.cc/protocols/antiemetic-prophylaxis-by-emetic-risk/)
- fronts: [Supportive Care & Survivorship](https://onco.cc/fronts/supportive-care/)
- institutions: [European Society for Medical Oncology (ESMO)](https://onco.cc/institutions/esmo/), [Multinational Association of Supportive Care in Cancer](https://onco.cc/institutions/mascc/)
- terms: [QT prolongation](https://onco.cc/terms/qt-prolongation/)
- bottlenecks: [Pain relief and palliative care are unavailable to most](https://onco.cc/bottlenecks/b-palliative/)

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