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Common Medications

Important Note: The class of drugs known as serotonin antognists (Zofran/ondansetron, Anzemet/dolasetron, Kytril/granisetron) are dose-dependent drugs. Both benefits and side-effects increase with the dose. Some women improve greatly on the higher doses, thus avoiding IV's and expensive hospitalization. Gradual reduction in dose, then frequency, is critical to avoid relapse. Intervene early in women with more severe symptoms, and in women who have a history of HG. It is equally important to prevent side-effects like constipation from dehydration, pregnancy and medications.

Read our brochure on medication strategies! Learn how to get the most from medications & use them to manage HG most effectively!

Remember: Individual responses to medications vary greatly. Treatment should start with targeting the triggers of nausea/vomiting such as motion sensitivity, while ensuring adequate hydration and metabolic balance. If there are numerous triggers, medications that directly target the vomiting center in the brain (serotonin antagonists) are likely most effective. If a woman is vomiting constantly, oral dosing of medications will likely be ineffective. Instead, try a few days of IV dosing followed by a trial of oral medication or an alternate route if vomiting remains uncontrolled.

To look up a drug for more information about its use or safety:

Important Note: The class of drugs known as serotonin antognists (Zofran/ondansetron, Anzemet/dolasetron, Kytril/granisetron) are dose-dependent drugs. Both benefits and side-effects increase with the dose. Some women improve greatly on the higher doses, thus avoiding IV's and expensive hospitalization. Gradual reduction in dose, then frequency, is critical to avoid relapse. Intervene early in women with more severe symptoms, and in women who have a history of HG. It is equally important to prevent side-effects like constipation from dehydration, pregnancy and medications.

Read our brochure on medication strategies! Learn how to get the most from medications & use them to manage HG most effectively!

Remember: Individual responses to medications vary greatly. Treatment should start with targeting the triggers of nausea/vomiting such as motion sensitivity, while ensuring adequate hydration and metabolic balance. If there are numerous triggers, medications that directly target the vomiting center in the brain (serotonin antagonists) are likely most effective. If a woman is vomiting constantly, oral dosing of medications will likely be ineffective. Instead, try a few days of IV dosing followed by a trial of oral medication or an alternate route if vomiting remains uncontrolled.

Mother's Note: If you have pre-existing medical conditions (diabetes, heart disease, etc.), a history of medication reactions, or are a smoker, please inform your physician before taking medications.

Medication Tips

SEROTONIN ANTAGONISTS

Highly selective antagonist of 5-HT3 receptors in the vagus, CTZ (chemotrigger zone) and gut. Mostly Class B drugs. Found to improve symptoms in >80% of women.

More common side-effects: Headache, mild liver function abnormalities, constipation*, diarrhea
* Proactive, daily bowel management is very important. For information on managing these symptoms, see this article on MedicineNet.

Often effective in mothers who have multiple triggers (smell, motion, etc.), a history of hormone sensitivity, and/or moderate to severe vomiting. If a woman has a history of HG that responded to serotonin antagonists, it should be considered as a first line drug to minimize symptom severity.

IMPORTANT: Effects are dose dependent. Expensive intravenous therapies and termination may be avoided with higher doses. Best taken on a strict schedule and weaned very slowly when asymptomatic for two weeks. It is not uncommon to need this medication until delivery. Different brands may have different effects and dissolvability.


Drug Name Min/Max Dosage Notes Research Studies

Zofran, Zuplenz
(Ondansetron)

 

(** Update on Zofran lawsuits)

4 to 8 mg every 6 hours

Given via SQ pump, oral tablet, liquid,NEW Researchquick dissolve film, or IV. Suppository available outside US.

Can be compounded into a suppository or other form.

Dosing throughout pregnancy may prevent relapse or stabilize symptoms.

Zofran tablets are available as a generic.

Widely available around the world.

Proactively treat with a daily regimen of stool softeners and laxatives as needed.

Some mothers report the generic oral dissolvable tablets do not dissolve as well.

Ondansetron compared with doxylamine and pyridoxine (Diclegis/Diclectin) for treatment of nausea in pregnancy

Antiemetic medications in pregnancy: a prospective investigation of obstetric and neurobehavioral outcomes.

Ondansetron in pregnancy and risk of adverse fetal outcomes. (2013)

Secular Trends in the Treatment of Hyperemesis Gravidarum. (2007)

Pharmacokinetics of Three Formulations of Ondansetron

More research articles on PubMed.

Kytril, Sancuso
(Granisetron)
1 mg every 12 hours (IV or orally)

Allows twice a day dosing.

Also available in transdermal patch form as Sancuso.NEW Research
Kytril is now available as a generic.NEW Research

Research articles on PubMed.
Mirtazapine (Remergil, Remeron)   May interact with sedatives, antihistamines, and tricyclic antidepressants.

Has both anti-vomiting and anti-depressant effects.

Mirtazapine (Remergil) for treatment resistant hyperemesis gravidarum: rescue of a twin pregnancy.

Mirtazapine use in resistant hyperemesis gravidarum: report of three cases and review of the literature.

More research articles on PubMed.

Aloxi
(palonosetron)
Dose not established in HG. 0.25 mg IV given for chemo. Half-life: 40 hr. & only given once in 5 days.
Reimbursement Support Network.
None for HG yet. Research on PubMed.
Anzemet
(Dolasetron)
Dose not established in HG. 50-150 mg orally daily is reported.   Research articles on PubMed.

SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONIST

This is a NEWER class of drugs so minimal safety data is available. No studies for its use in pregnancy are available. We caution the use of this medication class at this point.

Research Links:

Drug Name Min/Max Dosage Notes Research Studies
EmendNEW Research (Aprepitant)

80-125 mg per day is dose for chemotherapy

Oral and IV

Typical protocol (prevention of vomiting due to chemotherapy) includes combining with a serotonin antagonists and steroids. None for HG yet.

CORTICOSTEROIDS

Cortisone/Corticosteroids - Not recommended until after 8-10 weeks
Some possible side-effects include blood sugar instability, weight loss, nausea and vomiting.

Steroids are used for refractory hyperemesis gravidarum; however, there is some concern over fetal brain development with prolonged dosing at high levels, and use during the first trimester. No studies have conclusively proven a link thus far.

Complications including reduced birth weight, increased risk of preeclampsia, and increased risk of oral and lip clefts have been reported when corticosteroids were administered during early pregnancy. However, the Collaborative Perinatal Project monitored 50,282 mother-child pairs, 34 of which had first-trimester exposure to cortisone. No evidence of a relationship to congenital defects was observed. If these drugs are used during pregnancy, the potential risks should be discussed. Babies born to women receiving large doses of corticosteroids during pregnancy should be monitored for signs of adrenal insufficiency and appropriate therapy initiated, if necessary.

The typical treatment is a steroid burst with a rapid taper similar to what is used in acute asthma attacks. [Most studies of asthma patients using steroids show no adverse fetal effects.]

Women with hypothyroidism may have an exaggerated response to corticosteroids; use with caution in these mothers. Type 1 Diabetics may require as much as a 40% increase in their insulin when high dose steroids are started.

Drug Classification:
Methylprednisolone is classified as pregnancy category C. Prednisone is classified as category B but cortisone is classified as pregnancy category D. This probably reflects the fact that cortisone is more commonly used during pregnancy than is prednisone and therefore, more reports of problems have been associated with cortisone than prednisone, not that it is a more potent teratogen. Corticosteroids cross the placenta. [From: Clinical Pharmacology 2000]

(See below for FDA-Assigned Pregnancy Categories)

Drug Name Min/Max Dosage Notes Research Studies
Medrol or Solu-Medrol (Methylprednisolone or Prednisone) Typical oral dosage is 48 mg per day for three to five days, followed by slow tapering over two to three weeks.

Limit to one month of therapy if possible.

See article for more on dosing.
Consideration should be given to using with serotonin antagonists and/or during weaning from steroids to prevent relapse.

Corticosteroid therapy in hyperemesis gravidarum

Termination is not the treatment of choice for severe hyperemesis gravidarum: Successful management using prednisolone

More Research on PubMed

ANTIHISTAMINES

Common side-effects: Drowsiness, dry mouth, blurred vision, constipation, urinary retention, restlessness, insomnia, sedation, upset stomach, nervousness, headache.

Mostly Class B drugs

Effective for MILD cases of nausea and vomiting during pregnancy or as adjunctive therapy. Antihistamines with sedative effects can be helpful for sleep.

Research Links:

Drug Name Min/Max Dosage Notes Research Studies
Bonine, Antivert, Marezine
(Meclizine/Buclizine/Cyclizine)
Follow directions on the label. See Medline Plus  
Dramamine
(Dimenhydrinate)
50-100 mg every 4-6 hours Used for motion sickness.  
Doxylamine
(Unison)
25 mg orally at bedtime,
1/2 tablet every 6 hours as needed
Component of Bendectin/Diclectin.

Often taken with vitamin B6.
 
Diclectin, DiclegisNEW Research
(doxylamine plus pyridoxine)
Average dose is 1 tablet in morning, one in afternoon and two at night.

May be given in higher doses up to 12 tablets daily - see research links on right.
Differs from Unisom/B6 combo because it is a delayed release formula.

Ondansetron compared with doxylamine and pyridoxine (Diclegis/Diclectin) for treatment of nausea in pregnancy

The return to the USA of doxylamine-pyridoxine delayed release combination (Diclegis®) for morning sickness.

Benadryl
(Diphenhydramine or Gravol)
25 mg IVP/orally every 4–6 hours      
Tigan
(Trimethobenzamide)
25 mg orally every 6-8 hours
200 mg IM every 6-8 hours
   
Vistaril, Atarax
(Hydroxyzine)
25 mg orally every 6 hours Syrup available
Helpful for insomnia
 

ANTIDOPAMINERGICS: PHENOTHIAZINES

Common side-effects: Drowsiness, hypotension, dry mouth, constipation, urinary retention, rash, extrapyramidal symptoms (EPS), restlessness, confusion, fatigue. Phenothiazines lower seizure threshold.

Mostly Class C drugs.

May be helpful in mild and moderate cases or used in conjunction with other medications. Consider co-administration of antihistamines to minimize side-effects.

(Immediately report extrapyramidal symptoms include: involuntary movements, tremors and rigidity, body restlessness, muscle contractions and changes in breathing and heart rate.)

Drug Name Typical Min/Max Dosage Notes Research Studies
Compazine, Stemetil
(Prochlorperazine)
5–10 mg orally, IM, or IV every 6–8 hours

Rectal 25 mg every 6–8 hours
Risk of EPS additive with metoclopramide (Reglan). Treat EPS symptoms with Benadryl (can prophylax with Benadryl). Research articles on PubMed.
Phenergan
(Promethazine)

12.5–25 mg IVP/orally, IM/PR every 4-6 hours

 

*IV dose contains sulfite

NEW Research Warning: IV or injected doses can cause tissue damage. More info available on fda.gov. GIVE IV dose SLOWLY to avoid contractions.

Side-effects such as anxiety, sedation, and restlessness common and may limit use.
Research articles on PubMed.
Thorazine
(Chlorpromazine)
Oral/IM 12.5–25mg every 4–6 hours
Rectal 50–100 mg every 6–8 hours
May increase risk of fetal malformations.

May cause muscle spasms in neck/face and/or difficulty with speech.
Research articles on PubMed.
Haldol
(Haloperidol)
1–2 mg orally/IM every 8 hours Extrapyramidal symptoms (EPS) more common. May cause constipation. Research articles on PubMed.

ANTIREFLUX MEDICATIONS

Common side-effects: Headache, dizziness, difficulty sleeping, constipation, diarrhea.

This class of drugs is helpful both for reflux and for prevention of gastric irritation which worsens nausea. They should be considered whenever a woman is vomiting frequently and/or cannot eat and drink sufficiently. Studies suggest they are safe during pregnancy. Mostly Class B drugs. [This list is not inclusive of all medications available.]

Research Links:

Drug Name Min/Max Dosage Notes Research Studies
Zantac
(Ranitidine)
50 mg IV every 8 hours or 150 mg orally daily or twice a day    
Tagamet
(Cimetidine)
  Not recommended during pregnancy due to anti-androgenic effects in humans. Illinois Teratogen Information Service
Gastroesophogeal Reflux (GERD) Medications in Pregnancy
Pepcid
(Famotidine)
20 mg IVP/orally every 12 hours    
Prevacid
(Lansoprazole)
30-60 mg/day   AAFP 2002
Proton Pump Inhibitors: An Update.

Use of proton pump inhibitors during pregnancy and rates of major malformations: a meta-analysis.

PROKINETIC AGENTS

Reglan blocks dopamine receptors in the CTZ (chemoreceptor trigger zone) and increases the CTZ threshold & decreases the sensitivity of visceral nerves that transmit afferent impulses from the GI tract to the vomiting center.

May be helpful in women who typically vomit after eating/drinking, and who may not respond to other medications such as Zofran. These drugs are sometimes used in conjunction with meds such as Zofran. Use with antihistamines to minimize side-effects. Side-effects are very common and can be severe, especially when given quickly through an IV.

Common side-effects: Drowsiness, dizziness, abdominal pain, diarrhea, restlessness, EPS, depression

(Extrapyramidal symptoms include: involuntary movements, tremors and rigidity, body restlessness, muscle contractions and changes in breathing and heart rate.)

Drug Name Min/Max Dosage Notes Research Studies
Reglan or Maxeran
(Metoclopramide)
10–20 mg IV/orally every 6 hours

May be given orally, SQ pump, IV
NEW ResearchFDA recommends this drug be taken for up to 12 weeks. Risks of serious side-effects increase thereafter.

Additive CNS side effects when used with phenothiazines.

Side-effects common and may limit use.

Class B drug.

Ondansetrone or metoclopromide? Which is more effective in severe nausea and vomiting of pregnancy?

Ondansetron compared with metoclopramide for hyperemesis gravidarum: a randomized controlled trial.

The safety of metoclopramide during pregnancy

Home Infusion of Reglan

Propulsid
(Cisapride)
10 mg orally every 6 hours, before meals and at bedtime (maximum dose 20 mg every 6 hours) No CNS side effects. Limited availability in US.  

ANTICHOLINERGICS/ANTISPASMODICS

Common side-effects: Confusion; dizziness, lightheadedness (continuing) or fainting; eye pain; skin rash or hives.

Should not be used in treatment of hyperemesis gravidarum. These agents slow gastric emptying and prolong GI transit time. Since slowed gastric emptying is part of the etiology of HG, these agents are inappropriate.

Drug Name Min/Max Dosage Notes Research Studies
Scopolamine, Belladonna
(Hyoscine Hydrobromide)

0.3 to 0.65 mg administered IV, intramuscularly or subcutaneously every 6 to 8 hours as needed

1.5 mg transdermal disc behind the ear every 3 days

 

Effectiveness studies are lacking.

Optimal management of nausea and vomiting of pregnancy

MISCELLANEOUS & NEW MEDICATIONS

Clonidine New medication being used for HG.
Drug Name Min/Max Dosage Notes Research Studies
Catapres-TTS (Clonidine)   New medication being used for HG. Transdermal clonidine in the treatment of severe hyperemesis. A pilot randomised control trial: CLONEMESI.
Gabapentin (Neurontin)   New medication being used for HG.

Potential maternal symptomatic benefit of gabapentin and review of its safety in pregnancy.

A case of treatment refractory hyperemesis gravidarum in a patient with comorbid anxiety, treated successfully with adjunctive gabapentin: a review and the potential role of neurogastroentereology in understanding its pathogenesis and treatment.

Research articles on PubMed.

Thiamine
(Vitamin B1)
5 mg/day minimum; Considered non-toxic. For HG: 100-500 mg BID IV.

Body's stores depleted in < 3 weeks.

Infographic

Iatrogenic wernicke encephalopathy in a patient with severe hyperemesis gravidarum.

Wernicke's encephalopathy induced by hyperemesis gravidarum.

Neurological complications in hyperemesis gravidarum.

Pyridoxine
(Vitamin B6, Hexa-Betalin)

Cobalamin, Cyanocobalamin, Hydroxocobalamin (Vitamin B12)

 

20-75 mg/day
Doses up to 150 mg are being used.

100 mcg/day

Paresthesias may occur if B6 is taken in high doses.

Note: reactions to vitamins are uncommon but possible.
Serious adverse drug reaction in a woman with hyperemesis gravidarum after first exposure to vitamin B complex containing vitamins B1, B6 and B12.

Reprivex

Each tablet contains 25mg of Vitamin B6 (as Pyridoxine Hydrochloride) and 100mg of Ginger Root PE 5% Gingerois (Zingiber Officinalis)

3 tablets daily

 

A prescription is NOT required for this medication.  
Ginger 250 mg orally every 6 hours Helpful as adjunctive therapy.  
Emetrol
(Fructose, Dextrose, and Phosphoric Acid)
One or two tablespoonfuls upon arising and every three hours as needed. Helpful as adjunctive therapy.  
Marijuana
(Cannabis)
or the pharmaceutical extract: Marinol
(Dronabinol)
Dose not established for HG.  

Effects of prenatal exposure to marijuana.

Research on PubMed

International Association for Cannabis as Medicine
Does cannabis/THC do harm to the fetus if it is used during pregnancy?

Washington Hemp Education Network
Cannabis Indications

Benzodiazepine Derivatives:
Valium
(Diazepam)
Dose not established for HG. Class D drug. Evaluation of treatment of hyperemesis gravidarum using parenteral fluid with or without diazepam.
Neuroleptic:
Inapsine
(Droperidol)
Gerald G. Briggs
Briggs (LBMMC) Hyperemesis Protocol
Use with diphenhydramine to avoid side-effects.

Category C drug.
Droperidol and diphenhydramine in the management of hyperemesis gravidarum.

Droperidol-diphenhydramine for hyperemesis gravidarum.


** IM = Intramuscular (injection)
** IV = Intravenous
** IVP = Intravenous push (injected into an IV)
** PR = Per rectum
** SQ = subcutaneous (injected under the skin)

FDA-Assigned Pregnancy Categories for Drugs (United States Classification)

  • Category A
    Adequate and well-controlled studies have failed to demonstrate a risk to the fetus in the first trimester of pregnancy (and there is no evidence of risk in later trimesters).
     
  • Category B
    Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in pregnant women.
     
  • Category C
    Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.
     
  • Category D
    There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.
     
  • Category X
    Studies in animals or humans have demonstrated fetal abnormalities and/or there is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience, and the risks involved in use of the drug in pregnant women clearly outweigh potential benefits.

Excerpted from Drug Information for the Health Care Professional, USP-DI, Volume 1A, 11th ed., 1991.

Updated on: Jun. 25, 2015

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