Emetics, anti-emetics

Dr. Jibachha Sah

M.V.Sc ( Pharmacology)
College of veterinary science, NPI,
Bhojard, Chitwan
 Emetics

Emetics are agents that cause vomiting.

There are two general classes of emetics, one acting on

the chemoreceptor trigger zone (CTZ) of the medulla and the second
acting on the stomach itself.

The chemoreceptor trigger zone (CTZ) is an area of the medulla oblongata that receives
inputs from blood-borne drugs or hormones, and communicates with other structures in
the vomiting center to initiate vomiting. The CTZ is located within the area postrema,
which is on the floor of the fourth ventricle and is outside of the blood–brain barrier. It is
also part of the vomiting center itself.
Emetics

Emetics such as syrup of ipecac have been used in emergent cases

of poisoning because they induce forceful emptying of the stomach.
 Emetic Drugs

Drug Dosage

Dogs: 4 mg/kg, PO; 0.02 mg/kg, IV;

Apomorphine 0.3 mg/kg, SC; 0.25 mg in the
conjunctival sac

Xylazine Cats: 0.4–0.5 mg/kg, IV or IM

Hydrogen peroxide Dogs: 5–10 mL, PO

●Apomorphine is an opioid drug that acts as a potent central dopamineagonist to directly
stimulate the CRTZ. Therefore, it is less effective in cats than in dogs. It can be administered
PO, IV, or SC; the IM route is not as effective.
Vomiting usually occurs in 5–10 min. Although apomorphine directly stimulates the CRTZ, it
has a depressant effect on the emetic center.

●Xylazine is an α2-adrenergic agonist used primarily for its sedative and analgesic action. It is a
reliable emetic, particularly in cats, in which it stimulates the CRTZ. Because xylazine can
produce profound sedation and hypotension, animals should be closely monitored after
administration.

● Hydrogen peroxide (3%) applied to the back of the pharynx stimulates vomiting via the
ninth cranial nerve. Small doses (5–10 mL) of hydrogen peroxide can be administered via oral
syringe until emesis occurs. It should be administered cautiously, especially in cats, because
aspiration of hydrogen peroxide foam causes severe aspiration pneumonia. When small
amounts are administered, 3% hydrogen peroxide is relatively nontoxic. Stronger
concentrations (eg, hair dye peroxide) are more toxic.
●Although sometimes suggested, sodium chloride (salt) and powdered mustard should not
be used. Mustard is rarely effective and can be inhaled and cause lung damage, whereas salt
toxicity can easily occur if overdosed and can result in fatal cerebral edema.

● Syrup of ipecac is no longer recommended for "home use" in people or animals. The
active ingredient is emetine, a toxic alkaloid, which produces vomiting by acting as a
stomach irritant.
 Neurotransmitters of Emesis:
●Acetylcholine (muscarinic receptors) and substance P (NK-1 receptors) act on the emetic
center. The CRTZ is stimulated by dopamine (D2 receptors), α2-adrenergic drugs (NE
receptors), serotonin (5-HT3 receptors), acetylcholine (M1 receptors), enkephalins, and
histamine (H1 and H2 receptors).

● α-Adrenergic receptors in the CRTZ are important in inducing emesis in cats. α2-
Adrenergic agonists (eg, xylazine) are more potent emetics in cats than in dogs.

● 5-HT1A antagonists (eg, buspirone) and α2-adrenergic antagonists (eg, acepromazine,

yohimbine, mirtazapine) suppress vomiting in cats.
Adverse effects

• Emetics are contraindicated in patients that are hypoxic, dyspneic,

unable to swallow, hypovolemic or comatose.

• Emetics should not be given to animals which have ingested strong acids
or alkalis because the contents of the vomitus may cause further damage
to esophageal, pharyngeal or oral tissues.

• Given the risk of aspiration, emetics should not be given after ingestion
of petrolatum or related compounds because the risk of subsequent
aspiration outweighs the potential toxicity.

• The syrup is clear, with a mild odor. It has an unpleasant taste and, as a
consequence, may be difficult to administer successfully to cats.
 Antiemetic Drugs
Drug Dosage

0.025–0.2 mg/kg, IV, IM, SC, maximum

Acepromazine
3 mg; 1–3 mg/kg, PO
Chlorpromazine 0.5 mg/kg, IV, IM, SC, tid-qid

Prochlorperazine 0.1 mg/kg, IM, tid-qid; 1 mg/kg, PO, bid

Aminopentamide 0.022 mg/kg, PO, SC, or IM, bid-tid

Dimenhydrinate 4–8 mg/kg, PO, tid
Diphenhydramine 2–4 mg/kg, PO, tid

Butorphanol 0.2–0.4 mg/kg, IM, once to twice daily

0.1–0.5 mg/kg, IM, SC, or PO, tid; 0.01–

Metoclopramide
0.02 mg/kg/hr, IV infusion
●CRTZ D2 dopamine receptors are not as important in mediating humoral emesis in
cats as they are in dogs. Apomorphine, a D2 dopamine receptor agonist is a more
reliable emetic in dogs than cats, and D2 dopamine receptor antagonists
(eg, metoclopramide) are not very effective antiemetic drugs in cats.

● Histamine H1 and H2 receptors are found in the CRTZ of dogs but not cats.
Histamine is a potent emetic in dogs but not cats, and H1 antagonists
(eg, diphenhydramine) are ineffective for motion sickness in cats.

● Muscarinic M1 receptors are found in the vestibular apparatus of cats. Mixed

M1/M2 antagonists (eg, atropine) inhibit motion sickness in cats.

● Substance P binds to NK-1 receptors, which are found in the gut and the emetic
center of the CNS. Substance P induces emesis, and selective substance P
antagonists (eg, maropitant) are potent antiemetics in both dogs and cats with a
broad spectrum of activity against a variety of emetic stimuli.
They may also act centrally to block stimulation of the CRTZ and emetic center.

phenothiazine tranquilizers are α2-adrenergic antagonists and

antagonize the CNS stimulatory effects of dopamine and decrease vomiting from
a variety of causes, including motion sickness in cats. These drugs also have
antihistaminic and weak anticholinergic action. Phenothiazine tranquilizers used
as antiemetics include acepromazine, chlorpromazine, and prochlorperazine.
 Anticholinergic drugs block cholinergic afferent pathways from the GI
tract and the vestibular system to the vomiting center. Alone, they are less
effective than the other emetics. Aminopentamide is approved for use in dogs and
cats in the USA as an injectable formulation and oral tablets.

Antihistamines can block both cholinergic and histaminic nerve transmission

responsible for transmission of the vestibular stimulus to the vomiting center of dogs. The
commonly used histamine (H1) blocking drugs
are diphenhydramine and dimenhydrinate (diphenhydramine plus 8-chlorotheophylline).
Metoclopramide exerts its antiemetic effects via three mechanisms. At
low doses, it inhibits dopaminergic transmission in the CNS, whereas at high
doses, it inhibits serotonin receptors in the CRTZ.
Peripherally, metoclopramide increases gastric and upper duodenal
emptying. Metoclopramide is a useful antiemetic for dogs.

serotonin antagonists ondansetron, granisetron, and dolasetron are specific

inhibitors of serotonin subtype 3 receptors in the CRTZ. These are the most effective
antiemetics used in people undergoing radiation and chemotherapy, and they have been
used in cats and dogs receiving chemotherapy.
Butorphanol is an effective antiemetic for dogs receiving cisplatin chemotherapy.
It causes only mild sedation. It is believed to exert its antiemetic effect directly on the
vomiting center.

Maropitant is a neurokinin 1 (NK-1) receptor antagonist approved to treat and

prevent emesis in dogs and cats.
Adverse effects are rare with maropitant, but the most common ones are
excessive drooling, lethargy, lack of appetite, and diarrhea.

●Maropitant injections may also cause a stinging sensation; this can be minimized by
keeping the injectable solution refrigerated and, once the drug is drawn up, injecting right
away at the refrigerated temperature. A few dogs may vomit after treatment.