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Abstract
Hospice patients at the end stages of life often suffer nausea and vomiting, distressing symptoms that are either side effects of medications or direct effects of the underlying disease state. Such symptoms can greatly diminish the hospice patient's quality of life. Effective pharmacotherapy is available, but in many cases traditional dosage forms are incompatible with the patient's physical condition, cause discomfort, or are difficult for family members to administer. In such cases, a compounded preparation containing lorazepam, diphenhydramine, haloperidol, and metoclopramide-commonly referred to as ABHR gel-has proven highly effective. A number of case reports are presented to illustrate the effectiveness of ABHR gel in relieving the symptoms of nausea and vomiting in hospice patients. Also discussed are the causes of vomiting and the mechanisms of each of the medications contained in the ABHR gel.
Lorazepam, diphenhydramine, haloperidol, and metoclopramide are the drugs contained in the compounded gel commonly referred to as ABHR. The gel was named after the brand names Ativan, Benadiyl, Haldol, and Reglan, under which these drugs were originally marketed. This gel is an option that has proven highly effective for relieving the symptoms of nausea and vomiting for terminally ill hospice patients. This combination of drugs works to block each physical pathway that is responsible for nausea and vomiting. Case reports are provided to illustrate ABHR gel's effectiveness in relieving these symptoms.
Pathophysiology and Overview of Nausea and Vomiting
Boomsma published an excellent review of the mechanisms involved in nausea and vomiting and the medications used in the treatment of these symptoms in hospice patients.1 There are three distinct stages of vomiting (Table 1). The body's vomiting center (VC) is the final pathway that controls all vomiting. The VC does not respond directly to chemical stimuli but is triggered by four different mechanisms, as follows:
* Chemoreceptor trigger zone (CTZ): The CTZ incorporates various receptors (serotonin, dopamine, and opiate) that mediate the emetic effects of blood toxins and drugs. The CTZ is unable to induce vomiting without an intact VC.2,3
* Afferent impulses from the periphery: Stimulation of the VC from outside the central nervous system occurs when chemical stimulation and physical factors cause afferent impulses from the periphery. Serotonin, dopamine, and opiate receptors are the mediators of emesis.2,4
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